Every finding on record at Crestmoor Care Center

Based on observations, interviews, and record review the facility failed to ensure an environment free of accident hazards for one (#3) of three residents reviewed for accidents/hazards out of 16 sample residents.Specifically, the facility failed to prevent Resident #3 from eloping from the facility.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/8/26 to 7/9/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/23/26.I. Elopement incident on 3/21/26On 3/21/26 at 3:30 p.m. the facility failed to ensure a staff member kept a door alarmed, which resulted in Resident #3, who had a wander prevention device, eloping from the facility.Resident #3 eloped from the facility and wandered in the community for approximately a half an hour. The resident was found by a staff member approximately 0.4 miles away from the facility. The resident had no injuries noted and was returned to the facility.Video review revealed that a dietary aide used the keypad to unlock the entryway to the breezeway. Resident #3 followed the dietary aide through the doors and appeared to be speaking with the dietary aide before exiting the facility. The video revealed that the dietary aide did not attempt to redirect Resident #3 back into the facility, II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #3's elopement incident on 3/21/26 was provided by the assistant nursing home administrator on 7/8/26 at 11:00 a.m. The plan documented the following:A. Immediate action to correct the deficient practice for Resident #3On 3/21/26 when Resident #3 returned to the facility, the resident was placed on 15-minute checks by staff. The staff examined and determined the exit door alarms worked correctly. The staff placed signage on all six exit doors to remind staff and visitors to be mindful of who might exit with them. The four residents with wander prevention devices had their devices checked and all devices functioned correctly.On 3/23/26 at 8:45 a.m. the video footage was reviewed. It was determined that a dietary aide had used a code to turn the alarm off for an exit door as Resident #3 followed the staff member through the doors. The resident appeared to speak to the dietary aide before the facility was exited. The dietary aide did not attempt to redirect Resident #3 back into the building. The dietary aide did not work in the facility after that day (3/21/26). B. Identification of other residentsOn 3/21/26 the other three residents in the facility with wander prevention devices had their devices checked and all devices worked correctly. The exit doors were checked and also worked correctly. Signs were placed on six exit doors to remind anyone leaving the facility to be mindful of who might be near the exit.On 3/23/26 all facility doors and resident wander prevention devices were assessed and tested by the assistant nursing home administrator and the director of nursing (DON) for proper device functions.On 3/23/26 the elopement binders were reviewed and updated to ensure that all residents who were at risk for elopement/wandering were identified. The binders were located at the front reception desk, and two nurses' stations.C. Systemic changesOn 3/23/26 all staff were educated on the following;1. The need to check the elopement risk binder located at the front desk prior to allowing any resident to leave the building.2. Missing residents, elopement, residents who wandered, and one-to-one monitoring policies.The physician's orders for any resident's wander prevention devices were updated with the expiration of the device and orders to replace the wander prevention devices at the expiration in the electronic medical records (EMR).The elopement binder was to be reviewed weekly to ensure that all identified residents who were assessed to be wander risks were present in the binder by the assistant nursing home administrator. The DON or designee would check the physician's orders and date of expiration for residents with wander prevention devices weekly for three months.The social service director (SSD) and the DON would review wander risk evaluations for new admissions each week to ensure that if needed resident wander prevention devices were in place and had proper orders.The exit doors with alarms would be checked and monitored monthly to ensure proper working order by the maintenance director. D. Plan to Monitor for Sustained ComplianceThe assistant to the chief executive officer/designee would report findings from audits to the QAPI (quality assurance and performance improvement) committee's Performance Improvement Project (PIP) which was implemented to review and interpret all audit findings. All findings would be discussed at the monthly QAA (quality assessment and assurance) meeting for a minimum of three months or until the pattern of compliance was maintained. The anticipated completion date would be documented in the QAPI meeting.III. Facility policy and procedureThe Elopement policy and procedure, dated 2/29/24, was provided by the assistant nursing home administrator on 7/8/26 at 11:08 a.m. via email. It read in pertinent part, It is a goal of the facility to provide a safe environment using the least restrictive measure available in caring for residents who are exhibiting elopement behavior. The facility defines 'wanderers'as residents who move around the facility in a non-goal directed manner, but do not make efforts to leave the premises. Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. A wander/elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team (IDT) during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with change of condition. If the resident is identified as an elopement risk, the following will be maintained: Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder. Implementing and care planning interventions to address safety and decrease risk of elopement. A physician's order will be required for the use of monitoring the wander prevention device. The order will include checking placement of device every shift and checking function of device daily. The care plan will be updated to include that an electronic alarm system is used for resident's safety.IV. Facility investigationThe facility's investigation revealed that on 3/21/26, Resident #3 was able to leave the facility with a wander prevention device in place. The investigation revealed that a nurse reported that Resident #3 was not in the building and reported that the resident was not in the facility at approximately 3:30 p.m. and a search of the facility grounds and the area and the surrounding neighborhood was initiated. The investigation revealed that at approximately 4:00 p.m., Resident #3 was seen walking approximately 0.4 miles from the facility. Resident #3 agreed to return to the facility in a staff member's car. Resident #3 had lived in the neighborhood prior and stated she was looking for her dog. Resident #3 was placed immediately on 15-minute checks. On 3/21/26 the facility staff thought the alarm system and the safety guards on residents did not function correctly. Resident #3 along with three other residents had their wander prevention devices checked, along with the alarm system of the doors. The doors and monitors were assessed to be working correctly. The video footage of the incident was unable to be assessed by the facility staff until the following Monday (3/23/26).On 3/23/26 the video footage was reviewed by the assistant nursing home administrator and it revealed that on 3/21/26, a dietary aide came out of the kitchen, walked across a hallway, and put a code into a secured door which disabled the alarm and opened the door. Resident #3 walked immediately behind the employee, who held the door open for Resident #3 and allowed Resident #3 to walk through the unalarmed door. The dietary aide then held another door open for the Resident #3 who continued to walk outside freely to the sidewalk. Resident #3 walked 0.4 miles and was then found without harm a half an hour later, at approximately 4:00 p.m. V. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE], and discharged on 3/25/26. According to the March 2026 computerized physician orders (CPO), diagnoses included vascular dementia, epilepsy, type 2 diabetes mellitus, a history of falling, and depression. The 1/7/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. She was independent with dressing, toileting, eating, and oral hygiene. She ambulated independently without any assistive devices. Her preferred language was Korean, and she did speak and understand some English. B. Record reviewThe 1/9/26 admission elopement wandering risk assessment revealed Resident #3 was assessed to be a high risk for elopement. The wander/elopement care plan, initiated 7/31/24 and revised 9/18/24, revealed Resident #3 was an elopement/wander risk due to her dementia. The resident would look for her previous apartment and dog. Interventions included ensuring every shift that the wander prevention device used for wandering prevention was located on her left ankle, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books and offering social gatherings and a walk around the building to the resident after meals. The nursing progress note, dated 3/20/26, revealed Resident #3 had been exit-seeking more frequently by walking towards doors and attempting to push the door, despite the alarm. Staff immediately intervened and 15-minute checks were put into place during every event when the resident was exit-seeking. There had been an increased frequency of exit-seeking. Referrals were sent to facilities with secure units. The nursing progress note, dated 3/21/26, revealed Resident #3 was noted to be absent from her usual location during a routine safety check. Resident #3 was located (off) facility grounds, near the neighborhood by the facility. Resident #3 returned back to the facility willingly with staff present. No sign of injury was noted and the resident's skin was clear and intact. The resident's vital signs were stable. Resident #3 was alert to self with no baseline confusion noted. A safety check was completed to ensure the wander prevention device was guard working and was on the resident's left ankle. Resident #3 was monitored with 15-minutes checks. The nurse notified the DON, the NHA and Resident #3's physician. The nursing progress note, dated 3/22/26, revealed Resident #3 continued on 15-minute checks to prevent an elopement, and in the evening a companion was provided.The nursing progress note, dated 3/23/26, revealed Resident #3 was provided with a stuffed dog with success due to looking for her dog when the elopement occurred (on 3/21/26). The resident was currently one-to-one supervision.The nursing progress note, dated 3/25/26, documented Resident #3 was discharged from the facility to another facility with a secured unit. VI. Staff interviewsRegional clinical resource #2 was interviewed on 7/8/26 at 12:00 p.m. Regional clinical resource #2 said that on 3/21/26, shortly after 4:00 p.m., she was notified about Resident #3 and the elopement. Regional clinical resource #2 said the nursing staff immediately, after Resident #3 was located and returned to the facility, checked all the exit doors to ensure the alarms were working correctly. She said they also checked all residents who wore wander prevention devices. Regional clinical resource #2 said everyone thought the alarm system with the devices on the residents malfunctioned and that was how Resident #3 eloped. Regional clinical resource #2 said the staff immediately handled the situation correctly with the assumption that the root cause was a malfunction with the alarm system. She said all the doors, alarms, and residents' alarms worked during a systems check immediately following Resident #3'selopement. Regional clinical resource #2 said on 3/21/26, after the incident, the staff put signs on the six exit doors reminding staff to be mindful of those around them when exiting through the door. Regional clinical resource #2 said the video footage of the facility that day (Saturday 3/21/26) was unable to be viewed until two days later (on Monday 3/23/26). Regional clinical resource #2 said when the video was reviewed, management was able to determine what really happened on 3/21/26 when Resident #3 eloped from the facility. Regional clinical resource #2 said a dietary aide came out of the kitchen, walked across the hall, and used a code on a keypad to turn off an alarm on a door. The dietary aide opened the unalarmed door and then another door to the outside. Regional clinical resource #2 said Resident #3 was right behind the dietary aide. Regional clinical resource #2 said the dietary aide held the door for Resident #3 to walk into the first room and then the dietary aide held the next door open for Resident #3 to walk outside. Regional clinical resource #2 said Resident #3 walked straight outside, turned right, and walked two blocks, to where Resident #3 was found approximately a half hour later (0.4 miles away). Regional clinical resource #2 said on 3/21/26 at 3:30 p.m., at the same time when Resident #3 eloped, a nurse was looking for Resident #3 and was unable to find the resident. Regional clinical resource #2 said the nurse immediately initiated a missing person protocol, and staff looked inside the facility, around the outside property, and then began a search in the close neighborhood for Resident #3. Regional clinical resource #2 said staff who were looking for Resident #3 in the surrounding neighborhood saw Resident #3 at 4:00 p.m., a few blocks from the facility. Regional clinical resource #2 said Resident #3 allowed two staff members to drive her back to the facility. Regional clinical resource #2 said the resident was not harmed.Regional clinical resource #2 said the day prior to the elopement (3/20/26), the IDT had sent a few referrals to facilities that had secured units because Resident #3 had started wandering and pushing on doors more frequently. Regional clinical resource #2 said on 3/25/26, Resident #3 transferred to a secured unit in another facility. The assistant nursing home administrator was interviewed on 7/8/26 at 2:00 p.m. The assistant nursing home administrator provided an observation of how Resident #3's elopement took place. The assistant nursing home administrator said the dietary aide walked out the kitchen door straight across the hallway, punched in a code to turn an alarm off to open a door to an employee only area. He said Resident #3 had walked very closely behind the dietary aide. The assistant nursing home administrator said the video revealed the dietary aide willingly held the door open for Resident #3 to walk into the private employee area, and then the dietary aide held the next door open to a small outside patio which led to the public sidewalk. The assistant nursing home administrator said Resident #3 turned right on the sidewalk and kept walking until she was found about a half hour later by staff members who safely brought her back to the facility. The assistant nursing home administrator said on 3/21/26, the doors, alarms, and wander prevention devices on the residents worked correctly. The assistant nursing home administrator said the problem was the dietary aide assumed that Resident #3 was a visitor. The assistant nursing home administrator said the dietary aide did not work in the facility after 3/21/26. The assistant nursing home administrator said upon review of the video footage on 3/23/26, the employee was terminated. The assistant nursing home administrator said all staff, prior to working in the facility again, were required to be trained on elopements and wandering. The assistant nursing home administrator said she believed the dietary aide had received the proper training, the aide just decided Resident #3 was a visitor and not a resident. The assistant nursing home administrator said it took until she viewed the video evidence on the following Monday (3/23/26) to realize what really happened with Resident #3's elopement. She said at that time, the plan of correction began and was implemented. The assistant nursing home administrator said on 3/23/26 all staff were educated on missing persons, one-to-one monitoring, elopement and wandering, and the location of the elopement binders on each of the two nurses' stations, and one elopement binder at the front desk by the front entry door. The assistant nursing home administrator said on 3/23/26 all doors and alarms were tested, and all residents who required wander prevention devices had their equipment tested. The assistant nursing home administrator said there had been no elopements or missing persons in the facility since the elopement incident with Resident #3 on 3/21/26.

Based on observations, record review and interviews, the facility failed to protect four (#12, #5, #9 and #15) of seven residents from abuse out of 12 sample residents.Resident #6 was admitted on [DATE] with a diagnosis of bipolar disorder (mental illness), depression, and dementia.Resident #12 was admitted on [DATE] with a diagnosis of dementia, other behavioral disturbance, anxiety disorder and depression.On [DATE], Resident #6 and Resident #12 were in the dining room when the residents began yelling at each other and hitting each other. On [DATE], Resident #6 grabbed Resident #12 on both of her arms. On [DATE], Resident #6 began yelling at Resident #12. Resident #6 then lunged at Resident #12 and pushed her to the ground, where she (Resident #6) attempted to hit Resident #12 in the face. As a result of the three incidents of physical and verbal abuse, Resident #12 began isolating herself and avoiding Resident #6. Resident #12 said she avoided Resident #6 when she could because Resident #6 was yelling at her, hitting her and pushing her. Resident #12 said she feared getting seriously injured. Observations revealed Resident #12 displayed anger and distress when talking about the encounter with Resident #6 and said she did not like talking about the incidents. Specifically, the facility failed to:-Prevent multiple abuse altercations between Resident #6 and Resident #12; and,-Protect Resident #5, Resident #9 and Resident #15 from physical abuse by Resident #4. Findings include: I. Facility policy and procedure The Abuse policy, dated February 2024, was provided by the corporate nurse consultant on [DATE] at 2:07 p.m. It read in pertinent part, “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. “Providing a safe environment for the resident is one of the most basic and essential duties of our facility. This facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. “Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through use of technology. “Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. “Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. “The following approaches and interventions are designated as part of the facility abuse prevention protocols: Education is provided at staff orientation and training programs that include topics such as abuse prevention, the elder justice act, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.” The Dementia-Clinical protocol, undated, was provided by the clinical nurse consultant on [DATE] at 2:07 p.m. It read in pertinent part, “As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. “The interdisciplinary team (IDT) will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. “Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. “The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.” II. Incident of physical and verbal abuse by Resident #6 towards Resident #12 A. Facility investigation The facility investigation, dated [DATE], documented Resident #12 and Resident #6 were in the hallway after lunch and started to argue and hit each other. Staff immediately separated both residents. The investigation documented neither resident could explain why they were hitting each other. Resident #12 sustained mild swelling, redness and warmth to her left cheek from the altercation. She received Tylenol for pain and an ice pack for the swelling. The facility investigation documented Resident #6 had a history of being physically aggressive towards other residents with whom she had been friends with in the past. After the altercation, Resident #6 was not able to recall the argument or physical altercations and said that everything was fine. Resident #6 said she would be friends again with the other resident (Resident #12) that she attacked after an incident occurred. The investigation documented Resident #12 was interviewed by registered nurse (RN) #4. Resident #12 said she went to the dining room and sat down. Then Resident #6 came over and accused Resident #12 of drinking her juice. Resident #12 said she did not drink Resident #6's juice. Resident #12 said Resident #6 started cursing at her. Resident #12 said she got angry and ended up cursing back at Resident #6. Resident #12 said she left the dining room, but Resident #6 followed her and continued to fight with her. The investigation documented Resident #6 was interviewed by RN #4. Resident #6 said when she went to the dining room, Resident #12 started cursing at her for no reason. Resident #6 said she fought with Resident #12, then Resident #12 left the dining room while she continued to curse at her. Resident #6 said she followed Resident #12 and fought with her. Later that day, Resident #6 said everything was fine. CNA #4 was interviewed as a witness to the incident on [DATE]. CNA #4 said she was passing room trays in the south unit. She saw Resident #6 and Resident #12 yelling and hitting each other. CNA #4 said she got in between them and yelled for help. CNA #4 said an unidentified RN came right away and helped her separate the residents. CNA #4 said she walked Resident #6 to her room and the unidentified RN took Resident #12 back to the north nurses' station. CNA #4 said the unidentified RN placed both residents on 15-minute checks and directed for them not to be in the same area. The facility investigation concluded Resident #6 was the aggressor and did have the intent to fight with Resident #12 because Resident #6 said she followed her out of the dining room on [DATE]. -However, abuse occurred due to Resident #6 and Resident #12 cursing at each other and hitting each other. III. Incident of physical abuse by Resident #6 towards Resident #12 on [DATE] A. Facility investigation The facility investigation, dated [DATE], documented Resident #12 was interviewed by the social services director (SSD). Resident #12 said she was asleep and was woken up by Resident #6 grabbing her arms and trying to pull her out of the bed. Resident #12 said she did nothing to retaliate and just yelled at Resident #6 to let her go and get out of her room. She said someone came and got Resident #6 out of the room. Resident #6 was interviewed by the SSD as part of the facility investigation. Resident #6 said they (Resident #6 and Resident #12) were coming in from outside and Resident #12 stepped on her foot. Resident #6 said she yelled at Resident #12 because it hurt, but Resident #12 did not care and they started yelling at each other. -However, Resident #6 was not able to explain how she ended up in Resident #12's room, grabbing at her. Licensed practical nurse (LPN) #2 was interviewed as a witness to the incident on [DATE]. LPN #2 said she was in the south hall near the nursing cart and saw Resident #6 yelling, screaming and cursing at Resident #12, who was standing in the south hall. LPN #2 said Resident #6 told her that Resident #12 was putting clothes in bags in front of Resident #6's room. LPN #2 said she did not observe anything on the floor in front of Resident #6's room and nothing inside the room. LPN #2 said Resident #6 grabbed Resident #12 on both arms and tried to hit Resident #12's head. LPN #2 said she and the nurse practitioner (NP) separated the residents immediately. LPN #2 said she took Resident #6 to the other side of the building and notified Resident #12's nurse about the incident. -The facility investigation did not document that the incident of physical and verbal abuse was substantiated. IV. Incident of physical and verbal abuse on [DATE] by Resident #12 towards Resident #6 A. Facility investigation The facility investigation, dated [DATE], documented Resident #12 and Resident #6 were observed yelling at each other by the double doors that separated the north hallway and the north nurses' station. The nurse observed Resident #6 lunge at Resident #12. Resident #6 grabbed Resident #12's shoulders and pushed her to the ground and attempted to hit her in the face. The staff were able to separate the two residents before Resident #6 was able to physically hit Resident #12. Resident #6 said she was upset with Resident #12 because Resident #12 was stealing from her. Resident #12 was interviewed by the SSD as part of the facility investigation. Resident #12 said she was just walking down the hall and Resident #6 started yelling at her, and she yelled back too. Resident #12 said Resident #6 pushed her on the ground. Resident #12 said she felt safe when staff kept Resident #6 away from her. The facility investigation documented Resident #12 had a history of being friends with Resident #6 shortly after an altercation, as they both had cognitive deficits. Once the police came to interview the residents, they were holding hands, stating they loved each other and they were friends. The police told the residents to get along and not fight. Resident #6 was interviewed by the SSD as part of the facility investigation. Resident #6 said she was upset at her friend (Resident #12), who went into her room and stole all her money while she was mourning the loss of her husband. Resident #6 said she went to yell and confront Resident #12 because she stole all her money. RN #4 was interviewed as a witness to the incident on [DATE]. RN #4 said Resident #12 was walking towards the nurses' station and Resident #6 was walking towards Resident #12 at the north nurses' station. RN #4 said Resident #6 accused Resident #12 of stealing her money and keys. RN #4 said Resident #6 grabbed Resident #12's wrists and pushed her, which caused Resident #12 to fall. RN #4 said the staff separated the residents immediately. A staff nurse witness said she was working on the north cart when she heard yelling and saw Resident #6 come up to Resident #12 and push her hard down on the ground. The staff witness said she ran over to the fight, told them to stop and separated them. The staff witness said RN #4 came and took Resident #6 away. The staff witness said she assisted Resident #12 from the floor and conducted her assessment. -The facility investigation did not document that the incident of physical and verbal abuse was substantiated. The facility investigation concluded that Resident #6 was having delusional thinking and Resident #12 did not have keys or any of Resident #6's items. Resident #6's physician adjusted her medication after the altercation on [DATE] to help with the loss of her husband and her behaviors. A. Resident #6 (assailant) 1. Resident status Resident #6 was admitted on [DATE]. According to the [DATE] computerized physician's orders (CPO), diagnoses included bipolar disorder, depression and dementia. According to the [DATE] minimum data set (MDS) assessment the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment documented that the resident was oriented to herself and displayed aggressive and violent behavior towards others. The resident was able to walk independently and wandered almost daily. 2. Resident observations During a continuous observation on [DATE], beginning at 12:30 p.m. and ending at 1:05 p.m., Resident #6 was walking up and down the hallway by herself, unsupervised by staff. The resident was walking in areas of the hall where she was not in direct line of sight of the staff for extended periods of time. During a continuous observation on [DATE] from 10:30 a.m. to 10:59 a.m., Resident #6 was walking up and down the hallway by herself, unsupervised by staff. The resident was walking in areas of the hall where she was not in the direct line of staff. 3. Resident interviews Resident #6 was interviewed on [DATE] at 1:00 p.m. Resident #6, due to her impaired cognition, was unable to answer many of the questions and often provided contradictory details. She said she did not know how long she had been at the facility and had nothing to do but lie in bed. However, she then contradicted her previous statement and said the facility had lots of games, which she enjoyed. Resident #6 said she got along well with the staff and residents and did not have issues with anyone at the facility. Resident #14, who was Resident #6's roommate, was interviewed on [DATE] at 1:01 p.m. Resident #14 said the staff was not taking very good care of Resident #6. She said Resident #6 was often pacing the halls of the facility without staff supervision and often appeared to be disheveled, unshowered and had an unpleasant body odor. 4. Record Review Resident #6's behavior care plan, initiated on [DATE], revealed the resident has potential to be physically aggressive related to dementia and bipolar disorder, and poor impulse control. She has a history of getting physically aggressive towards other residents. She has a history of being physically aggressive with one of the other residents, who was her friend. She can get physical but oftentimes does not remember all the details of the altercation or why she was making accusations. Interventions included documenting behaviors, administering medications as ordered and monitoring/documenting for side effects and effectiveness, providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting verbalization of the source of agitation, assisting in setting goals for more pleasant behavior, encouraging seeking out of staff members when agitated and when the resident became agitated, intervening before agitation escalated, guiding away from the source of distress, engaging the resident calmly in conversation and if the resident's response was aggressive, staff was to walk calmly away and approach later. Review of the resident's behavior log (from [DATE] to [DATE]) revealed the direct care staff had documented that Resident #6 had no identifiable aggressive or disruptive behaviors, including on [DATE] and [DATE], when Resident #6 was involved in altercations with Resident #12. B. Resident #12 (victim) 1. Resident status Resident #12, age [AGE], was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses included dementia, other behavioral disturbance, anxiety disorder and depression. The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The assessment revealed Resident #12 was independent in all activities of daily living (ADL) and exhibited verbal behavioral symptoms directed toward others, such as screaming and cursing at others. 2. Resident observation On [DATE] at 1:50 p.m. Resident #12 was observed eating her lunch in her room. 3. Resident interview Resident #12 was interviewed on [DATE] at 9:25 a.m. Resident #12 said Resident #6 grabbed her left arm, twisted it and threw her on the floor for no reason. She said Resident #6 repeatedly punched her. Resident #12 said she sustained a sore arm that required staff to wrap it with an elastic bandage for a week. Resident #12 said Resident #6 pushed her against the wall, which caused back pain and soreness. Resident #12 said she had another incident with Resident #6 in the past. Resident #12 became emotional, waving her arms, saying no, shaking her head, while saying she did not want to be with Resident #6 while recounting the incidents involving her with Resident #6. Resident #12's voice trembled as she spoke and she was visibly shaking. Resident #12 repeatedly waved her hands and shook her head no when Resident #6's name was mentioned. Resident #12 was tense and spoke in a shaky tone. Resident #12 said she had to stay in her room more than usual out of fear that Resident #6 would hurt her again. Resident #12 said she avoided going to the dining room to keep from crossing paths with Resident #6 during meal time. She said she did not want to be in contact with Resident #6, even though Resident #6 tried to talk to her. Resident #12 said she was friends with Resident #6 before, but she did not trust her much and kept her distance from her after the altercations. 4. Record review Resident #12's trauma care plan, revised [DATE], documented Resident #12 had a history of trauma that resulted in difficulty connecting and trusting others. She had the potential to be verbally and physically aggressive related to dementia. She could get upset and start yelling and cursing at other residents. She tended to forget why she became physically aggressive after an incident had occurred. Pertinent interventions included analyzing key times of day, places, circumstances, triggers, and how to de-escalate behavior and document, assessing the resident's coping skills and support system, when the resident was agitated, intervening before the agitation escalated, guiding away from the source of distress, engaging calmly in conversation, and staff to walk calmly away and approach later if the response was still aggressive. The interventions further included providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting verbalization of sources of agitation and setting goals for more pleasant behavior and encouraging seeking out of staff members when agitated. The [DATE] nursing progress note documented RN #4 heard the sounds of a fight in the hallway and went to check on the disturbance. RN #4 found Resident #6 and Resident #12 were physically struggling and grabbing each other by the collar. Resident #6 was twisting Resident #12's left arm and RN #4 separated them. The provider ordered an Xray, icepack and as-needed (PRN) pain medication to be administered for Resident #12. The [DATE] nursing progress notes documented Resident #12 was involved in a physical altercation with Resident #6. Resident #12 said she was punched in the face by Resident #6. The nursing assessment noted mild and warm swelling and redness to Resident #12's left cheek as a result of the altercation. Nursing staff administered PRN Tylenol 650 milligrams (mg) and offered an ice compress to Resident #12. Resident #12 had been on the north side of the building for the entire shift, staying in her room and the north hallway. The resident ate in her room. -Review of Resident #12's electronic medical record (EMR) did not reveal documentation regarding the incidents of physical abuse with Resident #6 on [DATE] and [DATE]. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 3:34 p.m. CNA #1 said when a resident became aggressive, there was not much the staff could do besides disengage the resident if the behavior was directed at staff. She said the staff would try to separate the residents and move the residents to different rooms if the behavior was directed at another resident. CNA #1 said she heard of an incident last week (week of [DATE]) between Resident #12 and Resident #6. She said she was not sure how it had happened since the two residents were in completely different hallways. The director of nursing (DON) was interviewed on [DATE] at 11:15 a.m. The DON said it was hard to decide what to do about the conflicts between Resident #6 and Resident #12 because most of the time they would be very friendly with each other and even called each other sisters. She said after all the altercations, the interdisciplinary team (IDT) moved the two residents to different halls and tried to encourage them to stay away from each other, but that it was ineffective. She said the facility had nothing that they could do in addition to the interventions they had already been implementing. The SSD was interviewed on [DATE] at 5:00 p.m. The SSD said Resident #6 had no identified triggers before displaying aggressive behavior, but sometimes had delusional thinking. The SSD said that the IDT had informed Resident #6 on [DATE] that Resident #6's husband had died. The SSD said she had noticed Resident #6 had more aggressive behaviors after the news of her husband's passing. The SSD said she had offered Resident #6 other activities to distract her. She said the IDT recently reviewed Resident #6's medications and there were no plans to change Resident #6's medications at the time of the review. LPN #2 was interviewed on [DATE] at 2:56 p.m. LPN #2 said she was Resident #6's nurse on [DATE]. LPN #2 said both Resident #6 and Resident #12 were at the south nurses' station. She said Resident #12 was about three doors away from Resident #6. She said when Resident #6 saw Resident #12, she began yelling, accusing Resident #12 of touching her belongings in front of her room, which was not true. She said Resident #6 then attempted to touch Resident #12. LPN #2 said the NP and she intervened and separated them. She said both residents were escorted back to their rooms and placed on 15-minute checks. LPN #2 said no injuries were observed after the nursing assessment. LPN #2 said she reported the incident to the SSD and the nursing home administrator (NHA). LPN #2 said the SSD met with both residents and addressed the situation and that there were no further issues that day. RN #2 was interviewed on [DATE] at 12:25 p.m. RN #2 said if a resident's behavior became aggressive or violent, she would leave the room to allow the resident time to calm down for about 10 minutes and would report the incident to the NHA. RN #2 said before leaving the room, she would ensure the resident was safe and would ask what happened and what triggered the behavior. RN #2 said then the NHA would come to the floor and check on the resident and ask if they would like to talk about the incident. RN #2 said she would also ask the CNAs to check on the resident. RN #2 said she would ask for assistance if a resident became dangerous or posed a risk of self-harm when trying to de-escalate a situation. RN #2 said she could not recall all specific interventions for Resident #6 and Resident #12, as the approach would depend on the situation. RN #2 said if a resident became very aggressive, she would contact the police. RN #2 said in situations involving two residents, she would remove the calmer resident from the area. RN #2 said it had been a while since her last training on managing aggressive residents or de-escalation techniques and she could not recall the name of the program where she had the training. RN #2 said she could not remember when she last had dementia training. RN #2 said if a resident was suspicious or paranoid, she would speak with them calmly and try to orient them to reality, reassuring them that they were safe. She said she would assist them in locating their belongings by showing the inventory list completed at admission. RN #4 was interviewed on [DATE] at 3:04 p.m. RN #4 said on [DATE] she was speaking with Resident #6 in the conference room near Resident #12's room about the passing of her husband. RN #4 said Resident #6 appeared to be experiencing hallucinations and believed that Resident #12 had stolen her belongings. RN #4 said Resident #6 became agitated, saying she wanted to leave and was searching for her keys. RN #4 said Resident #6 repeatedly said that another woman had killed her husband and continued accusing Resident #12 of stealing her keys. RN #4 said, later in the day, Resident #6 was wandering in the building and crossed paths with Resident #12 in the hallway. She said Resident #6 grabbed Resident #12, shoved her and pushed her against the wall. RN #4 said this caused Resident #12 to sit down on the floor. RN #4 said she immediately intervened, separated them and escorted Resident #12 to her room while another staff member took Resident #6 to her room. RN #4 said both residents were placed on 15-minute checks and Resident #12 complained about shoulder pain. RN #4 said an Xray was performed, which was negative, and Resident #12 was administered Tylenol for pain relief. RN #4 said she reported the incident to the DON, the NHA and the police. The NHA and the SSD were interviewed together on [DATE] at 4:31 p.m. The NHA said if a resident's behavior became aggressive or violent, staff would separate residents and place them on 15-minute checks. She said the staff would notify the NHA and the SSD, who would call the resident's physician for medication review if necessary. The NHA said behavior notes were documented in the care plan and in progress notes. The NHA said leadership had recognized the facility had a need to provide increased training to staff on managing aggressive behavior and providing dementia-focused care. The NHA said prior to [DATE], the facility's training compliance was at 31 percent and was now at 50 percent. The NHA said the facility would continue working to ensure all staff received training. The NHA said she was not aware Resident #12 was fearful of Resident #6. She said the facility should have investigated and implemented interventions as appropriate to ensure she was not fearful. She said Resident #12 was observed eating lunch with Resident #6 today ([DATE]). The NHA said she spoke with the ombudsman regarding the situation between Resident #6 and Resident #12. The NHA said the ombudsman expressed a desire to uphold the residents' right to remain friends. The NHA said both residents verbalized that they were friends and considered each other like sisters and wished to remain together. The NHA said it would be detrimental to separate the residents and she did not know how to prevent resident-to-resident altercations between the two residents. V. Incident of physical abuse by Resident #4 towards Resident #5 on [DATE] A. Facility investigation The facility investigation, dated [DATE], documented that Resident #4 punched his roommate, Resident #5 in their room, after returning to the facility intoxicated from his community outing. Resident #5 alerted staff of the altercation. The local police department and emergency medical services were called to the facility. Resident #4 appeared to be intoxicated, per the incident report, and continued to demonstrate aggressive behaviors while staff attempted to de-escalate the situation. Resident #4 was taken to the hospital by emergency medical services. Staff relocated Resident #4 to a different room in the facility upon his return from the hospital. B. Resident #4 (assailant) 1. Resident status Resident #4, age less than 65, was admitted to the facility on [DATE] and discharged to jail on [DATE]. According to the [DATE] CPO, diagnosis included history of alcohol dependence, depression, and post-traumatic stress disorder (PTSD). The [DATE] MDS assessment documented the resident was cognitively intact with a BIMS score of 13 out of 15. The resident had verbal and physical aggression towards others. The resident was able to walk short distances and used a manual wheelchair to get around the community. 2. Resident interview Resident #4 was interviewed on [DATE] at 2:00 p.m. Resident #4 said he was on his way to the bar down the street. He said there was not much for him to do at the facility besides get drunk, high and gamble. He said that he could not do those activities on the facility grounds, but he could do them elsewhere. He said he usually came back to the facility drunk. He said that the facility discouraged him from drinking, but there were no real consequences. He said that he often felt like the other residents and staff were talking poorly of him, so he felt like he had to talk (expletive) to them. Resident #4 said that many people in the facility had bad attitudes and he often wanted to beat them up if they said disrespectful things to him. He said that his fights with residents were usually because other residents made false claims about his ethnic heritage. He said that made him very angry and that was why he would beat others up. Resident #4 said staff tried to keep residents apart from one another when they got into fights, but did not do anything to intervene when one resident was being disrespectful or threatening another resident. He said most of the time, the staff did not notice or ignored that behavior. 3. Record review The behavioral care plan, initiated on [DATE], documented Resident #4 occasionally returned to the facility from the community intoxicated. The care plan documented when the resident was intoxicated, he could become verbally and physically aggressive towards staff and residents. Pertinent interventions included while the resident appeared intoxicated, the staff were to provide the resident one-to-one observation. -However, the facility was unable to provide documentation that one-to-one observations were completed when Resident #4 was intoxicated on [DATE], [DATE] and [DATE]. A review of the resident's behavioral tracking sheets, from [DATE] through [DATE], revealed that staff did not document any of the incidents of aggressive behavior towards others, as documented in the resident's record and in the incident investigation. C. Resident #5 (victim) 1. Resident status Resident #5, age less than 65, was admitted to the facility on [DATE] and was discharged in [DATE]. According to the [DATE] CPO, diagnoses included heart failure, diabetes and anemia. The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was not aggressive towards others. The assessment revealed Resident #9 needed substantial/ maximum assistance with ADLs involving mobility of his lower body (legs, hips and feet) and was independent with ADLs involving the uses of his upper body (hands, shoulders and arms). The resident used a manual wheelchair to get around independently. VI. Incident of verbal abuse by Resident #4 and Resident #11 towards Resident #9 on [DATE] A. Facility investigation The facility investigation, dated [DATE], documented

Based on record review and interviews, the facility failed to investigate allegations of abuse for one (#1) of five residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to complete a thorough and timely investigation after Resident #1 made abuse allegations that staff and other residents were trying to harm her. Findings include: I. Facility policy and procedure The Abuse policy, revised 2/29/24, was received from the nursing home administrator (NHA) on 6/17/25 at 12:46 p.m. It documented in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends or any other individuals. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing. In addition to an investigation by the police department, the facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents or family members who may have knowledge of the incident. II. Allegation of abuse A. Facility investigation The 4/17/25 alleged physical or verbal abuse occurrence packet was provided by the NHA on 6/17/25. The packet revealed Resident #1 was interviewed on 4/17/25 and said her granddaughter hired a certified nurse aide (CNA) to try to kill her. Resident #1 stated she felt safe at the facility because she was at the NHA's office all day yesterday (4/16/25) and she was feeling better. The packet documented that eight additional residents were interviewed on 4/18/25 with no additional information. A family member, who was not listed in Resident #1's electronic medical record (EMR) was interviewed on 4/18/25 with no additional information. -However, the family member who was interviewed was not involved in the incident (see interviews below). Licensed practical nurse (LPN) #1 was interviewed on 4/18/25. The interview revealed LPN #1 reported Resident #1's son had reported Resident #1 was afraid of someone hurting her and that was why she left the facility (see progress notes below). Registered nurse (RN) #2 was interviewed on 4/18/25. The interview revealed that RN #2 interviewed Resident #1 and Resident #1 reported her granddaughter hired a CNA to try and kill her. RN #2's interview revealed that Resident #1 had a history of accusing her granddaughter and other family members of trying to poison her for her money. B. Resident #1 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included dementia, delusional disorders and insomnia (sleeping disorder). The 5/30/25 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out 15. She was independent with all activities of daily living (ADL). The MDS assessment indicated Resident #1 did not exhibit physical or verbal behavioral symptoms directed toward others. 2. Resident's family member interview Resident #1's son was interviewed over the phone on 6/17/25 at 3:25 p.m. The resident's son said he got a call from the pharmacist at the grocery store across from the facility on 4/14/25 in the evening. He said Resident #1 was fearful of a staff member and was saying how the staff member was rough with her and would push her. The son said he talked to the nurse at the facility and then was able to bring her back. He said at first Resident #1 refused to go back to the facility but he was able to bring her back. He said he stayed with her at the facility for a little while before having to leave to go to work. He said no staff from the facility had reached out to him about the incident after it occurred. 3. Record review The 4/14/25 nursing progress note documented by LPN #1 revealed that Resident #1 was socializing with other residents. When the time came to give Resident #1 her medication, Resident #1 could not be found. The resident's son came to the facility stating that Resident #1 said three other residents were trying to kill her. Resident #1 was calling her son from her cellphone. Resident #1 was found across the street from the facility at a grocery store. Resident #1's son was able to talk Resident #1 into coming back to the facility. Resident #1 entered the facility crying and upset, still stating that other residents were trying to kill her. Resident #1's son was going to stay in the facility overnight. The RN supervisor, the NHA and resident's representative were notified. 15-minute checks were started on Resident #1. A second 4/14/25 nursing progress note documented by RN #1 revealed that Resident #1 was assessed by the RN on the floor, the resident had no bruises or skin tears and Resident #1 was started on 15-minute checks. Resident #1 was in a stable condition and presently relaxed in her room with her son. The unit manager was notified and a report was given to the night supervisor. III. Staff interviews Regional clinical resource (RCR) #1, RCR #2 and the director of nursing (DON) were interviewed together on 6/17/25 at 1:52 p.m. RCR #1 said another RCR came to the facility on 4/17/25 to check in with other care areas. RCR #1 said the RCR identified the nursing progress note from 4/14/25 and initiated an investigation for Resident #1's allegations. RCR #2 said during the investigation, it was determined by the social services director (SSD) that Resident #1 was fearful of a staff member and not fearful of any residents. LPN #1 was interviewed on 6/17/25 at 2:20 p.m. LPN #1 said she was the nurse taking care of Resident #1 on the evening of 4/14/25. She said Resident #1 was outside in the courtyard with other residents during the evening of 4/14/25. LPN #1 said she saw the residents come back inside and she saw that Resident #1 was with them. She said she told Resident #1 it was time for her medications and LPN #1 went to get the medications. She said when she came back with the medications a few minutes later, Resident #1 was no longer there. She said she started to look around and asked the other residents where she had gone. She said the residents did not know where Resident #1 was and they started to look around. LPN #1 said she looked in rooms and could not find Resident #1. LPN #1 said she told other staff she could not find Resident #1 and one staff member told LPN #1 that Resident #1 sometimes used the bathroom in room [ROOM NUMBER]. LPN #1 said she looked in room [ROOM NUMBER] and could not find Resident #1. LPN #1 said the staff at the facility looked in all the rooms and bathrooms. She said after about 15 minutes of knowing Resident #1 was gone, Resident #1's son called the facility and talked to LPN #1. LPN #1 said the son called from the grocery store across the street and said he was with Resident #1. He said Resident #1 had said she was scared of three other residents at the facility and that they were trying to poison and kill her. He said she was very fearful and did not want to come back to the facility. After a few minutes, LPN #1 said the son convinced Resident #1 to go back to the facility and he brought her back. LPN #1 said she immediately called and reported the incident to the NHA and the unit nurse manager (RN #2). LPN #1 said the NHA and RN #2 had instructed her to do 15-minute checks on Resident #1 and assess her. LPN #1 said Resident #1 was very fearful and upset when she initially came back to the facility but calmed down back to her baseline after about an hour. The SSD was interviewed on 6/17/25 at 2:58 p.m. The SSD said she was employed at the facility during the incident on 4/14/25. She said she was not there the evening of 4/14/25 or the next day, on 4/15/25. She said the process with any abuse allegations was to start an investigation right away. She said she typically helped with interviews. She said in this incident, the NHA had told her he wanted to run it through his bosses to see if it was necessary to do an investigation. She said there should have been no reason for delays in starting the investigation into Resident #1's allegations. The pharmacist was interviewed over the phone on 6/17/25 at 4:20 p.m. The pharmacist said she worked as a pharmacist at the grocery store pharmacy across the street from the facility. She said she had a good friend who she worked with at the facility and she referred community members needing assistance to the facility. The pharmacist said she knew Resident #1 from working with her and the facility. She said Resident #1 had a history of having delusions of people poisoning her food. She said she was not at the pharmacy on the evening of 4/14/25 but she had received a call from another pharmacist who was working and a pharmacy technician. She said the staff at the pharmacy had informed her that Resident #1 was at the pharmacy looking for the pharmacist. She said the technician said Resident #1 was very upset and scared. She said she tried talking to Resident #1 on the phone and could not completely understand what Resident #1 was saying. She said she called the resident's son and he said he was going to pick her up. The pharmacist said no staff from the facility had reached out to her about the incident that occurred. The DON and RCR #1 were interviewed together on 6/17/25 at 4:45 p.m. The DON said when there were abuse allegations involving a resident, the NHA was expected to be notified right away. The DON said the DON, the resident's representative and the physician were all expected to be notified as soon as possible. She said if a staff member called with abuse allegations during hours in which the DON or the NHA were not at the facility, the DON or the NHA would guide the staff on how to initially start the investigation.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, activities room, and two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the nourishment room refrigerators; and, -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen. Findings include: I. Failure to safely and appropriately store food items A. Professional reference The Colorado Retail Food Establishment Regulations, ([DATE]), were retrieved on [DATE]. It revealed in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. 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. (,d+[DATE].17) B. Facility policy and procedure The Food Receiving and Storage policy and procedure, revised [DATE], was provided by the clinical consultant (CC) on [DATE] at 11:56 a.m. It read in pertinent part, Time/temperature control foods are stored at or below 41 degrees F. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented. Refrigerated foods are labeled, dated and monitored so they are used by their' use-by' date, frozen, or discarded. Frozen foods are maintained at a temperature to keep the food frozen solid. All food items to be kept at or below 41 degrees F are placed in the refrigerator located at the nurse's station and labeled with a use by date. All foods belonging to residents are labeled with the resident's name, the item and the use by date. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines. Other opened containers are dated and sealed or covered during storage. C. Observations and record review On [DATE] at 10:35 a.m., the following items were observed in the south hall nourishment refrigerator: -An open bottle of thickened apple juice, with an expiration date of [DATE]; -A container of yogurt, with an expiration date of [DATE]; -A container of milk, with an expiration date of [DATE]; -An unidentified food item rolled in aluminum foil in a plastic bag, dated [DATE]; -An open and partially used butter packet, undated; and, -A medical ice pack. On [DATE] at 9:21 a.m., the following items were observed in the north hall nourishment refrigerator: -An open container of applesauce, unlabeled and undated; and, -A nutritional frozen dessert cup which was thawed and easy to squeeze, undated. Instructions on the dessert cup revealed it was to be stored frozen and used within five days of thawing in the refrigerator. The refrigerator was 56 degrees F. A refrigerator temperature log for February 2025 was posted on the nourishment refrigerator. The refrigerator temperature was recorded as 58 degrees F each day from [DATE] through [DATE]. The temperature log had instructions written at the bottom which read in part, refrigerator temperature range is less than 41 degrees F, freezer temperature is less than 20 degrees F. Adjust setting if temperature is out of range. Verify the thermometer every three days. -There was no documentation on the refrigerator temperature log that indicated the temperature of the refrigerator was addressed when it was noted to be out of acceptable range. On [DATE] at 2:50 p.m., the following items were observed in the south hall nourishment refrigerator: -The same open bottle of thickened apple juice, with an expiration date of [DATE]; -The same container of yogurt, with an expiration date of [DATE]; -The same container of milk, with an expiration date of [DATE]; -The same unidentified food item rolled in aluminum foil in a plastic bag, dated [DATE]; -The same open and partially used butter packet, undated; and, -Several dumplings wrapped together in plastic wrap, unlabeled and undated. On [DATE] at 4:44 p.m., the following items were observed in the activities room refrigerator: -A bottle of dijon mustard, with an expiration date of [DATE]; -A bottle of yellow mustard, with an expiration date of [DATE]; -A jar of olives, with an expiration date of [DATE]; and, -A bottle of chocolate syrup, with an expiration date of [DATE]. -The activities director (AD) threw away the expired contents of the refrigerator during this observation. On [DATE] at 10:30 a.m., the February 2025 refrigerator temperature log on the south nourishment refrigerator only had one temperature recorded on [DATE]. No temperatures were recorded for [DATE] through [DATE]. D. Staff interviews Registered nurse (RN) #1 was interviewed on [DATE] at 9:16 a.m. RN #1 said the dietary staff or the night shift nurses checked the nourishment refrigerator temperatures. RN #1 said she was not sure who checked through the foods in the nourishment refrigerators or when that task was done. Certified nurse aide (CNA) #10 was interviewed on [DATE] at 10:13 a.m. CNA #10 said the dietary staff filled the nourishment refrigerators and the night shift nurses checked the refrigerator temperatures. CNA #10 said the dietary staff checked the nourishment refrigerator contents during the day. The AD was interviewed on [DATE] at 4:44 p.m. The AD said the activities staff and dietary staff shared responsibility for maintaining the contents of the activities refrigerator. The dietary manager (DM) was interviewed on [DATE] at 11:50 a.m. The DM said the north nourishment refrigerator was 53 degrees F. The DM said the unit needed a new refrigerator and she would alert the maintenance staff. The DM said the refrigerator temperature should be checked daily. The DM said the temperature of the refrigerator was above what it needed to be, as it needed to be below 41 degrees F. The DM said cold food needed to be kept below 41 degrees F. The DM said the facility nurses checked the refrigerator daily and should have notified the dietary staff about the temperatures. The DM said she reviewed the south nourishment refrigerator. She said the bottle of milk and thickened apple juice were expired and she threw them away. The DM said the contents and temperature of the refrigerator should be checked daily. The DM verified the refrigerator had only had its temperature monitored once in February 2025. The DM said she would do an inservice with the staff on recording the dates food items were opened. II. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, ([DATE]), were retrieved on [DATE]. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. (,d+[DATE].11) B. Observations During a continuous observation of the lunch meal service on [DATE], beginning at 10:40 a.m. and ending at 12:37 p.m. the following was observed: At 11:50 a.m. DA #1 donned (put on) a pair of gloves and began preparing two hamburgers. DA #1 retrieved a bag of hamburger buns, opened the bag and grabbed two hamburger buns with the same gloved hands. With the same gloved hands, DA #1 selected lettuce leaves and placed them on the hamburger buns. DA #1 repeated this process with onion slices using the same gloved hands. DA #1 opened a bag of potato chips and retrieved a handful of chips to put onto the plates with the hamburger buns with his gloved hands. DA #1 retrieved a new bag of potato chips, opened the bag and used the same gloved hands to grab another handful of chips to put on the plate with the hamburger buns. C. Staff interview The DM was interviewed on [DATE] at 9:51 a.m. The DM said ready-to-eat foods should be handled with clean gloves used only for one task.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high-frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff performed appropriate hand-hygiene; -Ensure enhanced barrier precautions (EBP) were in place for Resident #52 and Resident #284; -Follow infection control procedures for catheter care; -Follow infection control procedures for endotracheal tube care; and, -Clean equipment between use with residents. Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 2/13/25 from https.//pubmed.ncbi.nlm.nih.gov. It read in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 2/13/25 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy and procedure, revised August 2013, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Perform hand hygiene after removing gloves. C. Observations During a continuous observation on 2/5/25, from 9:43 a.m. to 10:11 a.m., housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. HK #1 removed his gloves from a previous room and donned (put on) a new set of gloves without performing hand hygiene. HK #1 entered room [ROOM NUMBER] and began spraying the entire surface of the toilet with Clorox hydrogen peroxide cleaner. HK #1 returned to his cart, removed his gloves and donned a new pair of gloves without performing hand hygiene. HK #1 retrieved a rag from a bin with cleaning solution and began wiping the door handles, light switch, sink area, and sink faucet. HK #1 pulled a chisel from his pants pocket and scraped something on the sink surface before returning it to his pants pocket. HK #1 wiped over the area he chiseled with the rag. HK #1 did not sanitize the chisel. HK #1 returned to his cart, removed his gloves and donned a new set of gloves without performing hand hygiene. HK #1 grabbed a new rag and began to wipe down the bedside table on side B of the room. HK #1 retrieved the chisel from his pants pocket, used it to scrape something on the side table, then returned the chisel to his pants pocket. HK #1 used the rag to wipe over the area he had scraped. HK #1 then used the chisel to scrape something on the floor underneath the bedside table before returning the chisel to his pants pocket. -HK #1 did not disinfect high-touch areas such as the resident's call light or remotes. HK #1 returned to his cart, removed his gloves and donned a new set of gloves without performing hand hygiene. HK #1 took a mop head out of a bin with cleaning solution and put it on the floor in side A. HK #1 then pushed the mop into Side B and began mopping. HK #1 used the chisel from his pocket to scrape the floor in several areas. HK #1 wiped the chisel along the back of the mop head before returning it to his pants pocket. HK #1 used the mop to push crumbs and a pillowcase from side B to side A and into the hallway. HK #1 used the same mop head to mop side A. -HK #1 failed to mop the two sides of the room separately. HK #1 returned to his cart, removed his gloves and donned new ones without performing hand hygiene. HK #1 grabbed two new rags from the cleaning solution bin and began to wipe down the sink area, the paper towel holder, the walls in the bathroom, then the bathroom handrail. HK #1 used a new rag to wipe the base of the toilet and the outside of the toilet bowl. HK #1 returned to the cart, removed his gloves and donned a new pair of gloves without performing hand hygiene. HK #1 grabbed a new rag from the cleaning solution bin, removed the raised toilet seat and set it on the bathroom floor, wiped the toilet flusher, the top of the toilet seat, bottom of the toilet seat and the rim of the toilet. HK #1 then began wiping the bottom side of the raised toilet seat before wiping down the top side of the raised toilet seat with the same rag. -HK #1 did not wipe the handles of the raised toilet seat. HK #1 removed his gloves, retrieved the Clorox hydrogen peroxide spray and sprayed the inside of the toilet bowl. HK #1 donned a new set of gloves, retrieved the toilet brush from the cart, and began scrubbing the inside of the toilet bowl. HK #1 put the toilet brush back onto the housekeeping cart. -HK #1 did not disinfect the toilet brush after use. HK #1 retrieved a new mop head, placed it on the bathroom floor and began mopping the bathroom. HK #1 used the chisel to scrape fecal material off of the bathroom floor. HK #1 wiped the chisel on the top of the mop head several times before wiping the chisel on his pants and placing the chisel back into his pocket. HK #1 then used the mop to sweep pieces of feces from the bathroom through side A of the room and into the hallway. HK #1 said the material he chiseled off the ground was feces. During a continuous observation on 2/6/25, from 9:22 a.m. to 9:44 a.m., HK #2 was observed cleaning room [ROOM NUMBER]. At 9:22 a.m. HK #2 finished cleaning room [ROOM NUMBER], removed her gloves and donned a new set of gloves without performing hand hygiene. HK #2 entered room [ROOM NUMBER] and began cleaning. HK #2 went into the bathroom and collected the trash bag from the trash can, grabbed a paper towel and removed something from the sink, then used the same gloved hand to move one of the resident's walkers by the handle. HK #2 returned to her cart, removed her gloves and donned a new set without performing hand hygiene. HK #2 grabbed a rag from the bin with cleaning solution and began wiping the dresser for side A and the top of the cart used to hold personal protective equipment (PPE). With the same gloved hands, HK #2 grabbed a new rag and wiped the area around the sink. HK #2 then used the same rag to wipe a small area of the outside portion of the door handle. HK #2 retrieved a new rag with the same gloved hands and began wiping the bedside table in side B of the room. The bedside table was mostly covered with the resident's personal items, which HK #2 did not move but instead wiped the available surface area of the table. -HK #2 did not disinfect the high-touch surfaces on side A or side B of the room including call lights, light switches and remotes. HK #2 returned to her cart, removed her gloves and donned new gloves without performing hand hygiene. HK #2 grabbed a toilet brush and a new rag from the bin with cleaning solution. HK #2 hung the toilet brush from the hand rail in the bathroom, squeezed the cleaning solution out of the rag and into the toilet, and used the same rag to clean the sink area in the bathroom. HK #2 used the toilet brush to scrub the bowl of the toilet, then used the same rag to clean the underside of the seat, the rim of the toilet bowl, then the top of the toilet seat and the toilet basin. HK #2 returned the toilet brush back to her cart without disinfecting it. -HK #2 did not disinfect high-touch surfaces in the bathroom including the sink faucet, the hand rail in the bathroom, the soap dispenser or the toilet flusher. HK #2 grabbed a mop pad and put it onto the B side and began to mop that side. HK #2 used the mop to sweep debris including cotton gauze and a rubber band through side A into the hallway. HK #2 then used the same mop pad to mop the A side. HK #2 retrieved a new mop head and put it on the bathroom floor and mopped the bathroom. HK #2 lifted and carried the mop through the room, removed the mop head, put her equipment onto the cart and removed her gloves. HK #2 knocked on the door to room [ROOM NUMBER] and donned a new pair of gloves without performing hand hygiene. HK #2 then began cleaning room [ROOM NUMBER]. D. Staff interviews The environmental services director (ESD) was interviewed on 2/6/25 at 12:08 p.m. The ESD said the housekeeping staff should start at the sink in the room and work from dirtiest surfaces to cleanest surfaces. The ESD said the housekeeping staff should start at the sink, then clean the bathroom, then the B side of the room and the A side last. The ESD said the housekeepers had a specific toilet cleaner they used to clean the bowl of the toilet. The ESD said he did not know the exact steps the housekeepers followed, but said they should wipe the toilet handle, then the seat to prevent transferring bacteria from the seat to the handle. The ESD said the toilet scrub brush should be sanitized between each room. The ESD said the housekeeping staff should use one mop head for side A and one mop head for side B. The ESD said the housekeeping staff should use hand sanitizer after removing dirty gloves and before putting on clean gloves. The ESD said the housekeeping staff should use a disinfectant spray and rag to wipe all high-touch surface areas. The ESD said he knew HK #2 was using a chisel when cleaning the rooms. He said he assumed HK #2 disinfected the chisel between use. The CC was interviewed on 2/6/25 at 6:01 p.m. The CC said the housekeeping staff should perform hand hygiene before entering a resident's room and before each glove change and should change their gloves frequently. The CC said it was not an acceptable practice to move from the bathroom to the room with the same mop head. The CC said high-touch surfaces should be cleaned daily with a disinfectant solution. II. EBP failures A. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 2/13/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions policy, revised March 2024, was provided by the CC on 2/10/25 at 11:56 a.m. It read in pertinent part, EBPs are used as an infection prevention and control intervention to reduce the transmission of MDROs. Gloves and gown are applied prior to performing high-contact resident care activities. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. C. Observations On 2/5/25 at 11:45 a.m. an EBP sign was observed on Resident #284's door. Registered nurse (RN) #2 was providing tube feeding care for Resident #284. RN #2 entered Resident #284's room performed hand hygiene and donned gloves. He raised the head of Resident #284's bed. RN #2 pulled back Resident #284's gown and opened the gastrostomy tube (G tube) cover. He then connected the tube feeding tubing to the open G tube port and started the tube feeding. He then disposed of supplies in the trash, removed his gloves and performed hand hygiene. -RN #2 did not don a gown before touching the patient, tube feeding supplies or the G tube port. On 2/5/25 at 2:21 p.m. certified nurse aide (CNA) #5 was observed as she finished emptying Resident #52's catheter bag. CNA #5 was wearing gloves but was not wearing a gown. There was no sign indicating Resident #52 needed EBP on her door and there was no PPE observed inside or outside of the resident's room (which was indicated in the facility's policy and interviews as the facility's process for identifying residents on EBP - see facility policy above and interviews below). On 2/6/25 at 8:30 a.m. licensed practical nurse (LPN) #1 was providing catheter care for Resident #52. Resident #52's room did not have an EBP sign on the door. LPN #1 filled a basin with warm water, washed her hands, pulled the privacy curtain and put on gloves. LPN #1 did not don a gown. -LPN #1 did not don the appropriate PPE to care for Resident #52's indwelling catheter. D. Staff interviews RN #2 was interviewed on 2/5/25 at 11:50 a.m. RN #2 said before touching a resident with a tube feeding hand hygiene should be performed and gloves should be donned. He said if there was a risk of blood or body fluids being sprayed a mask should be used. He said he was not aware of the EBP outside of the door. He said he was not aware that a gown needed to be used for residents on EBP. CNA #5 was interviewed on 2/5/25 at 2:21 p.m. CNA #5 said the CNAs only wore gloves to empty the resident's catheter bags if the resident did not have anything infectious. She said the CNAs did not wear gowns when providing catheter care. RN #1 was interviewed on 2/6/25 at 9:16 a.m. RN #1 said EBP was used for residents with wounds or urinary catheters. RN #1 said the EBP signs on the resident's doors indicated the nursing staff needed to wear a gown and gloves. RN #1 said EBP were to protect the workers and other residents in case the resident with EBP had an infection. CNA #10 was interviewed on 2/6/25 at 10:13 a.m. CNA #10 said EBP was used for residents with catheters. CNA #10 said EBP meant the staff needed to wear gloves only when they were specifically working with the resident's catheter or indwelling line, but not when providing other high-contact care. CNA #10 said the nursing staff only needed to wear gloves and not a gown when providing catheter care. LPN #1 was interviewed on 2/6/25 at 8:40 a.m. LPN #1 said she normally put on a gown on when providing catheter care. CNA #6 was interviewed on 2/6/25 at 3:10 p.m. CNA #6 said she looked for the EBP signs on resident's doors to see what PPE she needed to put on when working with those residents. The CC was interviewed on 2/6/25 at 6:01 p.m. The CC said EBP were used for any residents with chronic wounds or indwelling devices. The CC said the need for EBP was identified on admission. The CC said the residents that needed EBP had a sign outside their door that indicated they needed EBP and a bin of PPE outside of their room. The CC said anyone that entered the room to provide direct care needed to don a gown and gloves. The CC said EBP should be indicated in the resident's care plan. III. Catheter care failures A. Facility policy and procedure The Urinary Catheter Care policy and procedure, revised August 2022, was received from the CC on 2/10/25 at 11:56 a.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. B. Observations On 2/6/25 at 8:30 a.m. LPN #1 was providing catheter care for Resident #52. LPN #1 filled a basin with warm water, washed her hands, pulled the privacy curtain and put on gloves. LPN #1 did not don a gown. LPN #1 removed Resident #52's incontinence brief. LPN #1 used a warm wet washcloth and wiped down the front of Resident #52's perineum from front to back and then wiped down her catheter with the same cloth. LPN #1 disposed of the washcloth. LPN #1 obtained a new washcloth and wiped the catheter towards the catheter bag then wiped back up the catheter tubing towards Resident #52's perineum. LPN #1 used the same cloth to wipe Resident #52's perineum and disposed of the washcloth. -LPN #1 wiped the catheter tubing from the catheter bag to the perineum -LPN #1 used the same washcloth to wipe Resident #52's perineum before wiping down the catheter tubing. C. Staff interviews LPN #1 was interviewed on 2/6/25 at 8:40 a.m. LPN #1 said she washed her hands and put on gloves before performing catheter care. LPN #1 said she normally put on a gown as well. LPN #1 said when providing catheter care she should wipe from front to back and use a separate washcloth when moving from the perineum to the catheter. LPN #1 said when cleaning the catheter she should start at the perineum and wipe away (down the line toward the catheter bag). The director of nursing (DON) was interviewed on 2/6/25 at 7:47 p.m. The DON said when providing catheter care, the nursing staff should wipe from the urethra down to the catheter bag and work from clean surfaces to dirty surfaces. The DON said the nursing staff needed to don a gown and gloves when providing catheter care. 51163 IV. Tracheostomy failures A. Professional reference Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), chapter 33, page 1437, Performing Tracheostomy or Endotracheal Suctioning. It read in pertinent part [NAME] a nonsterile glove and face shield or goggles. Test the suction equipment by oscillating the connection tubing. Remove and discard gloves. Perform hand hygiene. Open the suction catheter kit. Maintain sterility of the inside of the suction kit. [NAME] gloves, consider your dominant hand clean and your nondominant hand as contaminated. Pour the sterile saline solution into a sterile container. Pick up the suction catheter with your dominant hand and attach it to the connection tubing. Do not touch the connection tubing with your dominant hand. B. Observations and interviews On 2/6/25 at 10:12 a.m. RN #2 was observed providing suctioning for Resident #284's tracheostomy. RN #2 said the procedure could be performed as a clean or sterile procedure and that he tried to be as sterile as possible. RN #2 laid all of the prepackaged sterile equipment on Resident #284's bedside table without cleaning the table or removing the items that were already on the bedside table. RN #2 did not designate a clean area and dirty area. RN #2 proceeded to wash his hands for approximately 12 seconds. He dried his hands and opened a trash bag and put it in the trashcan. He then washed his hands again for approximately 10 seconds and opened the box of gloves and put on a pair of the gloves. He then touched the privacy curtain, touched the bed control, pulled out the pulse oximeter from his pocket, touched the resident's hand, touched the tracheostomy tubing that was still connected to the resident and touched the bedside table. The package of suctioning equipment fell to the floor. He then picked up the package of suctioning equipment from the floor, opened the sterile suctioning equipment, grabbed his pen out of his pocket, raised the head of the bed and removed his gloves. Without performing hand hygiene, he put on his gown, opened and poured the distilled water into the sterile container. He then put on gloves without performing hand hygiene. He treated his left hand as his dirty hand. The tracheostomy tubing and tracheostomy mask fell to the floor. He picked up the tubing from the floor and removed the tracheostomy mask from the end of the tubing with his right hand, which was his sterile hand. He began to suction using both hands. He used his right hand to touch the resident and to check the pulse oximeter. He then grabbed the tracheostomy mask with his right hand, went to the sink and rinsed the tracheostomy mask off using water. He then said that he thought it was clean enough. He used his right hand to dry the mask with a paper towel. He then used his left hand to open and dig through all of Resident #284's bedside table drawers looking for a new tracheostomy mask. He touched the tracheostomy mask with both hands. He attached the tubing to the mask and put the tracheostomy mask onto Resident #284's tracheostomy. RN #2 then took off his gloves and washed his hands. D. Staff interview The CC was interviewed on 2/6/25 at 6:31 p.m. The CC said when the staff were completing tracheostomy suctioning, it was important to establish a clean area. She said the person doing the suctioning should have a clean hand and a dirty hand. She said that hand hygiene should be done before putting on sterile gloves. V. Failure to clean vital signs equipment between residents A. Professional reference According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), retrieved on 2/13/25 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly. It read in pertinent part, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin. B. Observation During a continuous observation on 2/4/25, beginning at 3:59 p.m. and ending at 5:32 p.m., the following was observed: At 3:59 p.m. CNA #7 came out of a resident's room with vital signs equipment (blood pressure cuff, pulse oximeter, thermometer and a vitals clipboard) and went directly into another resident's room. She did not disinfect the equipment between residents. She then left the room and went into another resident's room, she did not clean the equipment. After taking that resident's vital signs she then put the vital signs equipment away without cleaning it and took a resident outside to smoke. At 4:19 p.m she returned from the smoke break. She did perform hand hygiene and did not clean the vital signs equipment. She then entered another resident's room and obtained their vital signs. C. Staff interview The CC was interviewed on 2/6/25 at 6:01 p.m. The CC said the CNAs were responsible for cleaning the equipment between use and on a routine basis. The CC said the vital sign machine should be cleaned with sanitizing wipes in between residents. 47350

Based on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for three (#15, #69 and #64) of six residents reviewed for dignity out of 47 sample residents. Specifically, the facility staff failed to treat Resident #15, Resident #69 and Resident #64 in a dignified manner. Findings include: I. Facility policy and procedure The Quality of Life - Dignity policy and procedure, revised February 2020, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. II. Resident #15 A. Resident status Resident #15, age 69, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included encephalopathy (a condition that affects the brain's function), schizophrenia and major depressive disorder. The 1/6/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) assessment score of nine out of 15. The resident required supervision to partial/moderate assistance for all activities of daily living (ADLs). B. Observations During a continuous observation of housekeeper (HK) #1 on 2/5/25, beginning at 9:28 a.m. and ending at 10:11 a.m., the following was observed: At 9:28 a.m. HK #1 was standing in the open doorway of Resident #15's room preparing to clean the room. Resident #15 was lying in his bed in the room. HK #1 said the room was very stinky. -HK #1's comment was loud enough for it to be heard in the facility hallway. At 9:56 a.m. Resident #15 remained in his bed in his room. HK #1 said hold your nose before opening the door to Resident #15's bathroom. HK #1 said the bathroom was always bad but was especially bad today (2/5/25). HK #1 said the material on the bathroom floor was feces and Resident #15 had a problem with pooping and wiping himself. -HK #1's comment was said in a normal volume that could be heard by anyone in the room or in the hallway outside of Resident #15's room. C. Staff interviews The social services director (SSD) and the social services consultant (SSC) were interviewed together on 2/5/25 at 2:55 p.m. The SSD said HK #1 calling Resident #15's room stinky was a dignity issue. The SSD and the SSC said HK #1's comment would make them both feel awful if it was said about them. The SSD said it was already an uncomfortable situation to need someone to clean up after you. The SSD said the incident with HK #1 was an issue of failing to provide dignity and respect for to Resident #15. The environmental services director (ESD) was interviewed on 2/6/25 at 12:08 p.m. The ESD said housekeepers saying residents' rooms were stinky was not a normal practice. The ESD said the incident with HK #1 calling Resident #15's room stinky was a dignity issue. The nursing home administrator (NHA) and the CC were interviewed together on 2/6/25 at 6:53 p.m. The NHA and the CC both said calling Resident #15's room stinky was a dignity issue. The NHA said hearing a comment like that would not make him feel great and would make him feel undignified. III. Resident #69 A. Resident status Resident #69, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia and depression. The 1/9/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. The resident was dependent on staff for most ADLs. B. Observation On 2/3/25 at 11:45 a.m. registered nurse (RN) #7 was following Resident #69 to a chair at a table in the dining room. Resident #69 walked past the chair RN #7 intended for her to sit in and RN #7 grabbed Resident #69 by the waistband of her pants to prevent Resident #69 from continuing to walk forward. RN #7 assisted Resident #69 into the chair at the dining table using the waistband of the resident's pants to guide her. C. Staff interviews Restorative nurse aide (RNA) #1 was interviewed on 2/5/25 at 1:59 p.m. RNA #1 said if a resident was walking past the chair she was trying to have them sit in, she would ask them to sit down. RNA #1 said she would never grab onto a resident's clothes to stop them. RNA #1 said if she did not have eye contact with the residents, it could be difficult to get them to understand what she wanted them to do. RNA #1 said the nursing staff had to make eye contact, face the resident and walk with them wherever they were supposed to go. Certified nurse aide (CNA) #5 was interviewed on 2/5/25 at 2:21 p.m. CNA #5 said if a resident was walking past a chair she wanted them to sit in, she would make sure she talked to them so the resident knew what she was doing. CNA #5 said she would never grab a resident by their clothes and tell them to sit somewhere. CNA #5 said it was not appropriate to grab a resident by their clothes. CNA #5 said if she grabbed a resident by their clothes, they could get mad. The SSD and the SSC were interviewed together on 2/5/25 at 2:55 p.m. The SSD said when nursing staff were trying to get a resident to sit down, they should be patient and give the resident a reason for why they were redirecting them. The SSD said the nursing staff should talk to the residents and make them feel comfortable. The SSC said she would not want someone to grab onto her clothes. The SSC said the nursing staff were not trained to grab residents' clothes, but to use a gait belt and to guide the residents wherever they needed to go. The NHA was interviewed on 2/6/25 at 6:53 p.m. The NHA said the nursing staff should guide residents verbally and show them the chair if the staff member needed them to sit somewhere. The NHA said it would not be okay for a nurse to grab a resident by the waistband of the pants. The NHA said he would not appreciate it if someone grabbed him by the waistband of his pants to get him to sit down. 51163 IV. Resident #64 A. Resident status Resident #64, age 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included Alzheimer's disease, metabolic encephalopathy and degenerative disease of the nervous system. The 1/17/25 MDS assessment revealed Resident #64 had moderate cognitive impairment with a BIMS score of nine out of 15. The resident was independent with the majority of his ADLs, but he required supervision or touching assistance for showering and personal hygiene. B. Observations On 2/3/25 at 9:55 a.m. Resident #64 was walking towards his room wearing a windbreaker type jacket with stains and food spills down the front of it and a heavier leather jacket with a large tear on the left sleeve. He was wearing two pairs of pants. His outer pants were falling down and were stained on the front and backside. On 2/4/25 at 10:24 a.m. Resident #64 was wearing the same stained pants, shirt and jackets as the day before (see 2/3/25 observation above). On 2/5/25 at 10:29 a.m. Resident #64 was wearing the same clothes as the previous two days, however, the resident's pants were inside-out. On 2/5/25 at 10:45 a.m. Resident #64 was walking down the hall and his pants fell completely to the floor. The resident pulled his pants back up and tried to walk with his four-wheel walker while holding his pants up. On 2/5/25 at 11:09 a.m. the NHA told Resident #64 that he would help him with his pants and belt, after seeing him struggling with his pants falling all the way to the floor and trying to tighten his belt. On 2/5/25 at 11:12 a.m. Resident #64 and the NHA were observed leaving Resident #64's room. The resident's belt appeared to be re-looped, however, his pants were still on inside-out. On 2/5/25 at 11:29 a.m. the director of medical records (DMR) was offered Resident #64 a clean pair of pants. On 2/5/25 at 11:39 a.m. the DMR, who was a CNA, was observed with new clothing for Resident #64. She assisted Resident #64 to the shower room and was heard telling him that they were going to use the shower room because maintenance was in his room fixing something. On 2/5/25 at 11:53 a.m. Resident #64 and the DMR came out of the shower room. Resident #64 was wearing a completely new outfit, including a new sweatshirt that zipped up the front. The DMR bagged up the resident's dirty clothes and put them in the soiled linen container. She then assisted the resident to the dining room for lunch. C. Record review The behavior care plan, revised 7/12/24, revealed Resident #64 perseverated on thinking that people would go into his room and mess with his things with no indication that anyone had been in his room. At times, he had delusions that people were rude to him when they had not been around him. Interventions included, if appropriate, explaining why his behaviors were inappropriate, redirecting him from the situation, removing him from the situation and thoroughly investigating any claims of anyone going into his room. D. Staff interviews CNA #9 was interviewed on 2/6/25 at 2:00 p.m. CNA #9 said staff had to be very careful with Resident #64 because they did not want to violate his rights. He said Resident #64 could be very particular about who went into his room and he was resistant to allowing help. CNA #9 said when he saw the resident wearing soiled clothes, he talked to him and asked him to change his clothes, but he could be very resistant to changing his clothes. CNA #9 said it was a dignity issue when Resident #64 was walking around in dirty clothing and his pants were falling down. He said if it were him, he would feel embarrassed. The DMR was interviewed on 2/6/25 at 2:36 p.m.The DMR said Resident #64 was normally very resistant to care, but she had gone to a dementia training in October 2024 and was able to use those resources from the training to get him to change his clothes. She said she had noticed that his clothes were too small and she was able to get him some clothes that fit better from the facility's donated clothes. The DMR was interviewed again on 2/6/25 at 3:27 p.m.The DMR said she got her dementia training from a different facility where she worked as a CNA. She said she told the NHA and the interdisciplinary team (IDT) about how she was able to get Resident #64 to change his clothes. She said she spoke to social services about getting him some clothes that fit him and a new jacket that was not torn. The NHA was interviewed on 2/6/25 at 7:12 p.m. The NHA said Resident #64's willingness to change his clothes was inconsistent. He said Resident #64 could be very reactive to who was working with him and the staff had to be very careful with him. He said Resident #64 was previously homeless and had a tendency to hoard things so the facility had to find the right person to assist him with certain things. He said that the facility would care plan the DMR's approach to working with Resident #64 and educate the staff that worked with him about the effective approach.

Based on record review, observations, and interviews, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services for three (#80, #1 and #53) of 10 residents reviewed for ADLs out of 47 sample residents. Specifically, the facility failed to: -Provide appropriate repositioning for eating and eating supervision for Resident #80; -Provide timely eating assistance for Resident #1; and, -Provide timely repositioning, bathing and oral care for Resident #53. Findings include: I. Facility policy and procedure The Activities of Daily Living, Supporting policy, revised March 2018, was received from the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -hygiene (bathing, dressing, grooming, and oral care); -mobility (transfer and ambulation, including walking); -elimination (toileting); -dining (meals and snacks); and, -communication (speech, language, and any functional communication systems). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way, at a different time, or having another staff member speak with the resident may be appropriate. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.X. II. Resident #80 A. Resident status Resident #80, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing) and gastrostomy. The 1/16/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent with toileting and transfers, required substantial/maximal assistance with personal hygiene, bed mobility and supervision with eating. B. Observations and resident interview Resident #80 was interviewed in the presence of two family members on 2/3/25 at 10:14 a.m. Resident #80 said she had been given her medications crushed in yogurt. She said when the nurse left, she started choking on the medications and vomited. Resident #80's family members verified the choking/vomiting incident had occurred. During the interview, there was a sign observed above Resident #80's bed for meals and food to be in small bites and no straws in drinks. On 2/4/25 at 9:05 a.m. Resident #80 was lying in bed with her breakfast tray sitting on her overbed table. The head of the resident's bed was not positioned in an upright position and she was not attempting to feed herself. There were no staff members in the room offering or assisting the resident with her meal. During a continuous observation on 2/5/25, beginning at 8:45 a.m. and ending at 10:00 a.m., the following was observed: At 8:45 a.m. Resident #80 was lying in bed and the head of her bed was not positioned in an upright position. The resident's breakfast tray was on her overbed table with the lid removed. Resident #80 was not attempting to feed herself. There were no staff members in the room offering or providing cueing or eating assistance to the resident. At 10:00 a.m. an unidentified staff member entered the resident's room and removed her breakfast meal tray. The unidentified staff member did not offer or provide cueing or eating assistance to Resident #80 prior to removing the meal tray from the resident's room. During a continuous observation on 2/5/25, beginning at 12:45 p.m. and ending at 1:50 p.m., the following was observed: At 12:45 p.m. an unidentified staff member delivered a lunch meal tray to Resident #80 and left the room. Resident #80 was lying on her back and the head of her bed was not positioned in an upright position. The resident's lunch meal tray was not set up for her prior to the unidentified staff member leaving the resident's room. There were no other staff members who entered the resident's room to offer or provide cueing or eating assistance to the resident. At 1:50 p.m. registered nurse (RN) #1 entered Resident #80's room and asked the resident if she was done with her lunch meal tray before exiting the room RN #1 did not offer or provide cueing or eating assistance to the resident prior to leaving the room. At 2:45 p.m. Resident #80 was calling out and RN #1 entered the room a second time to check on the resident. RN #1 proceeded to remove the resident's lunch meal tray from the resident's room without offering or providing cueing or eating assistance to the resident. C. Record review The nutrition care plan, initiated 1/22/25, documented Resident #80 was at risk for nutritional problems related to diabetes mellitus, cerebral edema, hypertension and gastroesophageal reflux disease (GERD). Interventions included monitoring the resident's weights, monitoring/documenting/reporting signs of dysphagia (pocketing, choking, coughing, drooling, holding food in mouth, multiple attempts at swallowing, refusing to eat), providing diet as ordered, monitoring intake, reporting signs of malnutrition and the registered dietitian (RD) was to evaluate. -The care plan failed to reveal Resident #80 required supervision or assistance with eating and had swallowing precautions due to her dysphagia diagnosis. A comprehensive review of Resident #80's meal assistance documentation from 1/9/25 to 2/4/25 revealed inconsistent eating assistance was provided for the resident. The meal assistance documentation revealed the resident was documented as independent with eating 22 times, required set up 25 times, required partial/moderate assistance three times and required substantial/maximal assistance one time. D. Staff interviews RN #1 was interviewed on 2/6/25 at 7:55 a.m. RN #1 said Resident #80 could feed herself and did not require assistance with eating. She said staff needed to watch her while she ate and staff would periodically go into her room and check on her. The DON was interviewed on 2/6/25 at 3:26 p.m. The DON said Resident #80 had been at the facility for less than a month. She said Resident #80 had a traumatic brain injury and a craniotomy while at the hospital. She said Resident #80 had a speech evaluation for swallowing at the facility and had passed. She said the resident required a mechanically soft diet and could take her medications in pudding. She said anyone on a therapeutic diet had a potential for aspiration or choking and should have their head positioned in an upright position during meals. The DON said she did not know the level of assistance Resident #80 required for eating. She said residents that required supervision should have staff supervision during meals. She said therapeutic diets, diet restrictions and precautions should be care planned and communicated to nursing staff. 51163 III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included anoxic brain damage, memory deficit following cerebral infarction, vascular dementia, contracture to right and left elbows and contracture to right and left hands. The 12/30/24 MDS assessment revealed Resident #1 had severe cognitive impairment with a brief interview for mental status (BIM) score of three out of 15. The resident was dependent on staff for all of her ADLs. B. Observations During a continuous observation on 2/3/25, beginning at 12:40 p.m. and ending at 1:09 p.m., the following was observed: At 12:40 p.m. Resident #1's room tray was delivered. The tray was placed on her bedside table and was not within her reach. At 1:09 p.m. (29 minutes after the resident's meal tray was delivered) an unidentified certified nurse aide (CNA) went into Resident #1's room to assist her. The CNA asked the resident if she was hungry and she said, Yes, very hungry! During a continuous observation on 2/4/25, beginning at 8:49 a.m. and ending at 9:03 a.m., the following was observed: At 8:49 a.m. Resident #1 was in her bed with her room tray sitting on her bedside table. The oatmeal was not covered and Resident #1 was making whimpering noises and calling out, por favor, por favor. At 9:03 a.m. (14 minutes after the meal tray was observed sitting on the resident's bedside table) CNA #9 entered Resident #1's room to assist her with her meal. Resident #1 was heard saying, Por favor, I'm hungry. During a continuous observation on 2/4/25, beginning at 5:04 p.m. and ending at 5:31 p.m., the following was observed: At 5:04 p.m. Resident #1's room tray was delivered The tray was not placed within her reach. At 5:31 p.m. (27 minutes after the resident's meal tray was delivered) an unidentified CNA went into Resident #1's room to assist her with her meal. During a continuous observation on 2/5/25, beginning at 12:19 p.m. and ending at 1:31 p.m., the following was observed: At 12:19 p.m. Resident #1's room tray was sitting on her bedside table. The tray was not within her reach. At 1:31 p.m. (one hour and 12 minutes after the resident's meal tray was observed sitting on the bedside table) unidentified CNA went in to assist Resident #1 with her meal. During a continuous observation on 2/6/25, beginning at 12:28 p.m. and ending at 1:09 p.m., the following was observed: At 12:28 p.m. Resident #1's meal tray was delivered. The tray was not placed within her reach. At 1:09 p.m. (37 minutes after the meal tray was delivered) an unidentified nursing student went in to assist Resident #1 with her meal. C. Record review The nutrition care plan, revised on 1/24/25, revealed that Resident #1 had a nutritional problem due to difficulty with self-feeding which was related to physiological causes, dementia and brain damage. Interventions included assisting the resident one-on-one at meals and monitoring for signs and symptoms of dysphagia. The ADL care plan, initiated 8/16/23, revealed that Resident #1 had a self-care deficit related to her dementia and brain damage. The resident needed assistance with eating her meals. D. Staff interviews CNA #9 was interviewed on 2/6/25 at 2:00 p.m. CNA #9 said Resident #1 could only feed herself when it was finger foods. He said when she tried to use utensils to eat her meals, she spilled all over herself. He said he did not see any difference between the resident's food being left on her bedside table or being left in the meal delivery cart until someone can assist her because the resident's food would get cold either way. The nursing home administrator (NHA) was interviewed on 2/6/25 at 7:10 p.m. The NHA said it was inappropriate to have leave Resident #1's room tray sitting out of reach in front of her until someone could assist her with eating. 51915 V. Resident #53 A. Resident status Resident #53, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included central pontine myelinolysis, chronic pulmonary obstructive disease with exacerbations, chronic respiratory failure with hypoxia, dysphagia, aphasia, and quadriplegia. The resident could not communicate, was dependent on supplemental oxygen, and had a tracheostomy and a gastrostomy. The 1/23/25 MDS assessment revealed that a BIMS score assessment was not conducted. The resident had severely impaired cognitive skills for daily decision making and long term and short term memory problems, based on staff assessment. Resident #53 was dependent and required the assistance of two or more staff members for bed mobility, dressing, toileting, personal hygiene and bathing. B. Observations On 2/3/25 at 11:43 a.m. Resident #53 had white residual in her mouth, around her lips and between her teeth. The resident had a body odor and her face was oily. On 2/4/25 at 2:30 p.m. Resident #53 had a strong body odor. On 2/5/25 at 9:15 a.m. Resident #53 had white residual in her mouth and between her teeth. During a continuous observation on 2/5/25, beginning at 1:00 p.m. and ending at 5:00 p.m., the following was observed: At 3:29 p.m. RN#4 entered Resident #53's room and performed aspiration (removal) of secretions from the resident's tracheostomy. While RN #4 was in the room, checked the resident's brief for incontinence and noted the resident was dry. However, RN #4 did not reposition Resident #53 while he was in the room. -The facility failed to reposition Resident #53 during the four hour continuous observation. C. Record review The 1/21/25 ADLs care plan revealed Resident #53 was totally dependent on two staff members to provide baths and showers as necessary. The care plan indicated the resident was to be turned and repositioned frequently to decrease pressure. The care plan further indicated staff was to provide the resident with mouth care as per ADL personal hygiene and apply lip balm/ointment to the resident's lips as needed. A review of Resident #53's electronic medical record (EMR) revealed that the resident received only one bath per week. Resident #53 had her last two baths on 1/31/25 and 1/24/25. D. Staff interviews CNA #8 was interviewed on 2/6/25 at 3:26 p.m. CNA #8 said he checked Resident #53 every two hours for incontinence care, repositioned her every two hours and cleaned her mouth two to three times a day, and as needed. He said all CNAs should do the same. CNA #8 said Resident #53 needed two people for assistance. RN #4 was interviewed on 2/5/25 at 5:20 p.m. RN #4 said the CNAs checked Resident #53 every two hours because she could not move or communicate and staff should assist her with repositioning, toileting, mouth care and grooming. The DON was interviewed on 2/6/25 at 7:21 p.m. The DON said the staff should reposition Resident #53 and wash her face and mouth every few hours. The DON was unaware that Resident #53 had not received a bath in six days.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for four (#26, #31, #15 and #54) of nine residents reviewed for accident hazards out of 47 sample residents. Specifically, the facility failed to: -Ensure person-centered interventions were in place to prevent elopement incidents for Resident #26 and Resident #31; -Ensure staff provided appropriate supervision and implemented care-planned interventions for Resident #15 while smoking; and, -Ensure care-planned interventions for falls were consistently implemented for Resident #54. Findings include: I. Failed to ensure person-centered interventions were in place to prevent elopement incidents for Resident #26 and Resident #31 A. Facility policy and procedure The Elopement & Wandering policy and procedure, dated 2/29/24, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, It is a goal of the facility to provide a safe environment using the least restrictive measures available in caring for residents who are exhibiting elopement behavior. If the resident is identified as an elopement risk, the following will be maintained: implementing and care planning interventions to address safety and decrease the risk of elopement, the care plan will be updated to include that an electronic alarm system is used for the resident's safety. B. Resident #26 1. Resident status Resident #26, age 76, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included vascular dementia, adjustment disorder with mixed anxiety and depression and repeated falls. The 1/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) assessment score of three out of 15. The resident was dependent on staff for dressing, bathing and toileting and required setup to moderate assistance for all other activities of daily living (ADL). The assessment documented the resident did not have a wander/elopement alarm and did not exhibit wandering behavior. 2. Facility incident report The facility incident report, dated 9/14/24 at 5:40 p.m., was received from the nursing home administrator (NHA) on 2/6/25 at 1:31 p.m. The report revealed Resident #26 was last seen at 5:40 p.m. on 9/14/24. Review of camera footage revealed Resident #26 had followed a visitor out of the facility doors. The facility staff searched the building, neighborhood and nearby stores but could not find Resident #26. At 10:00 p.m. that night (9/14/24), Resident #26 was found wandering approximately one and a half miles away from the facility. Paramedics were called and Resident #26 was found to be in good health and returned to the facility. The building's wander alarm system was assessed and found to be in good working condition. Resident #26 still had her wander alarm on when she returned to the facility and the administrators verified it was working correctly. Resident #26 was temporarily placed on increased monitoring. 3. Record review The elopement care plan, initiated 7/31/24 and revised 10/31/24, revealed Resident #26 was an elopement risk due to her diagnosis of dementia. Pertinent interventions, initiated on 7/31/24, included assessing Resident #26 for fall risk and providing the resident with structured activities including toileting, walking inside and outside and reorientation strategies. Additional interventions, initiated on 9/18/24, included checking Resident #26 to ensure her wander alarm was in place and to redirect the resident when she was going toward the facility doors to exit-seek. -Resident #26's care plan was not updated following a second incident where she was found outside the facility on 10/1/24 (see progress note below). A wander/elopement evaluation, dated 7/31/24, revealed Resident #26 was an elopement risk and would be observed by staff closely. A wander/elopement evaluation, dated 10/31/24, revealed Resident #26 was a high elopement risk. Review of Resident #26's February 2025 CPO revealed the following physician's orders: -Apply wander alarm to prevent resident from going out of the facility unassisted. Monitor presence of wander alarm every shift, ordered 7/31/24; and, -Behavior monitoring for antidepressant medication: document number of episodes of target behavior and document in progress notes every eight hours as needed, ordered 7/31/24. A progress note, dated 7/31/24 at 4:00 p.m., revealed a nurse found Resident #26 trying to go out the front doors of the facility by herself. The nurse notified Resident #26's provider and received an order to apply a wander alarm to the resident. A progress note, dated 7/31/24 at 9:20 p.m., revealed Resident #26 attempted to go out of the facility three times but was redirected away from the doors. A provider note, dated 8/9/24 at 1:00 a.m., revealed Resident #26 was seen by the nurses station pacing back and forth wanting to find out if she could go home. A progress note, dated 9/2/24 at 12:52 p.m., revealed Resident #26 had a wander alarm applied to her leg since admission which still functioned well. The nurse reminded Resident #26 that she was not to leave the facility without facility support because of her memory problem and Resident #26 verbalized understanding. Resident #26 was kept on continuous monitoring. A progress note, dated 9/2/24 at 9:11 p.m., revealed at 3:00 p.m. that afternoon (9/2/24) Resident #26 had packed all of her belongings and brought them to the facility entrance to go home. The nurse explained to Resident #26 that the facility was her home but the resident did not listen to her and was agitated for the next hour. The nurse gave Resident #26 emotional support and explained her situation again and again, and the resident calmed down around 5:00 p.m. that evening (9/2/24). Resident #26's wander alarm was in place and the resident was kept on continuous monitoring. A progress note, dated 9/14/24 at 6:35 p.m., revealed the administration was alerted at approximately 5:30 p.m. that Resident #26 was missing from the facility. Staff searched the building and were unable to locate the resident. A nurse said she saw Resident #26 at approximately 5:00 p.m. that evening (9/14/24) and confirmed the resident wore a wander alarm that was working appropriately. Resident #26 had not signed out at the front desk and her emergency contacts had not seen her. The police and the facility's administrators were notified, and the department heads of the facility drove around the community but were unable to locate the resident. A progress note, dated 9/14/24 at 11:15 p.m., revealed Resident #26 was returned to the facility. Resident #26 did not have any complaints of pain or discomfort and her vital signs were within normal limits. A progress note, dated 9/14/24 at 11:31 p.m., revealed Resident #26 was returned to the facility by the NHA. Resident #26 was escorted back to her room by a nurse. A progress note, dated 9/15/24 at 11:56 a.m., revealed Resident #26 was alert and able to make needs known verbally. Resident #26 was reminded not to leave the facility without support. Resident #26 walked the hallways of the facility and in the courtyard several times and was monitored continuously. A progress note, dated 9/29/24 at 10:50 a.m., revealed Resident #26 was seen walking around and checking to see if the doors to the facility were unlocked. Resident #26 was observed trying to get out of the facility with two other residents. Resident #26 was redirected to attend bingo in the dining room. Resident #26 got upset and made a fist at the nurse as she was walking into the dining room. A progress note, dated 10/1/24 at 5:50 p.m., revealed Resident #26 was found outside the facility. Resident #26 was brought back into the facility, and the nurse heard the wander alarm sounding. Resident #26 said she knew she needed to stay inside but when she pushed the door it opened and she went through it. Resident #26 was reminded that she needed to stay inside the building because of her forgetfulness. Resident #26's location was monitored with frequent rounding by the nurse. Behavior monitoring records, from 7/31/24 through 2/6/25, revealed Resident #26's behaviors were monitored and recorded at least once each day since admission. In each instance of behavior documentation, it was documented that the behavior tracking was not applicable or that Resident #26 did not have any behaviors during that time. The behavior tracking monitored several behaviors, including wandering and exit-seeking. -However, progress notes from 7/31/24 through 10/1/24 revealed Resident #26 exhibited exit-seeking and wandering behaviors on several occasions (see above). 4. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 2/6/25 at 2:59 p.m. CNA #5 said the facility used wander alarms for residents who wandered around the building. CNA #5 said the alarm went off if the resident tried to exit the building and the staff had to go check the door if they heard the alarm going off. CNA #5 said Resident #26 was always walking around the facility but never tried to exit the building. -However, according to progress notes, Resident #26 was found outside the facility on 9/14/24 and 10/1/24 (see record review above). Registered nurse (RN) #1 was interviewed on 2/6/25 at 3:19 p.m. RN #1 said Resident #26 walked around the facility a lot but did not try to leave. RN #1 said Resident #26 would get confused and say she wanted to go home but the resident never went outside. -However, according to progress notes, Resident #26 was found outside the facility on 9/14/24 and 10/1/24 (see record review above). Receptionist (RECP) #1 was interviewed on 2/6/25 at 4:29 p.m. RECP #1 verified Resident #26's information was in the facility's elopement binder kept at the front desk. RECP #1 said Resident #26 did not try to get out of the facility. RECP #1 said Resident #26 was able to get a few feet out of the facility one time over the previous summer but was redirected back into the building. RECP #1 said the only times Resident #26 had gotten close enough to the facility doors to set off the wander alarm was when she went out for appointments. -However, according to progress notes, Resident #26 was found outside the facility on 9/14/24 and 10/1/24 (see record review above). The director of nursing (DON) was interviewed on 2/6/25 at 7:34 p.m. The DON said Resident #26 was declining. The DON said Resident #26 had been eloping from the facility previously and had gotten all the way to another area of the city from the facility. The DON said when Resident #26 first came to the facility, her previous apartment was just behind a nearby store, so the resident was familiar with the area. The DON said Resident #26 would stand in the facility lobby and talk about her previous apartment. The DON said Resident #26 would go to the doors every time the facility staff turned around. The DON said Resident #26 was very smart about her elopement attempts and would wait for groups of visitors to go in and out of the building. The DON said one night (9/14/24), Resident #26 walked out of the building with another family who let her out. The DON said the facility immediately went out to look for her and the NHA eventually found her. The DON said Resident #26 stopped wandering after the 9/14/24 incident. The DON said Resident #26 had her wander alarm in place during the incident and she had tried lots of ways to get her wander alarm off. The DON said the interventions used for Resident #26 prior to the 9/14/24 incident included having her room across from the nurse's station and trying to distract Resident #26. The DON said the nursing staff would also walk with Resident #26 around the facility. -However, according to progress notes, Resident #26 was found outside the facility a second time on 10/1/24 (see record review above). C. Resident #31 1. Resident status Resident #31, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included alcohol dependence with alcohol-induced amnesic disorder (short-term memory loss associated with chronic alcohol use), dementia with agitation and a history of falling. The 12/11/24 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 12 out of 15. The resident was independent or required supervision for all ADLs. The MDS assessment documented the resident did not exhibit wandering behaviors. The assessment documented a wander/elopement alarm was used daily. 2. Observations On 2/4/25 at 9:55 a.m. Resident #31 was redirected from the facility exit by an unidentified staff member. The staff member told Resident #31 not to go out the front door and if Resident #31 wanted to smoke, she needed to go to the smoking area doors. At 3:16 p.m. Resident #31 was seen pacing around the facility and going in and out of her room. On 2/5/25 at 8:59 a.m. Resident #31 was pacing through the facility hallways near the dining room. At 4:36 p.m. Resident #31 was pacing the hallways and asking for a cigarette. On 2/6/25 at 8:38 a.m. Resident #31 entered her room and promptly left her room before returning to pacing around the facility. 3. Record review The elopement care plan, initiated 9/15/17, revealed Resident #31 was at risk for elopement related to her intermittent confusion. Resident #31 had poor impulse control and at times would ask to leave the facility to move in with her sister and mother. Pertinent interventions, initiated on 9/15/17, included offering emotional and psychological support as needed, checking the placement and function of Resident #31's wander alarm and orienting the resident to her environment as needed. Additional interventions, initiated on 6/14/18, included having a wander alarm in place. A second elopement care plan, initiated 7/10/23, revealed Resident #31 was an elopement risk. Pertinent interventions included distracting Resident #31 from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. A progress note, dated 11/10/24 at 3:41 p.m., revealed Resident #31 was able to get out of the front door and into the parking lot. Resident #31 was redirected back into the facility and her wander alarm was in place and functional. The DON was notified. A psychiatric medication review note, dated 1/8/25 at 11:30 a.m., revealed Resident #31 displayed ongoing impulsivity and exit-seeking behaviors. Resident #31's dose of sertraline (an anxiety medication) was increased from 50 milligrams (mg) to 100 mg to manage her anxiety. A progress note, dated 1/19/25 at 1:52 p.m., revealed Resident #31 was seen outside of the facility on the street by another resident through her room's window at 11:15 a.m. that morning. Staff redirected Resident #31 back into the facility, assisted her to her room and encouraged her to lay in her bed. The DON and Resident #31's provider were notified. A discharge planning note, dated 1/21/25 at 1:50 p.m., revealed the social services director (SSD) spoke with Resident #31's representative to discuss Resident #31 needing a higher level of care due to her increased confusion and elopement attempts. Resident #31's provider recommended placing her in a secured unit. A referral to another facility was sent out and accepted but no discharge date was scheduled. 4. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/6/25 at 10:22 a.m. LPN #1 said Resident #31 got agitated and started walking around and tried to leave the facility. LPN #1 said Resident #31 tried to leave the facility to get cigarettes. LPN #1 said Resident #31 had a wander alarm but sometimes visitors held the door open for her because they thought she was a visitor. LPN #1 said the facility had to educate visitors to not let people out of the building. LPN #1 said Resident #31 had not made it out of the facility to her knowledge and was easily redirected back to her room or to an activity. -However, according to progress notes, Resident #31 was found outside the facility on 11/10/24 and 1/19/25 (see record review above). RECP #1 was interviewed on 2/6/25 at 4:29 p.m. RECP #1 verified Resident #31's information was in the elopement binder at the front desk. RECP #1 said Resident #31 was always trying to go out of the facility to get cigarettes. The DON was interviewed on 2/6/25 at 7:56 p.m. The DON said Resident #31 always wanted cigarettes. The DON said Resident #31 was exit-seeking but did not go out of the facility. The DON said Resident #31 had a wander alarm in place. The DON said the administration was looking for a different facility for Resident #31 as she would benefit from a smaller, less stimulating environment. -However, according to progress notes, Resident #31 was found outside the facility on 11/10/24 and 1/19/25 (see record review above). 51163 II. Failed to ensure staff provided appropriate supervision and implemented care planned interventions for Resident #15 while smoking A. Facility policy and procedure The Traditional Tobacco and Electronic Smoking Device policy, dated 5/10/23, was provided by the CC on 2/6/25 at 8:08 p.m. It read in pertinent part, All residents who smoke or desire to smoke will be appropriately assessed to determine if the resident requires supervision and protective equipment during smoking. Smoking assessments and potential restrictions shall be completed upon admission, quarterly or at the time of unsafe smoking behavior or suspicion of smoking in an undesignated area or upon change of condition. The interdisciplinary team (IDT) will implement a care plan for all residents who smoke on the baseline care plan. A care plan is required for all smoking residents and any smoking materials. The smoking assessment will also identify those residents who require protective devices such as a non-combustable apron or blanket or any other protective device. Supervised smokers shall not be permitted to smoke without the direct supervision of a designated staff member, family member or volunteer. Direct supervision will be provided throughout the entire smoking period. Supervised smokers will have their smoking supplies secured at the nurse's station. B. Resident #15 1. Resident status Resident #15, age 69, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included encephalopathy, type two diabetes, schizophrenia and major depressive disorder. The 1/6/25 MDS assessment revealed Resident #15 had moderate cognitive impairment with a BIMS score of nine out of 15. The resident required partial to moderate assistance with most of his ADLs. 2. Observations On 2/4/25 at 9:55 a.m. Resident #15 was observed having his cigarette lit by another resident as he was standing beside her and smoking. An unknown staff member approached and watched the lighting of the cigarette and then returned to the inside of the building. Resident #15 was not wearing a smoking apron. On 2/4/25 at 4:12 p.m. CNA #7 was observed taking Resident #15 outside for a cigarette. Resident #15 was observed lighting his own cigarette while CNA #7 watched him. Resident #15 and CNA #7 moved over to the smoking bench and table. CNA #7 handed Resident #15 the ash tray and a long tube (the tubing was for the resident to inhale from the cigarette while the cigarette rested in the ashtray and ensured the resident did not have to hold the cigarette) that were already outside and on the table. Resident #15 did not use either the ash tray or the tubing and held the cigarette as he smoked.CNA #7 did not encourage or assist Resident #15 with placing the tubing on his cigarette. Resident #15's hands and arms were moving involuntarily and he was shaking. A smoking apron was lying on the bench next to Resident #15 but he did not put the apron on and CNA #7 did not ask Resident #15 put on the apron. CNA #7 remained outside with Resident #15 for the duration of the cigarette, however, CNA #7 was looking at her phone the entire time and was not observing the resident to ensure the cigarette did not drop hot ash on the resident. 3. Record review Resident #15's smoking care plan, revised 1/21/25, revealed the resident was a supervised smoker and was required to wear a smoking apron while smoking. Resident #15's 10/1/24 admission smoking assessment indicated the resident was a supervised smoker and was unable to light a cigarette safely independently. He was required to wear a smoking apron while smoking. Resident #15's 1/1/25 smoking assessment indicated the resident was a supervised smoker and was unable to light a cigarette safely independently. He was required to wear a smoking apron while smoking. -However, Resident #15's care plan and the smoking assessments did not indicate that Resident #15 was to use any other type of adaptive equipment while smoking (see observations above). C. Staff interviews The NHA and the CC were interviewed together on 2/6/25 at 7:16 p.m. The NHA said if Resident #15 used the tubing then he did not have to be supervised for the entire smoke break, however, he said staff did need to take him out and light his cigarette. If he used the tubing then he was not physically holding the cigarette because the cigarette stayed in the ashtray and he inhales through the other end of the tube. He said Resident #15 was supposed to use the tubing. The NHA said if Resident #15 did not use the tubing, staff needed to stay outside with him. -However, the use of the tubing was not included on Resident #15's care plan or smoking assessments (see record review above). III. Failed to ensure care-planned interventions for falls were consistently implemented for Resident #54 A. Facility policy and procedure The Fall Management policy and procedure, dated 2/29/24, was provided by the CC on 2/6/25 at 8:08 p.m., It read in pertinent part, A fall reduction program will be established and maintained to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. The fall reduction program is characterized by four components: - Fall risk evaluation; - Care planning and implementation of interventions; - On going evaluation process quality assurance performance improvement (QAPI); and, - Commitment by caregivers to make it work. B. Resident #54 1. Resident status Resident #54, age 64, was admitted on [DATE]. According to the February 2025 CPO diagnoses included fracture of right patella, fracture of T11-T12 vertebra, epilepsy, schizophrenia, muscle weakness and repeated falls. The 12/18/24 MDS assessment indicated that Resident #54 had moderate cognitive impairment with a BIMs score of 12 out of 15. The assessment further indicated that he needed supervision or touching assistance for all of his transfers and ambulating and partial to moderate assistance with toileting and substantial to maximal assistance with dressing and personal hygiene. 2. Observations On 2/5/25 at 9:18 a.m. Resident #54 was sleeping in his bed. The resident was leaning far to the right and nearly off the side of his bed. His walker was seen outside of his room in the hallway. His bed was not in the lowest position. On 2/5/25 at 11:27 a.m. Resident #54 was sleeping in the same position as before and his bed was still not in the lowest position. His walker was seen outside of his room in the hallway. On 2/6/25 at 8:50 a.m. Resident #54 was sitting on the edge of his bed eating his breakfast. The resident's bed was not in the lowest position. On 2/6/25 at 12:14 p.m. Resident #54 was asleep in his bed. The resident's right leg was hanging over the edge of his bed and his bed was not in the lowest position. On 2/6/25 at 1:51 p.m. Resident #54 continued to sit on the edge of his bed eating his lunch. The resident's bed was not in the lowest position. His walker was in his room by his bed. 3. Record review The fall care plan, revised 9/23/24, revealed Resident #54 had a history of falls and was at risk for injuries due to falling. The interventions included making sure the resident was wearing appropriate footwear, anticipating and meeting the resident's needs, encouraging the resident to use the call light, ensuring the resident's room was clutter free and the resident's bed was in the lowest position when the resident was in the bed. The 2/3/25 nursing progress note revealed Resident #54 was found on the floor in his bathroom. The 2/4/25 nursing note indicated that Resident #54's fall precautions were maintained and the resident's bed was in the lowest position and the room was clutter free. The 2/4/25 interdisciplinary team (IDT) note indicated that the root cause of the 2/3/25 was due to a recent fracture. The note indicated interventions that were put in place included re-educating the resident of the importance of using his call light and using his wheelchair brakes when transferring. C. Staff interviews CNA #9 was interviewed on 2/6/25 at 2:00 p.m. CNA #9 said Resident #54's bed was not in the lowest position because he was a tall person and if the bed was in the lowest position, he would not be able to get up to go to the bathroom. He said Resident #54 was not on any fall precautions and he was able to ambulate on his own. -However, Resident #54's 12/18/24 MDS assessment indicated the resident needed supervision or touching assistance for all of his transfers and ambulating and partial to moderate assistance with toileting (see resident status above). RN #4 was interviewed on 2/6/25 at 4:20 p.m. RN #4 said Resident #54 was on fall precautions because he had a recent fall. He said when Resident #54 ambulated, he was supposed to be supervised and he was supposed to call for help before he got up. RN #4 said Resident #54's bed should be in the lowest position.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart; and, -Ensure injectable medications were labeled with the date they were opened. Findings include: A. Professional references The United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24), was retrieved on 2/12/25 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. The Food and Drug Administration (FDA) Insulin Storage and Effectiveness (revised 9/19/17), was retrieved on 2/12/25 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. B. Facility policy and procedure The Storage of Medications policy, revised November 2020, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they were received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. C. Observations On 2/6/25 at 5:07 p.m. the medication cart on the second south hall was observed with registered nurse (RN) #6. The following items were found: -A bottle of vitamin C supplements, with an expiration date of December 2024; -A bottle of vitamin C supplements, with an expiration date of August 2024 ; -A bottle of fish oil supplements, with an expiration date of August 2024; -A bottle of vitamin D3 supplements, with an expiration date of January 2025; -A COVID-19 testing reagent, with an expiration date of December 2023; -A nicotine lozenge, with an expiration date of July 2024; -A bottle of calcium acetate, with an expiration date of October 2024; -A bottle of zinc sulfate, with an expiration date of September 2024; -A bottle of naproxen sodium, with an expiration date of March 2024; -Two bisacodyl suppositories, with an expiration date of May 2024; -A bottle of Prostat, with an expiration date of 10/24/24; and, -Five insulin injection pens for four different residents which were not labeled with the date they were opened; -Nine loose pills in the back of the top drawer; -Multiple loose pills in two other drawers of the medication cart. On 2/6/25 at 5:34 p.m. the medication cart on the north hall was observed with RN #4. The following items were found: -A bottle of thiamine supplements, with an expiration date of September 2024; -A bottle of oyster shell calcium supplements, with an expiration date of August 2024; and, -A bottle of Latanoprost ophthalmic solution, undated. IV. Staff interviews RN #4 was interviewed on 2/6/25 at 5:34 p.m. RN #4 said the night shift nursing staff went through and cleaned the medication carts each week. The director of nursing (DON) was interviewed on 2/6/25 at 8:01 p.m. The DON said the over-the-counter medications on the medication carts should be reviewed every day. The DON said as soon as a resident was discharged , their old medications were discarded. The DON said she and another staff member went through the medication room to try to discard old medications. She said they had been falling behind with doing so because they were the only two staff members doing this task. The DON said she was trying to get the night shift nursing staff to go through the medication carts each night and discard any expired medications or medications from residents that had discharged . The DON said there should not be any loose pills in the medication carts.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to: -Ensure the resident's personal refrigerator temperatures were monitored correctly for appropriate temperatures; and, -Implement the facility policy for food brought by visitors and ensure food that was kept in residents' refrigerators had safe and sanitary storage. Findings include: I. Professional reference The Colorado Retail Food Regulations, ([DATE]) were retrieved on [DATE]. It read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. (,d+[DATE].16) Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. 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. (,d+[DATE].17) The Food and Drug Administration (FDA) food code ([DATE]) were retrieved on [DATE] from https://www.fda.gov/food/fda-food-code/food-code-2022 revealed in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. II. Facility policy and procedure The Refrigerators and Freezers procedure and policy, revised [DATE], was provided by the clinical consultant (CC) on [DATE] at 11:56 a.m. It read in pertinent part, Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily. Supervisors are responsible for ensuring food items in refrigerators are not past use by or expiration dates. III. Observations On [DATE] at 9:05 a.m., Resident #13's refrigerator contained the following items: -A container of rice, unlabeled and undated; and, -A bottle of chocolate syrup, dated [DATE] and the expiration date was obscured by marker. The thermometer in the refrigerator read 42 degrees Fahrenheit (F). The February 2025 temperature log on the refrigerator revealed the temperature had not been recorded on [DATE], [DATE] and [DATE] through [DATE]. The temperature recorded on [DATE] was 42 degrees F. -However, there were no indications that the staff member who recorded the temperature attempted to correct the temperature of the refrigerator. On [DATE] at 1:29 p.m., the temperature log on Resident #66's personal refrigerator had temperatures recorded for [DATE] through [DATE]. On [DATE] the refrigerator was recorded at 42 degrees F, on [DATE] it was 42 degrees F and on [DATE] it was 44 degrees F. The temperature was not recorded on [DATE] or [DATE]. The temperature was 42 degrees F at that time. -However, there were no indications that the staff member who recorded the temperature attempted to correct the temperature of the refrigerator. On [DATE] at 10:08 a.m., the temperature log on Resident #68's personal refrigerator did not have temperatures recorded on [DATE], [DATE] and [DATE] through [DATE]. The temperature of the refrigerator was 42 degrees F at that time. -However, there were no indications that the staff member who recorded the temperature attempted to correct the temperature of the refrigerator. IV. Resident interviews Resident #13 was interviewed on [DATE] at 9:08 a.m. Resident #13 said the facility's maintenance staff checked the temperature of his refrigerator but did not do it every day. Resident #13 said no one came in and checked through his refrigerator to see if things were expired. Resident #68 was interviewed on [DATE] at 10:08 a.m. Resident #68 said the facility's maintenance staff came and checked her refrigerator's temperature but did not do so every day. V. Staff interviews The dietary manager (DM) was interviewed on [DATE] at 9:51 a.m. The DM said refrigerators should be kept at 41 degrees F or below to keep food out of the danger zone for bacterial growth. The DM said any temperature above 41 degrees F was too warm and the refrigerator needed to be serviced. The DM said she checked multiple of the resident's refrigerators throughout the facility and found they had not had their temperature checked for several days according to their February 2025 temperature logs. The DM said the housekeeping staff checked the resident's refrigerators daily. The environmental services director (ESD) was interviewed on [DATE] at 12:08 p.m. The ESD said the housekeeping staff were responsible for checking the temperatures of resident's personal refrigerators daily. The ESD said he was only told to have the housekeeping staff check the temperatures, not the refrigerators' contents. The ESD said it was a grey area which department was responsible for the refrigerators.

Based on record review and interviews, the facility failed to ensure one (#24) of one resident out of 47 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed to provide prompt resolution to grievances for Resident #24. Findings include: I. Facility policy and procedure The Grievances policy and procedure, dated 5/8/23, was provided via email by the nursing home administrator (NHA) on 2/6/25 at 8:08 p.m. It read in pertinent part, The resident, or person acting on behalf of the resident, will be informed of the investigation's findings and any corrective actions recommended, within five working days of filing the grievance or complaint. II. Resident #24 A. Resident status Resident #24, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder and postencephalitic parkinsonism (a Parkinson's disorder that develops after an inflammation to the brain). The 11/30/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He required substantial/maximal assistance with toileting and personal hygiene. B. Resident interview Resident #24 was interviewed on 2/3/25 at 1:37 p.m. Resident #24 said he had been missing four pairs of pants for a while. He said he spoke with the NHA and social services about it and was told the facility was only going to replace two pairs of pants. He said he hand delivered his own clothes to the laundry so he knew the pants were lost somewhere in the laundry. He said the facility had not yet replaced any of his pairs of pants. Resident #24 was interviewed a second time on 2/6/25 at 2:00 p.m. Resident #24 said the facility told him they would replace all four pairs of his pants and he was happy with the resolution. C. Record review The 9/9/24 grievance form filed by Resident #24 documented he was missing two pairs of pants after the pants were sent to the laundry and were not returned. It documented follow up by the facility with the laundry department and indicated they were unable to locate his pants. It documented Resident #24 refused staff help to look for the pants in his room. The grievance form was not signed by Resident #24. The form was signed by the NHA, but there was no date to indicate when the NHA signed it. The 1/29/25 grievance form filed by Resident #24 documented he was missing two pairs of pants. It documented that the social services director (SSD) searched the room and could not find the pants in his closet. It documented that his last inventory sheet had four pairs of pants. The NHA approved purchasing four new pairs of pants for the resident. The form was signed by Resident #24 and the NHA on 2/3/25, during the survey. D. Staff interviews The social services consultant (SSC) was interviewed on 2/6/25 at 1:10 p.m. The SSC said that grievance forms were at the front of the building and could be filled out by residents or staff members and be submitted anonymously. The SSC said social services started the grievance process and then forwarded it to the appropriate department to follow up on the concern. She said grievances were also discussed in the morning meetings and forwarded to the appropriate department for follow up and a resolution to the grievance should be reached with the resident within 72 hours of the date the grievance was filled out. The NHA was interviewed on 2/6/25 at 1:25 p.m. The NHA said he had been at the facility for two years and Resident #24 had a pattern of asking the facility to replace his pants since 2017. He said the resident had multiple inventory lists and it had been unclear which inventory list he had been working off of. He said the grievance process for the missing pants had begun in September 2024. He said the facility had not been successful in finding the missing pants and did not come to a successful resolution with Resident #24. He said the issue came up again recently, and this time they were able to successfully resolve the issue with the resident. The NHA said the facility would be purchasing four new pairs of pants for Resident #24.

Based on observations, record review and interviews, the facility failed to ensure two (#77 and #69) of eight residents reviewed for abuse out of 47 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #77 from verbal abuse by Resident #23; and, -Protect Resident #69 from physical abuse by Resident #235. Findings include: I. Facility policy and procedure The Abuse Policy, dated 5/3/23, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Identification of abuse shall be the responsibility of every employee. If abuse happens: separate the assailant from the victim, isolate the assailant to protect others, assess and treat the victim, and notify the abuse coordinator. II. Incident of verbal abuse of Resident #77 by Resident #23 A. Observations During a continuous observation of the lunch meal service on 2/3/25, from 11:35 a.m. to 1:34 p.m., the following was observed: At 11:35 a.m. Resident #77 and Resident #23 were talking to each other and were in a disagreement. Resident #77 told Resident #23 she should be in hell. Resident #23 said she did not want to sit at the table anymore. Resident #23 was sitting at a table alone and facing the wall and Resident #77 was sitting at another table a few feet away from Resident #23. At 11:45 a.m. Resident #23 told Resident #77 to shut up and that she would kick her explicit word. -Two nursing staff members were in the dining room at the time and were talking about something on the news. They did not address Resident #77 or Resident #23. At 12:02 p.m. Resident #23 held her hand in a fist and directed the gesture at Resident #77, who was able to see the gesture. At 12:06 p.m. Resident #23 again held her hand in a fist and directed the gesture at Resident #77. Resident #23 said she would knock her so she would not get up. Resident #23 then told Resident #77 to go back to where she came from and called her a monkey. Resident #77 said Resident #23 was bad to her and was talking about her country. Resident #77 was upset and said she wanted Resident #23 to be moved somewhere else. Restorative nurse aide (RNA) #1 went over to Resident #77 and Resident #23 and started talking to each resident individually. RNA #1 asked Resident #77 if she wanted to move seats so she would not be next to Resident #23. RNA #1 then returned to assisting residents during the lunch service and Resident #23 and Resident #77 remained in the same spots. At 1:55 p.m. Resident #77 was in the hallway talking with the social services director (SSD). Resident #77 told the SSD that someone was mean to her during lunch. Resident #77 said someone made her cry and was bad. B. Facility incident report The facility incident report, dated 2/4/25 at 4:00 p.m., was provided by the nursing home administrator (NHA) on 2/6/25 at 2:48 p.m. The report revealed the following: On 2/3/25 at 12:15 p.m. Resident #23 and Resident #77 were sitting at different tables in the dining room. Without any noticeable provocation, Resident #23 began to call Resident #77 explicit names. Resident #77 was upset by this and began to argue with Resident #23, asking what she did to her and why she was calling her those names. Neither resident left their table. Staff intervened and calmed both residents down. The alleged victim and assailant were interviewed, along with the six closest residents to the area where the event took place, and six staff members were also interviewed. Video of the incident was reviewed and Resident #77 and Resident #23's care plans were reviewed. Resident #23 was unable to recall the incident. Resident #77 was interviewed on 2/4/25 at 4:30 p.m. by the SSD. Resident #77 said she and Resident #23 were sitting at separate tables in the dining room and waiting for lunch to be served when, without warning, Resident #23 started yelling out curses. Resident #77 said she did not like that and told her to stop and that she had not done anything wrong. Resident #77 said the staff intervened and calmed Resident #23 down. Resident #77 said she was not frightened or fearful at the time or afterward. RNA #1 was interviewed on 2/4/25 at 6:00 p.m. by the NHA. RNA #1 said she heard Resident #23 start saying expletives and nasty things, and Resident #77 did not like it and told her how she felt. RNA #1 said Resident #77 did not say anything back to Resident #23, but just said she did not do anything wrong and asked why she was talking to her that way. RNA #1 said she comforted Resident #23 and calmed her before checking on Resident #77, who said she was okay. Six residents were interviewed, none of which could recall any altercation that had taken place. Video footage of the incident was reviewed by the NHA and revealed at 11:55 a.m. Resident #77 picked up a straw from the straw dispenser on Resident #23's dining table. At 11:57 a.m. Resident #23 started to talk, then stopped. At 12:05 p.m. Resident #23 started to yell something in the general direction of Resident #77 who was sitting approximately six feet away. Resident #77 seemed to respond and gestured with her hands. RNA #1 walked over and spoke with Resident #23, who then calmed down and returned her attention to the dining table. RNA #1 then checked on Resident #77 who had turned back to her table. The facility concluded the allegation of verbal abuse was unsubstantiated. Resident #23 often responded to internal stimuli/confusion by calling out or talking, sometimes with profanity. The facility determined Resident #23 was not addressing Resident #77 when she began cussing in the dining room. Resident #77 also did not feel frightened or threatened at any point. -However, verbal abuse occurred due to Resident #23, who had a history of verbal aggression towards others, calling Resident #77 derogatory names and cursing at her. C. Resident #23 (assailant) 1. Resident status Resident #23, age greater than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with other behavioral disturbance and depression. The 11/12/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Record review The mood care plan, revised 8/23/22, revealed Resident #23 was at risk for a mood problem due to her disease process and her diagnoses of depression and dementia with behavioral disturbance. Pertinent interventions included administering medications as ordered, providing behavioral health consults as needed, assisting the resident with identifying strengths and positive coping skills and providing the resident with a meaningful program of activities. The psychotropic medication care plan, revised 9/25/23, revealed Resident #23 was prescribed antidepressant and antipsychotic medications. Pertinent interventions included monitoring and recording occurrences of target behavior symptoms, including violence/aggression toward staff and others. A progress note, dated 4/29/24 at 2:42 p.m., revealed Resident #23 had a behavioral outburst on 4/27/24. Resident #23 had opened her roommate's closet and flung her clothes on the floor, told her roommate to get out and that it was her house, and blocked her roommate from coming inside. Resident #23's provider was notified and her condition was continuously monitored. A behavior note, dated 4/29/24 at 8:35 p.m., revealed Resident #23 had agitated behavior and refused to take her evening medications. Emotional support was provided to Resident #23 to help her calm down and her practitioner was notified. A behavior note, dated 5/5/24 at 1:54 p.m., revealed Resident #23 showed aggressive behavior and had a verbal outburst toward her roommate and her roommate's representative. A provider note, dated 7/30/24 at 1:00 a.m. revealed Resident #23 was seen by the provider at the request of the nursing staff as they had observed increased aggressive behaviors in the evening. A behavior note, dated 10/2/24 at 9:26 p.m., revealed Resident #23 refused to go to bed. Resident #23 was cursing and screaming at staff and other residents and was kicking and grabbing at the staff. Resident #23 was offered a snack which she refused and threw at the staff. Staff tried to distract Resident #23 but she continued to yell. A provider note, dated 12/11/24 at 12:00 a.m., revealed Resident #23 was seen for a psychiatric follow-up. The provider met with Resident #23 and spoke with her representative to discuss discontinuing her quetiapine (antipsychotic medication) since Resident #23 had not had any new behaviors and was stable. The provider planned to decrease Resident #23's quetiapine to one tablet once a day for two weeks, then one half of a tablet for two weeks, then discontinue the medication. A provider note, dated 1/8/25 at 12:00 a.m., revealed Resident #23 was seen for a psychiatric follow-up. Resident #23's escitalopram (antidepressant medication) dose was decreased from 7.5 milligrams (mg) to 5 mg. Per the provider, Resident #23's representative did not notice any difference in the resident when they decreased her quetiapine dose and she wanted Resident #23 to be removed from any psychotropic medications. A behavior note, dated 2/4/25 at 1:01 p.m., revealed a staff member reported Resident #23 was yelling and cursing at another resident in the dining room around 12:30 p.m. The other resident was sitting next to Resident #23 and Resident #23 was saying do not look at me and started cursing and yelling. Resident #23 was distracted by the staff and became calm. The nurse practitioner was notified. D. Resident #77 (victim) 1. Resident status Resident #77, age 75, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia, anxiety and depression. The 12/2/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of ten out of 15. The resident was independent for all ADLs. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Resident interview and observations Resident #77 was interviewed on 2/4/25 at 3:22 p.m. Resident #77 said some people in the facility were bad and made her feel bad. Resident #77 said a person in the dining room made her feel bad, made her scared and hurt her feelings. Resident #77 said she could not go into the dining room. Resident #77 said the person gave her a hard time and told her to go back to her country. Resident #77 said people in the dining room saw it happen but did not say anything. On 2/4/25 at 4:09 p.m. Resident #77 was looking into the dining room and pacing, going in and out of the dining room. Resident #77 would peer into the dining room and then walk back out. She said someone gave her a hard time. Resident #23 was in the dining room with her representative at the time of the observation. E. Staff interviews The CC was interviewed on 2/5/25 at 10:11 a.m. The CC said the facility was investigating the incident from 2/3/25, reviewing footage and interviewing residents who were in the dining room. The CC said it seemed like Resident #23 was overstimulated and was saying things out loud but not directing them at anyone specifically. The CC said the facility was talking with Resident #23's representative about moving her to a lower-stimulus facility. RNA #1 was interviewed on 2/5/25 at 1:59 p.m. RNA #1 said most of the time, Resident #23 liked to get other residents' attention and fix whatever they were doing that she did not like. RNA #1 said the conflict on 2/3/25 started because Resident #23 told Resident #77 not to look at her. RNA #1 said Resident #23 was directing her words at Resident #77. RNA #1 said Resident #23 was using explicit language and asking Resident #77 why she was looking at her. RNA #1 said Resident #77 was saying she did not know why Resident #23 was saying that to her and why she was abusing her, and said she (Resident #77) did not do anything. RNA #1 said the incident on 2/3/25 was her first time seeing Resident #23 have an issue with another resident. She said Resident #23 had conflicts with staff and refused care. RNA #1 said the staff tried to calm Resident #23 down but the best thing was usually to leave her alone. RNA #1 said Resident #77 could also be trouble at times, but she had not had any conflict with any other residents or her caregivers. RNA #1 said the 2/3/25 incident was a big fight, but usually there were just smaller conflicts between residents. Certified nurse aide (CNA) #5 was interviewed on 2/5/25 at 2:21 p.m. CNA #5 said Resident #23 was fine if she was left alone but she would lash out when provoked. CNA #5 said she knew to redirect Resident #23 if she started talking about her daughter because that was when the resident started to become agitated. CNA #5 said if no one listened to Resident #23, she would put up a fight because Resident #23 knew what she wanted. CNA #5 said if she saw a resident-to-resident altercation she would separate the residents right away and tell the supervisor or administrator with no delay. The SSD and the social services consultant (SSC) were interviewed together on 2/5/25 at 2:55 p.m. The SSD said they were investigating a verbal altercation at the time of the interview that occurred between Resident #23 and Resident #77 on 2/3/25. The SSD said there were two residents in the dining room and, from what they could tell based on video footage and interviews, one resident started saying profanities. The SSD said Resident #23 was very particular about how she liked things. The SSD said Resident #77 took a straw from Resident #23's table and Resident #23 became upset and started cursing. She said Resident #77 was upset because Resident #23 was cursing. The SSD said Resident #23 did not recall the incident. The SSD said Resident #77 denied fear but said the incident was scary, made her sad and hurt her. The SSD said she still needed to complete one more interview, but most of the residents they had interviewed said they did not hear any altercation. The SSD said there was a restorative aide (RNA #1) that stopped the altercation right away who was interviewed but said she did not see what caused the incident. -However, Resident #77 began yelling at Resident #23 at 11:35 a.m. and RNA #1 did not intervene until 12:06 p.m. The SSD said she saw Resident #23 and Resident #77 in the hallway together on 2/3/25 and Resident #77 told the SSD that Resident #23 did not like her. The SSD said she asked Resident #77 if she was fearful of Resident #23 and she said no, but that she just did not know why Resident #23 did not like her. Registered nurse (RN) #1 was interviewed on 2/6/25 at 10:31 a.m. RN #1 said Resident #23 did not like being told what to do. RN #1 said Resident #23 would scream and yell at staff if they tried to tell her to go to bed. RN #1 said Resident #23 had behaviors with refusing care and yelling at staff, but she had not had any incidents with any other residents. RN #1 said Resident #23 was able to be redirected when she was angry. RN #1 said the last time Resident #23 had a behavior was when she screamed at a CNA for pushing her wheelchair. RN #1 said the nursing staff documented behaviors in the progress notes as a behavior note. CNA #6 was interviewed on 2/6/25 at 3:10 p.m. CNA #6 said Resident #23 did not have any issues with any other residents but would yell and cuss at facility staff. CNA #6 said Resident #23 had called her a fat expletive and told her to shut up. The NHA was interviewed on 2/6/25 at 6:53 p.m. The NHA said the facility did not substantiate abuse for the 2/3/25 incident for several reasons. The NHA said Resident #23 had internal stimuli that she responded to by cursing, as well as sundowning, in which she had cursing behaviors with staff. The NHA said Resident #23 usually cursed in an empty hallway and the cursing was not directed at any residents. -However, interviews with RNA #1 and observations revealed Resident #23's cursing was directed at Resident #77 on 2/3/25 (see observations and interviews above). The NHA said Resident #77 was reactive to Resident #23's cursing and asked her why she was saying that. The NHA said there was no willful infliction of verbal aggression, and Resident #23 was not calling anyone names. The NHA said this was supported by the six residents who were interviewed that were sitting near Resident #23 and Resident #77 at the time of the incident and did not recall any altercation. The NHA said Resident #23 was asking Resident #77 what country she came from. III. Incident of physical abuse of Resident #69 by Resident #235 A. Facility incident report The facility incident report, dated 3/4/24, was provided by the NHA on 2/6/25 at 2:48 p.m. The report revealed the following: Resident #69 chose to sit in the seat that Resident #235 typically sat in the dining room. When Resident #235 arrived to the dining room, she struck Resident #69 with an open hand on the head or neck. Staff intervened and separated the two residents immediately. Resident #69 was assessed by an RN and was unhurt and not upset or frightened. The facility notified the police and the ombudsman and initiated an investigation. The alleged assailant (Resident #235) was placed on increased monitoring and temporary one-on-one monitoring during mealtimes. Resident #235 had a history of being aggressive at home and had been observed to be physically and verbally aggressive towards other residents and staff members. The investigation documented Resident #235 had been involved in three other incidents in the 90 days prior to the incident. Resident #69 was interviewed but could not recall the event. Resident #235 was interviewed and said a lady was sitting in her spot and would not move. Resident #235 said she and the lady got into an argument and she moved. The facility did not substantiate the allegation of abuse. The facility determined the alleged assailant (Resident #235) did hit the alleged victim (Resident #69) with an open hand in the neck or head area, it was light and did not cause any bodily damage and did not cause the alleged victim pain or fear. The facility determined the incident did not rise to the level of abuse, per the abuse manual. -However, Resident #235 willfully hit Resident #69, when she was in her seat. B. Resident #235 (assailant) 1. Resident status Resident #235, age 85, was admitted on [DATE] and discharged to another facility on 4/4/24. According to the April 2024 CPO, diagnoses included Alzheimer's disease and a mood disorder with depressive features. The 4/4/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident was independent for most ADLs. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others. 2. Record review The behavior care plan, initiated 2/20/24, revealed Resident #235 had a history of being aggressive at home. Resident #235 had been observed to be physically and verbally aggressive toward other residents and staff members at the facility. Pertinent interventions included calling family members to spend time with Resident #235, finding a place for the resident to calm down, redirecting her away from staff members and residents, reviewing medications as needed and quarterly and engaging the resident in activities that interested her. The mood care plan, initiated 1/1/24, revealed Resident #235 had a mood disorder. Pertinent interventions included administering medications as ordered, arranging for a psychiatric consult and following up as needed and monitoring for any signs or symptoms of depression. A progress note, dated 1/22/24 at 12:20 p.m., revealed Resident #235 fought with another resident for a dining room seat. Resident #235 pushed the other resident. A social services staff member came to the dining room and tried to separate the residents but Resident #235 did not move. A progress note, dated 3/12/24 at 9:29 p.m., revealed Resident #235 was yelling at other residents in the hallway. Nursing staff attempted to separate Resident #235 from the other residents. C. Resident #69 (victim) 1. Resident status Resident #69, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia and depression. The 1/9/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. The resident was dependent on staff for most ADLs. The MDS assessment documented Resident #69 did not have physical and behavioral symptoms directed toward others. D. Staff interviews CNA #5 was interviewed on 2/6/25 at 3:03 p.m. CNA #5 said Resident #69 did not have any issues with any other residents. CNA #5 said other residents would hold onto Resident #69 or follow her, but Resident #69 did not initiate contact with them. The NHA was interviewed on 2/6/25 at 6:48 p.m. The NHA said Resident #69 and Resident #235 got into a scuffle over seating in the dining room in March 2024. The NHA said he did not think Resident #235 was trying to hurt Resident #69, but she did hit her in the face. The NHA said Resident #235 had a history of resisting care. The NHA said there was a situation in the dining room in which two residents were trying to be friends with a third resident, so they were all trying to sit in one specific seat in the dining room. The NHA said the facility got rid of the seat in question and that eliminated the issue.

Based on observations, record review and interviews, the facility failed to ensure two (#184 and #75) of seven residents reviewed for pressure ulcers out of 47 sample residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries. Specifically, the facility failed to: -Provide dressing changes for consecutive days for Resident #184, who was admitted to the facility with an unstageable pressure wound to his coccyx; -Ensure Resident #184's care plan was updated in a timely manner; and, -Provide timely wound prevention interventions and ensure interventions were consistently implemented for Resident #75, who was admitted to the facility with pressure ulcers to his coccyx and both heels. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from https://www.internationalguideline.com/guideline on 2/10/25, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Injury policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 2/10/25 at 11:56 a.m. It read in pertinent part, Conduct a thorough skin assessment. The facility will complete this assessment upon admission and weekly thereafter unless otherwise indicated. It is important that each existing pressure injury be identified, whether present on admission or developed after admission, and that factors that influenced its development, potential for development of additional pressure injuries, or for the deterioration of the pressure injuries be recognized, assessed or addressed. A comprehensive assessment of a pressure injury will be performed by the wound nurse or designee to include the following: differentiate the type of injury (pressure versus non pressure related), determine the stage of the pressure injury, measure the pressure ulcer (length by width by depth), description of exudate, description of wound, description of surrounding skin, presence of tunneling/sinus tract formation, determine if infection is present, monitor the progress toward healing and for potential complication, assess, treat, and monitor pain and monitor the efficacy of dressings and treatments. III. Resident #184 A. Resident status Resident #184, age 70, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included right lower extremity cellulitis with skin transplant on open wound right lower leg, malnutrition and unstageable ulcer of sacral region. According to the 1/29/25 nursing admission assessment, Resident #184 was alert and oriented to person, time, place and situation. He was independent with eating, required assistance with bed mobility, personal hygiene and transfers and was dependent with toileting. B. Resident interview and observation Resident #184 was interviewed on 2/3/25 at 10:06 a.m. Resident #184 said he had a pressure wound on his tail bone and that was why he had an air mattress. During the interview, Resident #184 was observed to be on an air mattress with heel boots in place. C. Wound care observations On 2/6/25 at 10:00 a.m. the wound care physician (WCP) removed a bordered gauze dressing covering Resident #184's sacral wound. The sacral wound bed (the surface area of a wound, encompassing the tissue within the wound itself) appeared dark red in color. There was no slough (dead yellow or white tissue present on the wound bed) or eschar (necrotic or dead tissue covering a wound bed, typically dry, black and firm) noted in the wound bed. According to the WCP, measurements of the coccyx wound were 2.2 centimeters (cm) by 2.1 cm by 0.7 cm, with undermining (when the edges of the wound separate from the surrounding healthy tissue, creating a cavity or pocket beneath the skin) present from the 9:00 position to the 2:00 position and a maximum measurement for undermining of 1.5 cm at the 12:00 position. D. Record review The skin integrity care plan, initiated 2/4/25, indicated Resident #184 had a coccyx pressure injury. Interventions included administering treatments and monitoring effectiveness, assessing and monitoring wound healing weekly, assisting the resident to shift weight and pressure relieving devices in wheelchair, encouraging repositioning throughout shifts and assisting as needed, utilizing pressure relieving devices, enhanced barrier precautions, floating heels, assessing and monitoring by the wound care physician and using a pressure relieving mattress. -However, the comprehensive skin care plan was not initiated until 2/4/25, seven days after Resident #184 was admitted to the facility with a pressure wound to his coccyx (tail bone). The 1/28/25 nursing progress note documented a pressure wound on Resident #184's tail bone. The nurse practitioner was notified and an air mattress was initiated. -Review of Resident #184's January 2025 CPO revealed there was no physician ordered treatment for the resident's coccyx wound. Resident #184's 1/29/25 nursing admission assessment documented the resident had a coccyx wound with an intact dressing. -However, there were no physician's orders for dressing changes of the coccyx wound (see January 2025 CPO above). The 1/31/25 nursing progress note documented a coccyx wound with an intact dressing. -However, there was no physician's order for dressing changes of the coccyx wound (see January 2025 CPO above). -A review of Resident #184's January 2025 treatment administration record (TAR) failed to reveal wound care orders for the treatment of the coccyx wound or documentation to indicate the resident had been provided with wound dressing changes to his coccyx wound. Review of Resident #184's February 2025 CPO revealed the resident had the following physician's order for wound care: Cleanse the coccyx with wound cleanser, pat dry, apply skin prep, calcium alginate and a bordered gauze dressing. Change dressing every other day and as necessary, ordered 2/2/25. -The physician's order for treatment of Resident #184's coccyx pressure wound was not obtained until five days after the resident's admission to the facility. A review of Resident #184's February 2025 TAR revealed the resident's coccyx wound dressing was not documented as being changed on 2/2/25 or 2/3/25, after the physician's order was obtained on 2/2/25 (see physician's order above). The February 2025 TAR documented a dressing change for the resident's coccyx wound on 2/4/25. -Resident #184's dressing was not documented as being changed until seven days after the resident was admitted to the facility. E. Staff interviews The WCP was interviewed on 2/6/25 at 10:20 a.m. The WCP said the facility would notify him what wounds he needed to see for residents. He said he had seen Resident #184 for the first time the week prior for care of his right lower leg wounds. He said early and accurate identification of pressure wounds was important to be able to place interventions timely, which included dressing changes, pressure relieving devices and frequent repositioning to help prevent deterioration. He said the unstageable coccyx wound was now open which was good because now it could heal. Registered nurse (RN) #1 was interviewed on 2/6/25 at 2:45 p.m. RN #1 said a head to toe skin assessment was completed on all residents and was documented on the admission nursing assessment. She said any wounds identified were reported to the director of nursing (DON) so that the resident could be referred to the WCP. Certified nurse aide (CNA) #1 was interviewed on 2/6/25 at 2:55 p.m. CNA #1 said Resident #184 had a wound and should be offered frequent repositioning. He said if he identified a new wound while providing resident care or a resident's wound looked worse or smelled, he would notify the nurse taking care of the resident. The DON was interviewed on 2/6/25 at 4:54 p.m. The DON said when residents were admitted to the facility, she and the minimum data set (MDS) coordinator would review the admission referral and identify which residents had existing pressure wounds upon admission. She said she would take a picture of the residents' wounds and send it to the WCP to get guidance on how to proceed with treatment of the wound. The DON said Resident #184 had been admitted to the facility with a coccyx wound. She said she reviewed the hospital's referral for the resident, during the survey, and the wound note documentation said the resident's wound was an unstageable pressure wound. She said Resident #184 was placed on an air mattress after admission as a preventative measure for his coccyx wound. She said it was important that treatment interventions, such as dressing changes be completed timely to help prevent further deterioration of the wound. She said further education was required for staff to make sure that interventions were care planned and dressing changes were initiated timely. 51710 IV. Resident #75 A. Resident status Resident #75, age 82, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included displaced fracture of the left hip, difficulty swallowing, generalized muscle weakness, history of falling and limitation of activities due to disability. The 1/9/25 MDS assessment revealed the resident had mild cognitive impairment with a BIMS score of 11 out of 15. He required setup assistance with eating and oral/personal hygiene. He required moderate assistance with bed mobility and transfers. He was dependent on staff for toileting hygiene and dressing. He was frequently incontinent of bowel and bladder. It documented Resident #75 was admitted with two Stage 2 pressure injuries. It documented interventions in place: a pressure-reducing device for a chair, pressure-reducing device for his bed, pressure injury care, and application of dressings to Resident #75's feet. -However, Resident #75 was not observed utilizing a pressure-relieving mattress upon observation (see below). The assessment indicated he did not have behaviors. B. Resident interview Resident #75 was interviewed on 2/6/25 at 8:58 a.m. Resident #75 said he had pain in both of his heels and floating his heels on a pillow helped alleviate some of the pain. He said his coccyx hurt as well, however, it was painful for him to lay on his left and right sides. He said he had difficulty repositioning himself onto his sides from his back and said staff did not often reposition him. He said he had not been feeling well the past few days and wanted to stay in bed. C. Observations On 2/3/25 at 11:55 a.m. Resident #75 was lying on his back in bed. He had a wrapped dressing on his left heel and his right heel was open to air. His left heel was floated (offloaded) on a pillow, however, his right heel was not on the pillow and was resting directly on the bed. There was no alternative pressure mattress on his bed. On 2/4/25 at 10:47 a.m. Resident #75 was sleeping in his bed. He was lying on his back and both heels were floated on a pillow. However, the bottoms of both of his feet were touching the footboard. On 2/4/25 at 3:23 p.m. Resident #75 received incontinence care from CNA #2. Resident #75 required maximum assistance from CNA #2 to reposition from his back to his left and right sides. He was visibly incontinent of stool and urine, and there was stool visible on his gown and bed sheets. His coccyx and groin were red with approximately four to eight dark spots towards the edge of the redness. There was no dressing on Resident #75's coccyx and his skin was slightly covered with a previously applied barrier cream. He had a wrapped dressing on his left heel, which was dated 2/4/25. His right heel was red and was open to air with a non-skid sock covering the rest of his foot. After completing incontinence care, Resident #75 was repositioned onto his left side by CNA #2 and his heels were floated on a pillow. A pillow was not placed in between his knees to help offload pressure. On 2/5/25 at 1:22 p.m. Resident #75 was lying on his back in bed asleep. His heels were floated on a pillow, however, the bottoms of his feet were touching the footboard. There was not an alternative pressure mattress on the resident's bed. On 2/5/25 at 4:48 p.m. Resident #75 received incontinence care from CNA #1. Resident #75 required maximum assistance from CNA #1 to reposition from his back onto his left and right sides. There was no dressing on the resident's coccyx, and it was red with approximately four to eight dark spots towards the edge of the redness. Resident #75's coccyx was slightly covered with a previously applied barrier cream. He was incontinent of urine. He had a gauze-wrapped dressing to his left heel, dated 2/4/25. His right heel was red and open to air. On 2/6/25 at 11:40 a.m. Resident #75 was seen for a visit by the facility's WCP. The DON was present to assist during the visit. The DON told the WCP that Resident #75 was being seen as a follow-up for an existing pressure injury on his left heel, however, she did not mention the resident's right heel or coccyx. Upon repositioning Resident #75 to his left side for wound care, the WCP and the DON observed the redness to the resident's coccyx, which was not covered with a dressing, and the resident's right heel. The WCP said Resident #75 had a re-opened deep tissue injury (DTI) over scar tissue on his right heel. The WCP applied wound cleanser to Resident #75's right heel and patted it dry with sterile gauze. The WCP measured and assessed the wound. The WCP instructed the DON to apply betadine to Resident #75's right heel, which she did. The DON then applied skin prep to Resident #75's heel. The WCP applied a dated bordered gauze dressing to Resident #75's right heel. The DON removed the old dressing on Resident #75's left heel. His heel was red with an open dark wound in the center. The WCP said there was alginate (old dressing) stuck on Resident #75's skin. The WCP instructed the DON to soak Resident #75's heel with normal saline and attempt to mechanically debride the wound to get it off. The DON was successful in removing the old dressing after approximately two to three minutes of mechanically debriding the wound using normal saline and sterile gauze. The WCP measured and assessed the wound. He instructed the DON to apply honey gel and a bordered gauze applied to Resident #75's wound. The WCP applied wound cleanser to Resident #75's coccyx and patted it dry with a sterile gauze. He assessed and measured the wound. He instructed the DON to apply honey gel to the wound, which she did. The WCP covered the wound with a dated bordered gauze. D. Record review A review of Resident #75's February 2025 CPO revealed the following physician's orders for pressure injuries/wound management: Float heels when in bed every shift, ordered 1/9/25. Wound care to left heel: cleanse the site with wound cleanser and pat dry. Apply skin prep (skin protectant) and then silver alginate (antibacterial wound dressing). Cover with an abdominal (ABD) pad and kerlix (rolled gauze dressing). Change every other day and as needed, ordered 2/1/25. Apply nystatin and zinc cream on open area on coccyx and cover with mepilex every evening shift for coccyx wound, ordered 1/2/25. -However, observations on 2/4/25, 2/5/25 and 2/6/25 revealed Resident #75 did not have a mepilex dressing covering his coccyx wound (see observations above). Apply skin prep to right heel and leave open to air every shift, ordered 2/3/25. Alternating pressure mattress to bed, set at medium/alternating firmness. Check the mattress every shift for proper setting and function, ordered 2/4/25. -The physician's order for an alternating pressure mattress was not obtained until 2/4/25, one month after Resident #75 was admitted to the facility with pressure wounds on his coccyx and both heels. Review of the activities of daily living (ADL) care plan, initiated 1/2/25 and revised 1/22/25, revealed Resident #75 had an ADL self-care performance deficit related to a left hip fracture. Pertinent interventions included assisting the resident with toileting/mobility/transfers, inspecting the resident's skin for redness, open areas, scratches, cuts, or bruises, and reporting changes to the nurse. Review of the skin care plan, initiated 2/3/25 (during the survey), revealed Resident #75 was receiving treatment for a stage two pressure injury to his right heel, a stage three pressure injury to his left heel and a dehisced (separation of the edges of a previously closed wound) abdominal wound. Pertinent interventions included administering treatments as ordered and monitoring for effectiveness, an alternating pressure mattress to bed set to medium/alternating firmness, encouraging Resident #75 to reposition himself throughout the shift and assisting as needed, floating heels while in bed, using barrier cream after incontinent episodes, as indicated and weekly nursing skin checks. -However, the skin care plan was not initiated until one month after Resident #75 was admitted to the facility (1/2/25) with wounds. -Additionally, the care plan failed to include the wound to Resident #75's coccyx (see observations above). A general record note, dated 1/2/25 at 12:43 p.m., documented Resident #75 was admitted to the facility at 12:25 p.m. The note documented Resident #75 had open wounds to both of his heels and an open area and redness on his coccyx. A weekly nursing documentation assessment, dated 1/21/25 at 9:40 p.m., documented Resident #75 utilized a wheelchair cushion. The note documented he had a rash/redness to his coccyx that was being treated and a right heel wound that was healing well with betadine. The note documented a left heel wound that was noted upon admission and was being treated. It documented Resident #75 had existing bruises and rashes on his skin. A WCP visit note, dated 1/23/25, documented Resident #75 was evaluated for pressure injuries to both the right and left heels, a neuropathic (nerve damage) wound on his left heel and a dehisced abdominal wound. The note documented Resident #75's left heel wound was worsening and should be listed as unavoidable. His right heel was not healed, however, it was improving. The note documented a debridement (tissue removal) procedure on Resident #75's left heel wound was performed. The note additionally documented orders for pressure injury interventions included turning and repositioning the resident frequently while in bed or chair, placing Resident #75 on a low air loss or alternative pressure mattress, floating his heels while in bed and checking incontinence briefs frequently. -However, observations during the survey revealed several occasions when the resident's heels were not floated or were in contact with the bed's footboard, and there was no alternative pressure mattress on the resident's bed (see observations above). -Additionally, the physician's order for an alternative pressure mattress was not obtained until 2/4/25, during the survey (see physician's orders above). A weekly nursing documentation assessment, dated 1/29/25 at 2:06 p.m., documented Resident #75's skin was intact and he had no new skin concerns. The note documented Resident #75 was not using any specialized equipment, such as a specialty bed or wheelchair cushion. -However, the WCP visit note on 1/23/25 documented the presence of several wounds on the resident's skin. A weekly wound note, dated 1/30/25 at 8:26 a.m., documented Resident #75's left heel pressure injury had a date of onset 1/2/25, was a stage three wound and was worsening. The note documented the wound was being treated with silver alginate. A nurse progress note, dated 2/3/25 at 11:33 p.m., documented Resident #75 was noncompliant with care. The note documented the resident would have a bowel movement and sit in it, refusing to allow staff to assist in cleaning him up. The note documented the nurse explained to Resident #75 that his care refusals could lead to skin breakdown, however, Resident #75 stated he did not care. E. Staff interviews The WCP and the DON were interviewed together on 2/6/25 at 12:12 p.m. The WCP and the DON said they were not aware of the wounds on Resident #75's right heel and coccyx. The DON said Resident #75 had a previous wound on his right heel, however, it had improved and was resolved on 1/30/25. She said she was not aware the wound had reopened. The WCP said Resident #75's left heel wound was stage four pressure injury, his right heel wound was a deep tissue injury over scar tissue and the coccyx wound was a stage two pressure injury. The WCP and the DON said Resident #75 was not currently using an alternative pressure mattress and the resident needed one to assist with wound healing. CNA #3 was interviewed on 2/6/25 at 2:40 p.m. CNA #3 said Resident #75 was total care and dependent on staff for assistance with ADLs. She said the resident was incontinent. CNA #3 said dependent residents should be repositioned every two hours. She said skin protectant creams were supposed to be used every time peri-care was completed and any new skin issues should be reported to the nurse. CNA #1 was interviewed on 2/6/25 at 3:07 p.m. CNA #1 said Resident #75 was dependent on staff for incontinence care, showering and repositioning. She said residents should be repositioned every two hours, however, some residents may have different care plans. She said newly identified skin issues should be reported to the nurse. She said she had previously seen wound dressings on Resident #75's coccyx, however, she said he no longer needed them because his wound had improved. CNA #1 said barrier cream was applied after incontinent episodes to prevent skin breakdown. She said the resident's nurse should be notified if a dressing came off or became dislodged. RN #3 was interviewed on 2/6/25 at 3:16 p.m. RN #3 said dependent residents should be repositioned every two hours to prevent skin breakdown. She said Resident #75 was admitted to the facility with a stage two pressure wound on his coccyx, a widespread rash and stage two pressure wounds on both heels. She said there was an order to put zinc cream onto his coccyx for wound prevention, however, she said there was not an order to apply Mepilex to Resident #75's coccyx. After RN #3 reviewed Resident #75's February 2025 CPO for his coccyx wound orders, she said there was an order for Mepilex dressings, however, she said she had not been applying them because they would not adhere to Resident #75's skin due to the topical zinc cream applied to the wound. She said she would coat on a lot of zinc to treat the wound and told the CNAs to use a lot of barrier cream with incontinence care. The DON was interviewed a second time on 2/6/25 at 4:03 p.m. The DON said residents at high risk for skin breakdown and who were dependent on staff for ADL care should be repositioned at least every two hours. She said if a change in condition was noted, it should be reported to the resident's nurse or the DON. She said when Resident #75 was admitted , he had redness on his coccyx, however, she said it resolved with the use of barrier cream. The DON said she was not informed Resident #75 had new redness and an open wound on his coccyx. She said she asked RN #3 about his wound and RN #3 told her Resident #75's coccyx appeared red and shiny on 2/5/25, however, no open wounds were observed. The DON said RN #3 was not following physician's orders by not applying a Mepilex dressing to Resident #75's coccyx wound. She said she would follow up with RN #3. She said Resident #75's bed mattress was being switched to an alternative pressure mattress (on 2/6/25).

Based on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#52) of four residents reviewed for catheters of 47 sample residents. Specifically, the facility failed to: -Obtain physician's orders for the use of Resident #52's catheter; -Create a care plan addressing Resident #52's use of the catheter; and, -Maintain documentation for Resident #52's catheter care and maintenance. Findings include: I. Facility policy and procedure The Urinary Catheter Care policy and procedure, revised August 2022, was received from the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The nursing and interdisciplinary team should assess and document the ongoing need for a catheter that is in place. The following documentation should be recorded in the resident's medical record: the date and time that catheter care was given, the name and title of the individual giving catheter care, and all assessment data obtained when giving catheter care. II. Resident #52 A. Resident status Resident #52, age 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO) diagnoses included demyelinating disease of the central nervous system (a disorder that damages the myelin sheath-the protective covering around nerve fibers in the central nervous system), obstructive and reflux uropathy (a condition that affects the urinary tract, leading to an obstruction or blockage in the flow of urine), neuromuscular dysfunction of the bladder and a personal history of urinary tract infections (UTIs). The 1/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was dependent on staff for most activities of daily living (ADLs). The MDS assessment indicated she had an indwelling urinary catheter. B. Observations and resident interview Resident #52 was interviewed on 2/4/25 at 9:03 a.m. Resident #52 said she had a urinary catheter to keep the urine away from her kidneys. Resident #52 said she had not had any issues with her catheter and had used the catheter for the last two to three months. Resident #52 said she had just recovered from a UTI. Resident #52 said the facility staff did not say how she had gotten the UTI but they gave her antibiotics for it. Resident #52 was lying in bed with the catheter bag clipped to the foot of her bed. On 2/6/25 at 8:30 a.m. licensed practical nurse (LPN) #1 was providing catheter care for Resident #52. LPN #1 filled a basin with warm water, washed her hands, pulled the privacy curtain and put on gloves. LPN #1 did not don (put on) a gown. LPN #1 removed Resident #52's incontinence brief. LPN #1 used a warm wet washcloth and wiped down the front of Resident #52's perineum from front to back and then wiped down her catheter with the same cloth. LPN #1 disposed of the washcloth. LPN #1 obtained a new washcloth and wiped the catheter towards the catheter bag then wiped back up the catheter tubing towards Resident #52's perineum. LPN #1 used the same cloth to wipe Resident #52's perineum and disposed of the washcloth. -LPN #1 did not don the appropriate personal protective equipment (PPE) to care for Resident #52's indwelling catheter Cross-reference F880: failure to follow infection control practices. C. Record review A review of the February 2025 CPO revealed the following order: Indwelling catheter., monitor for placement and function every shift, change the catheter for complications and prior to obtaining a urine sample as needed, provide catheter care and ensure a privacy bag was in place every shift, ensure the catheter was unobstructed, secured, and draining properly every shift. Change the catheter tubing and bag as needed. Replace graduated cylinder or urinal used for draining catheter bag every Friday night, ordered 2/6/25 at 9:26 a.m. (during the survey process). -Review of the comprehensive care plan did not reveal any focus or interventions related to the use of the indwelling urinary catheter. A hospital note, dated 10/13/24 at 2:43 p.m., revealed Resident #52 had a foley (indwelling urinary) catheter which the resident would keep after her discharge back to the facility. A progress note, dated 10/14/24 at 10:57 p.m., revealed Resident #52 returned to the facility from the hospital at 6:45 p.m. that evening. Resident #52 had an indwelling catheter which was draining clear yellow urine. A progress note, dated 10/15/24 at 5:53 a.m., revealed Resident #52 had a foley catheter in place and a urine output of 450 cubic centimeters (cc) of urine. A progress note, dated 10/15/24 at 9:16 p.m., revealed Resident #52 had a foley catheter in place and a urine output of 1000 milliliters (ml). A weekly nursing note, dated 11/6/24 at 12:46 p.m., revealed Resident #52 used a foley catheter. A weekly nursing note, dated 12/23/24 at 9:40 p.m., revealed resident #52 used a foley catheter. Resident #52's urine was clear and yellow, and no odor was noted at that time. A weekly nursing note, dated 1/6/25 at 9:19 p.m., revealed Resident #52 used a foley catheter. Resident #52's urine was free of odor and yellow in color. A provider note, dated 1/17/25 at 1:43 p.m., revealed Resident #52 was seen by her provider after recent bloodwork revealed elevated white blood cell counts. Resident #52 denied having a fever but reported having burning urination, an intermittent cough and congestion. A urinalysis and culture were ordered. A provider note, dated 1/29/25 at 12:00 a.m., revealed Resident #52 was on antibiotics for five days for a UTI. Resident #52 said she was having urinary pain a few days prior which had resolved since starting the antibiotics. Resident #52 had a foley catheter in place which was draining clear yellow urine. A weekly nursing note, dated 1/31/25 at 8:10 p.m., revealed Resident #52 used a foley catheter. Review of the bladder elimination task for Resident #52 from 1/7/25 to 2/5/25 revealed the following: -Continence was not rated due to indwelling catheter was marked 37 times; -Incontinent was marked 17 times; and, -Continent was marked 10 times. D. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 2/5/25 at 2:21 p.m. CNA #5 said the CNAs emptied the catheter bags, gave the nurses the quantity of urine and the nurses charted the information. CNA #5 said the CNAs emptied the catheter bags every shift. Registered nurse (RN) #5 was interviewed on 2/5/25 at 3:39 p.m. RN #5 said catheter care was performed every day. RN #5 said the nurses or the CNAs could provide catheter care. RN #1 was interviewed on 2/5/25 at 4:31 p.m. RN #1 said the CNAs provided catheter care but the nurses could also do so if the CNAs were busy. RN #1 said the nursing staff provided Resident #52 catheter care whenever they changed her incontinence brief. RN #3 was interviewed on 2/5/25 at 4:55 p.m. RN #3 said catheter care was mostly done by the CNAs. RN #3 said the CNAs documented this in their catheter care task sheet. CNA #1 was interviewed on 2/5/25 at 5:07 p.m. CNA #1 said catheter care was documented in the electronic medical record (EMR) in the associated tasks. CNA #1 said catheter care should be performed and documented every shift. The CC was interviewed on 2/5/25 at 5:12 p.m. The CC said catheter care should be in the resident's orders, medication administration record (MAR) and the care plan. LPN #1 was interviewed on 2/6/25 at 8:40 a.m. LPN #1 said she washed her hands and put on gloves before performing catheter care. LPN #1 said she normally put on a gown as well. LPN #1 said when providing catheter care she should wipe from front to back and use a separate washcloth when moving from the perineum to the catheter. LPN #1 said when cleaning the catheter she should start at the perineum and wipe away (down the line toward the catheter bag). The DON was interviewed on 2/6/25 at 7:47 p.m. The DON said when providing catheter care, the nursing staff should wipe from the urethra down to the catheter bag and work from clean surfaces to dirty surfaces. The DON said the nursing staff needed to don a gown and gloves when providing catheter care. The DON said catheter care needed to be done every day and as needed, especially for Resident #52. The DON said the CNAs should empty the catheter bag but not clean it. The DON said the CNAs needed to wear a gown and gloves when emptying the catheter bag. The DON said the physician's order for catheter care was added on 2/6/25 and said it should have been added before then. The DON said there was not a catheter care plan in Resident #52's comprehensive care plan. The DON said the admission nurse missed the order for catheter care and the mistake just carried on. The DON said she had been pairing up with a staff member in the record-keeping department to try to do audits of residents' medical records.

Based on observation and interviews, the facility failed to ensure medications and biologicals were labeled properly on four of four medication carts. Specifically, the facility failed to ensure insulin (medication used for blood glucose control) pens were labeled with the resident's name and open dates. Findings include: I. Professional reference According to the Humalin N kwikpen instructions for use, retrieved on 3/10/24 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf, Do not remove the Insulin Pen Label, unused Pens may be used until the expiration date printed on the label. II. Facility policy and procedure The Medication Labeling and Storage policy, dated February 2023, was provided regional quality mentor (RQM) on 3/6/24 at 2:00 p.m. The policy read in pertinent part, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently acceptable pharmaceutical practices. Medication labeling includes, at a minimum: the medication name, prescribed dose, strength, expiration date, resident's name, route of administration, and precaution. Only the dispensing pharmacy may label or alter the label on a medication container or package. III. Observations South station #1 medication cart was reviewed with licensed practical nurse (LPN) #1 on 3/6/24 at 11:05 a.m. There were a total of eight insulin pens, six of them with no labels: A Levenir insulin pen with no label and the date it was opened. A Basaglar and Victosa insulin pen had the resident's first names written with a marker and no opened date. Abasaglar with no name and no label. All the insulin pens were stored together in the top left drawer of the medication cart. At 11:06 a.m. LPN #1 took the blood sugar for Resident #1. LPN #1 then left the room and went to the medication cart. The medication cart had six flex pens in the blue bin. The LPN was observed to flip through all of the flex pens to find Resident #1. The flex pens were labeled with a black sharpie marker with Resident #1's name. The other flex pens were labeled in the same manner. LPN #1 did locate the pen, however the resident's name was written in black pen. South station #2 medication cart was reviewed with registered nurse (RN) #1 on at 11:21 a.m. There were three Basaglar, a Levenir and a Novolog unlabeled insulin Ppens stored together in a medication cart drawer. The first names of the residents were written with a marker and no last names or the date it was opened were written on the insulin en. A Basaglar and Novolog insulin pen had no label, no marked name and dates it was opened. During medication administration at 11:30 a.m. RN #1 was shuffling through the insulin Pens trying to identify which belonged to which resident. North station #1 medication cart was reviewed with LPN #2 at 11:35 a.m. There were seven Insulin Pens stored together in the top left drawer of the medication cart. Three Basaglar, two Lenenir and two Novolog insulin pens were marked with a black marker with the resident's first names and no dates it was opened. North Station #2 medication cart was reviewed with RN #2 at 11:40 a.m. There were four insulin pens Victosa, Novolog and Basaglar insulin pens had no label, resident's first names were written with a marker and no open date. All four were stored together in the top left drawer of the medication cart. IV. Interviews The corporate nurse consultant was interviewed on 3/6/24 at 12:30 p.m. The corporate nurse said she understood the situation and she was going to work with the pharmacist to put a plan in place to ensure the flex pens were labeled correctly. LPN #1 was interviewed on 3/6/24 at 2:14 p.m. The LPN said insulin pens' open dates were important to know when the medication expired and when it should be discarded. The LPN said it was possible for names written with a marker to fade after cleaning the insulin pen after each use making it difficult to read. The LPN said the insulin pens arrived in a sealed box or bag from the pharmacy. She said sometimes the insulin pens were not individually labeled by the pharmacy when they were delivered. The director of nursing (DON) and the RQM were interviewed on 3/6/24 at 2:30 p.m. The DON said insulin pens should be dated so staff were able to know when they expired and when to discard them. The RQM said markers were not a reliable form of identification since they faded away as the staff continued to clean the insulin pens after each use. The pharmacist was interviewed on 3/6/24 at 2:39 p.m. The pharmacist said she had brought labels for all of the insulin pens. She said the pens (insulin) needed to be properly labeled with the prescription which included, name of resident, dose ordered and any instructions. She said when the medication was delivered in a box of four such as Basaglar. She said the box was then labeled with the proper prescription label. However, each individual pen was not individually labeled. She said that the pharmacist was not allowed to open the box. She said if the order was for only two pens then they could be individually labeled. The pharmacist said additional labels could not be sent to the facility as the nurses were not allowed to label drugs, only pharmacists were allowed to label a drug. She said she printed off the labels for all of the residents with flex pens and she did go through all of the medication carts and labeled all the pens. She said the black pens being used to label the drugs was not appropriate. She said she would come up with a solution to ensure each individual flex pen was labeled correctly. The pharmacist was interviewed again on 3/6/24 at 3:00 p.m. The pharmacist said they were not allowed to open the manufacturer's packaging before sending the insulin to the facility making it difficult to know if the individual insulin pens in the package were unlabeled. She said it was difficult to read the resident's names written with a marker. The pharmacist said the pharmacy could not send labels with the insulin packaging box for the facility to use because all insulin labeling should be performed by a licensed pharmacist. The pharmacist said the pharmacy would ensure all insulin pens were properly labeled individually before delivering them to the facility.

Based on record review, and interviews, the facility failed to perform regular control substance solution tests for four of 15 glucometers. Specifically, the facility failed to perform a control solution test on all glucometers used for monitoring resident's blood glucose. Findings include: I. Facility policy The Blood Glucose Monitoring policy, dated 10/1/2021 was provided by the regional quality mentor (RQM) on 3/7/24 at 10:45 a.m. The policy read in pertinent part, It is the policy of the facility to ensure calibration checks on glucometers must be performed per manufacturer's instructions. II. Manufacturer's recommendation A review of the manufacturer's recommendation for Assure Platinum a professional blood glucose monitoring system provided by the director of nursing (DON) on 3/6/24 at 3:36 p.m. recommended a control solution test be performed: -Before testing with the Assure Platinum System for the first time; -When new bottles of test trips were opened; -Whenever you suspect the meter or test strips may not be functioning properly; -If test results appear to be abnormally high or low or were not consistent with clinical symptoms; and, -Each time the batteries were changed. III. Record review -A 60 day review of the south station #1 glucometer testing log on 3/6/24 at 1:00 p.m. revealed a control solution test was completed and documented for one out of three glucometers. -A 60 day review of the south station #2 glucometer testing log on 3/6/24 at 1:15 p.m. revealed a control solution test was completed and documented for one out of six glucometers. -A 60 day review of the north station #1 glucometer testing log on 3/6/24 at 1:22 p.m. revealed a control solution test was completed and documented for one out of three glucometers. -A 60 day review of the north station #2 glucometer testing log on 3/6/24 at 1:30 p.m. revealed a control solution test was completed and documented for one out of three glucometers. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 3/6/24 at 1:45 p.m. The LPN said control solution tests were performed and documented by the night shift nurse. She said she could not identify which glucometer was tested because there was only one control solution test log for all three glucometers at the unit. The RQM was interviewed on 3/6/24 at 3:35 p.m. The RQM said the control solution test was performed on all glucometers according to the manufacturer's recommendation and the facility's policy regarding the proper maintenance of glucometers. The RQM said the facility had initiated glucose monitoring and maintenance education for all staff. She said the facility would ensure each glucometer had its separate control solution testing log.

Based on observations, record reviews, and interviews, the facility failed to ensure that drugs/biologicals were stored and disposed properly upon expiration. Specifically, the facility failed to dispose of expired Cephalexin (antibiotic medication) and Levemir injection pen (insulin medication device). Findings include: I. Professional reference According to the Food and Drug Administration (FDA), FDA, Keflex (Cephalexin) Oral Suspension, Highlights of Prescribing Information (2018), retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/,d+[DATE]s013lbl.pdf, on [DATE], advised refrigerate Cephalexin after mixing. Medication may be kept for 14 days without significant loss of potency. According to Novo Nordisk, manufacturer recommendations, Taking Levemir (2022), retrieved from https://www.mynovoinsulin.com/insulin-products/levemir/taking-levemir.html, on [DATE], Dispose of the Levemir pen after 42 days, even if there is insulin left in the pen. II. Facility policy The facility medication labeling and storage policy, revised February 2023, was provided by the nursing home administrator (NHA) on [DATE] at 5:30 p.m. It read in pertinent part, The nursing staff is responsible for maintaining storage and preparation areas in a clean, safe and sanitary manner. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Opened or accessed multidose vials are outdated and discarded within 28 days, unless manufacturer specifies shorter or longer duration. -The policy did not provide direction to nursing staff for determining discard dates for single patient use of insulin pens, including Levemir. III. Observations and interviews On [DATE] at 3:45 p.m. medication storage room was observed with registered nurse (RN) #1. The medication storage refrigerator contained two bottles of Cephalexin suspension labeled for Resident #57 with expiration label instruction to discard after [DATE]. Registered Nurse (RN) #1 was interviewed on [DATE] at 3:45 p.m. RN #1 said the Cephalexin suspension for Resident #57 with a written expiration on the bottle to discard [DATE] should be removed from the refrigerator and discarded. The RN took the medication out of the refrigerator to discard. On [DATE] at 11:50 a.m., the south hall medication cart was observed with certified nursing assistant with medication administration authority (CNA) #1. A Levemir insulin injection pen was observed in the cart. The Levemir insulin pen was labeled with an open date that was difficult to read and appeared to be labeled as being opened/first used on [DATE]. -The insulin injection had been opened and had been in use for 50 days well over the manufacturer recommendations for use to administer to a patient (see professional reference above). CNA #1 with medication administration authority was interviewed on [DATE] at 11:50 a.m. CNA #1 was unsure what date on the Levemir insulin pen was, as the writing on the label was difficult to read. CNA #1 said the open date written on the label of the insulin injection pen could have been [DATE] but it was not clearly written and therefore the insulin should be disposed of; because all insulin pens should be disposed of 28 days after opening. IV. Other interviews The director of nursing (DON) was interviewed on [DATE] at 12:55 p.m. The DON said that a refrigerated liquid medication (ie Cephalexin) with a discard by date of [DATE] should have been discarded on the last day of [DATE]. The DON said that the Levemir insulin pen should be discarded 28 days after opening.

Based on observation, interviews and record review the facility failed to store food in a sanitary manner in one of two residents' snack refrigerators. Specifically, the facility failed to ensure proper unit refrigerator temperatures were maintained in the south hall for resident snack refrigerators that contained ready to eat perishable foods intended for resident consumption. Findings include: I. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 9/5/23 from https://cdphe.colorado.gov/environment/food-regulations read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified. The FDA (Food and Drug Administration) food code reviewed 3/27/23 and retrieved 9/5/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) for too long. II. Facility policy The facility policy for food from outside sources was reviewed, revised 7/28/23, was provided by the nursing home administrator (NHA) on 8/23/23 at 10:00 a.m. It read, in pertinent part, To assure foods are safe, to prevent foodborne illness, to assure safety for swallowing and chewing, and to add quality of life for residents, questionable food may be removed until safety is determined. Food includes any edible food stuff, including snacks, candy, beverages, or anything made for human consumption. Cold foods must be stored at 41 degrees or lower. If food is above 41 degrees and temperature is documented for less than one hour, the food may be served. If food is higher than 41 degrees and exceeds one hour, the food is advised to be discarded. III. Observation and record review On 8/24/23 at 5:10 p.m., the resident snack refrigerator for the south hallway was observed. The thermometer inside the shared unit snack refrigerator had a high out of range temperature reading of 46 degrees F. The refrigerator temperature log for August 2023 was taped to the refrigerator, and contained a.m. and p.m. columns for recording refrigerator temperatures; the a.m. columns were completed, and the p.m. columns did not have any entries for any days of August 2023. The recorded temperatures for August, 2023 were as follows: -On 8/1/23, the temperature was 46 degrees F; -On 8/2/23, the temperature was 46 degrees F; -On 8/3/23, the temperature was 46 degrees F; -On 8/4/23, the temperature was 46 degrees F; -On 8/5/23, the temperature was 44 degrees F; -On 8/6/23, the temperature was 46 degrees F; -On 8/7/23, the temperature was 46 degrees F; -On 8/8/23, the temperature was 44 degrees F; -On 8/9/23, the temperature was 46 degrees F; -On 8/10/23, the temperature was 46 degrees F; -On 8/11/23, the temperature was 46 degrees F; -On 8/12/23, the temperature was 44 degrees F; -On 8/13/23, the temperature was 46 degrees F; -On 8/14/23, the temperature was 46 degrees F; -On 8/15/23, the temperature was 46 degrees F; -On 8/16/23, the temperature was 46 degrees F; -On 8/17/23, the temperature was 44 degrees F; -On 8/18/23, the temperature was 44 degrees F; -On 8/19/23, the temperature was 46 degrees F; -On 8/20/23, the temperature was 46 degrees F; -On 8/21/23, the temperature was 46 degrees F; -On 8/22/23, the temperature was 46 degrees F; -On 8/23/23, the temperature was 46 degrees F; -On 8/24/23, the temperature was 46 degrees F -The refrigerator temperature log contained a column for corrective action of temperature greater than 41 degrees F, however, the column had no corrective action entries documented. The refrigerator contained two partial containers of milk, one opened ranch salad dressing, one vanilla nutrition shake, a labeled resident's mango, and a cooked hamburger in a plastic bag. The freezer was stocked with packaged frozen food. There was no thermometer was not present in the freezer, and there was no log for the freezer temperatures being monitored. A review of the snack refrigerator temperature log for the months of July 2023 revealed that daily documentation of temperatures were completed with documented temperatures ranging from 44 to 46 degrees F. The column for corrective action documentation had no entries. Freezer temperatures logs were requested on 8/24/2, The requested freezer temperature logs were not provided by the end of the survey to show that staff were monitoring the freezer temperatures. IV. Interviews Registered Nurse (RN) #1 was interviewed on 8/24/23 at 5:15 p.m. The RN stated that she did not know what the correct refrigerator temperature should be, and stated the night nurse checked the refrigerator temperature. The RN confirmed that the items in the refrigerator were for the residents. The nursing home administrator (NHA) was interviewed on 8/24/23 at 5:45 p.m. The NHA acknowledged the high refrigerator temperatures documented on the refrigerator temperature record logs for July 2023 and August 2023, and said that he would provide education regarding acceptable temperature ranges to the staff who were completing the logs.

Based on observations, interviews and record review, the facility failed to provide a clean, comfortable, homelike environment for residents. Specifically, the facility failed to ensure: -Resident rooms and unit hallways were clean, comfortable, free of urine odors and in good repair throughout the facility; and -Resident bed linens were in clean, stain-free condition. Findings include: I. Facility policy The Homelike Environment policy, revised February 2021, provided by the nursing home administrator (NHA) on 8/28/23, included in pertinent part: Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes to the extent possible the characteristics of the facility that reflect a personalized, homelike setting to include: -clean, sanitary and orderly environment; -clean bed and bath linens that are in good condition; -pleasant, neutral scents. II. Observations and interviews On 8/23/23 starting at 8:45 a.m. the facility environment was observed, revealing the following conditions. -Resident room [ROOM NUMBER] was cluttered with boxes of the resident's personal items stacked in the corners and around the wall. Resident #48 said she was unhappy about all the boxes in her room and that she could not unpack and display her personal belongings. Resident #48 said staff do not help her get this done and no one is willing to help her create space for her personal belongings. -Resident room [ROOM NUMBER] was cluttered with the resident's belongings; items were packed on the furniture and piled in the corner. Resident #5 and Resident #1 said there was not enough space to store personal belongings so the items were left on the floor; and staff does not offer any solutions. -Resident room [ROOM NUMBER] had holes in the ceiling in the resident's bedroom. -Resident room [ROOM NUMBER] had boxes stacked on the resident's bed and around the bed. Resident #8 said she does not have enough room to unpack or store her personal belongings so she keeps them on her bed. -Resident room [ROOM NUMBER] had cluttered items, food stains on the wall, floor and bedside table; and particles that appeared to be dried food debris on the bedroom floor. -Resident room [ROOM NUMBER] had a strong urine odor that drifted out in the hall. There was no shelving or dresser space for the resident's personal items, so the resident's personal items were sitting on the floor around the resident's bed. -Resident rooms #27 and #28 were cluttered and disorganized, resident personal items were sitting on the floor around the resident's bed. -Resident room [ROOM NUMBER] had dirty bed linen with multiple yellow and brown stains. There was a soiled urinal hanging off a trashcan next to the resident's bed. The floor near the resident bed was soiled and stained with blackened debris and was sticky under foot. The bedside was soiled with dried liquid and food crumbs. -Resident room [ROOM NUMBER] had a strong smell of urine throughout the room. The smell was so strong it could be smelled from down the hall. -The floors in resident rooms #115, #116, #117, #124 were heavily stained with black marks, and had food and paper debris across the floors. -The south side of the building had dark stains on the walls around most of the doors. The overall condition of the hallway was unsanitary with food crumbs and staining visible on the floor. On 8/24/23 at 3:40 p.m., in resident room [ROOM NUMBER], Resident #46 and the resident's representative were visiting. The resident's representative was observed cleaning up the room and collecting food plates and covers from the resident's lunch and piling them into the lunch tray. -The resident's representative said the dirty dishes were left over from the lunch meal. It was frustrating that the facility staff frequently failed to collect the resident meal trays timely after the meal was done. The representative said she frequently had to take the dirty dishes back to the kitchen and had to pick up the resident's room during their visits because the staff did not tidy up the resident's room. -The resident representative said every time she came in to visit the resident's wheelchair was full of stuff; the resident's artificial leg was laying on the floor and the call light as if it were tossed there instead of placed neatly in the corner. V. Additional staff interviews The housekeeping supervisor (HSKS) was interviewed on 8/28/23 at 11:30 a.m. The HSKS said he just started his position a couple of days ago. The prior housekeeping team had been short staffed and had not been keeping up with cleaning duties. Members of the corporate office had been in the building recently and completed a walkthrough with the HSKS. They made a list of cleaning tasks and set a deadline for 9/15/23 to complete the list. The HSKS said there were a lot of areas that needed attention and his new team was working to get their cleaning priority list completed. The HSKS said nursing staff would have to assist with organizing and tidying up the residents' belongings as his team was focused on environmental cleaning. The NHA said they had concerns with the long standing housekeeping team, the facility recently hired a new HSKS and gave the team a list of items that needed to be addressed with a strict deadline to complete the cleaning tasks.

Based on record review and interview, the facility failed to ensure immediate notification to the resident's representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for one (#120) resident reviewed out of 33 sample residents. Specifically, the facility failed to make timely notification of Resident #120's change of condition to the resident's legal representative. Findings include: I. Facility policy The facility Change in a Resident's Condition or Status policy revised February 2021 was provided by the nursing home administrator on 8/29/23 at 5:30 p.m. It read in pertinent part: Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medial/mental condition and or status. A 'significant change' of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not 'self -limiting'). II. Resident #120 A. Resident status Resident #120, age 69, was admitted to the facility on [DATE] under hospice care and passed away on 8/28/22. According to the August 2022 computerized physician's orders (CPO), diagnoses included respiratory failure, history of stroke, and anxiety. The 6/1/22 minimum data set assessment (MDS) documented the resident had moderately impaired cognition and was on hospice care. B. Record review The comprehensive care plan, initiated 3/10/22 and last revised 7/12/22 revealed the resident was receiving hospice care; had impaired cognition; was dependent on staff for emotional, intellectual, physical and social needs; and wanted the facility to Inform my family of any significant changes in condition. Other interventions documented throughout the care plan included: Encourage ongoing family involvement. Communicate with me/my family/my caregivers regarding my capabilities and needs. Hospice social work visit (SW) notes dated 8/13/22 at 11:44 a.m. read in pertinent part: Resident experiencing memory deficit failure to recognize familiar persons/places, impaired decision-making, inability to recall events of the past 24 hours, failure to perform usual activities of daily living. Patient is alert and oriented to the person but forgetful and confused. -The note documented that the hospice SW left a voice message for the POA/resident representative to call the hospice social worker with any questions. Nurse's notes dated 8/23/22 at 3:02 a.m. read in part: Resident is receiving pain and anxiety medications as ordered by Hospice. Condition is declining slowly. He is getting more anxious and restless. Body is showing more weight loss. Nursing notes dated 8/24/22 at 10:33 p.m. read in pertinent part: (Resident) started declining and Hospice notified. (Resident) resting comfortably with no SOB (shortness of breath), distress or anxiety noted. Medications given as prescribed. -There were no progress notes to document that the resident's POA/representative was notified by the facility of the resident's change of condition, including increased anxiety, weight loss and decline. Nursing notes dated 8/26/22 at 1:14 a.m. read in pertinent part: Resident appears actively dying. (Resident) is unable to open his eyes and hard to swallow medications, comfort care provided, body repositioned, mouth care provided, safety maintained, will continue to monitor per care plan. -There were no nursing notes documenting that facility staff notified the POA/resident representative of the resident's change of conation. The resident's POA/resident representative was not notified of the resident's change of condition until hospice arrived to assess the resident hours later (see hospice note below). Hospice registered nurse (RN) visit notes dated 8/26/22 at 8:22 a.m. read in pertinent part: Patient's current mental status: deteriorating, not oriented to person place or time. Current status of the patient's appearance: deteriorating. Current status of the patient's pain/comfort: deteriorating. Patient had a major change in condition precipitated by an episode of extreme agitation and is no longer able to communicate. Beginning daily updates to evaluate change in condition. POA/resident representative notified with an update. C. Staff interviews The assistant director of nursing (ADON) was interviewed on 8/29/23 at 3:10 p.m. The ADON said that the nurse on duty was to notify the resident's family/ representative any time a resident experienced a change of condition and document the contact in the resident record. The social services director (SSD) was interviewed on 8/29/23 at 5:30 p.m. The SSD said the resident representative should always be notified as soon as possible when there was a change in a resident's condition unless the resident did not want others to be notified. The NHA and director of nursing (DON) were interviewed on 8/29/23 at 5:45 p.m. The DON said the hospice provider made notification to Resident #120's family when the resident had a change in condition. The DON was unable to find documentation of facility staff making any notification to the resident's POA when the resident first experienced a change of condition and acknowledged that facility nursing staff did not make notification of the resident's change of condition to the resident's POA.

Based on observations, record review and interviews, the facility failed to ensure that one (#2) of one out of eight sample residents received treatment and care in accordance with professional standards of practice and comprehensive person-centered care. The facility failed to ensure: -Resident #2 (a non-english speaking resident), was provided with an adequate tool to communicate his needs on a regular basis; and, -Staff anticipated Resident #2's needs to prevent a decline in overall health and well being as the resident suffered multiple falls (cross-reference F689) and weight loss. Findings include: I. Facility admission agreement Resident #2's signed admission agreement, last revised in January 2020 read in part, English Translation: Point to your language. An interpreter will be called. The interpreter is provided at no cost to you. II. Resident #2's status Resident #2, older than [AGE] years old, was admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The resident was wrongly care planned as Armenian speaking instead of Albanian/Italian. The 8/4/2020 minimum data set (MDS) assessment, coded the resident as moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident did not reject evaluation or care. The resident required two persons physical assistance with transfers. He required extensive assistance of one person with bed mobility, dressing, eating, toilet use and personal hygiene. III. Observations Resident #2 was observed on 8/6/2020 at 10:44 a.m. lying in his bed. The resident had a certified nurse aide (CNA) #4 who was providing one-on-one (1:1) care in the room with him. The resident had a bruise to his right eye which was red and dark purple/black in color and an undressed stitches to the upper corner, just above his right eyebrow. The resident waved and spoke in a language (unknown). His gesture suggested he was greeting. There was nothing suggestive of the resident having a communication deficit. -At 3:35 p.m. observed Resident #2 awake in his wheelchair with his lunch tray on the bedside table in front of him. CNA #4 was sitting in a chair in front of him encouraging him to eat. CNA #4 said it had been his fourth time working with the resident. Resident #2 was speaking an unknown language, and CNA #4 said he had an App (application) on his phone which was supposed to detect what the resident was trying to say. He said the App was in Italian. CNA #4 said there was a Health Care Communication Board under Resident #2's food tray. The Health Care Communication Board had colored various pictures of items including signs of pain, food/fluids, family, clothes, equipment, and activities. CNA #4 said that was the first time he had seen the communication form and believed it was provided by the therapy department; however he did not attempt to use it. He said the App was not detecting what the resident was saying only words, so he was not sure what the resident wanted. He said the resident would point using hand gestures to communicate. He said the resident would shake his head no and put his hand up when he did not want anything to eat or drink, point to his brief if he needed to be changed and point to the bed when he wanted to lie down. The room did not have any other personalized activities in the room. The resident continued to yell out in his language, then CNA #4 pointed to the resident's bed and assisted him back to bed. IV. Record review A review of the resident's care plan, initiated on 7/13/2020 documented Resident #2 had a communication problem related to (r/t) language barrier. The goal portion of the care plan reported Resident #2 will be able to make basic needs known by (translator/son) on a daily basis through the review date. The intervention portion of the plan reported that nursing staff should anticipate and meet needs. It also documented to allow adequate time to respond, repeat as necessary, and do not rush. Request clarification from the resident to ensure understanding; Face when speaking, make eye contact, turn off television/radio to reduce environmental noise; Ask yes/no questions if appropriate; Use simple, brief, consistent words/cues; Use alternative communication tools as needed; Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. -Resident #2 was wrongly care planned as Armenian speaking instead of Albanian/Italian. An additional care plan related to the resident's communication was initiated on 7/18/2020 and revised on 8/10/2020 (during survey). The care plan reported that Resident #2 was unable to communicate all of his needs, due to a language barrier, but he does communicate with head nods and body gesture, so staff anticipate his needs. His primarily language is Albanian with Italian. He wears glasses and hearing is intact. Resident's family calls him frequently and are supportive. Per hospital paperwork, it was noted that he speaks Armenian but care plan has been corrected to Albanian. The progress note documented on 7/18/2020 at 8:29 a.m. read Resident #2 was unable to communicate all of his needs, due to a language barrier, but he does communicate with head nods and body gesture, so staff anticipate his needs. His primary language was Armenaian. He need assistance to/from activities. He wears glasses and hearing is intact. Resident #2's family calls him frequently and are supportive. Resident #2 enjoys spending time with his family. He also enjoy watching sports on TV. His care plan has been created and will continue through the next review. An additional progress note dated 7/30/2020 at 6:52 a.m. read Language barrier, resident is agitated, screaming most of the time. Sometimes make signs that is well understood, poor sleep this shift. Furthermore, a progress note dated 8/11/2020 at 11:12 a.m. read Updated note: Resident #2 was unable to communicate all his needs, so staff use the assistance of a communication board or I-Pad/cell phone to communicate with him, however he does understand some English. He responds to question ask with yes or no answers, or pointing to a communication board, or listening to an interpreter talking in Italian to him. He also does head nods and hand gestures, staff also anticipate his needs. His primarily language is Italian. A review of the neurological records dated 7/10/2020 through 7/13/2020; 7/21/2020 through 7/25/2020 and 8/1/2020 through 8/4/2020 all reported resident had a confused conversation. The nursing daily skilled charting was reviewed. The chart revealed contradictory information was documented under the level of communication portion of the assessment. The assessment asked the question Making Self Understood - Verbal. The response documented on 7/11/2020 reported unable to determine. However, the assessment dated [DATE], 7/13/2020, 7/14/2020, 7/15/2020, 7/16/2020, 7/17/2020, 7/18/2020, 7/19/2020, 7/20/2020, 7/21/2020, 7/23/2020, 8/2/2020, 8/3/2020, 8/4/2020, 8/5/2020, 8/6/2020, 8/8/2020, 8/9/2020, 8/10/2020 and 8/11/2020 reported understood. Conversely, the assessments dated 7/21/2020, 7/24/2020, 7/25/2020 and 7/26/2020 reported Resident #2 was rarely/never understood. Moreover, the assessments dated 7/28/2020, 7/29/2020, 7/30/2020 and 8/1/2020 documented Resident #2 was sometimes understood The social services assistant (SSA) provided a telephone call log between herself and Resident #2's family member. The log listed Resident #2's family member was called on 7/14/2020 at 11:57 a.m., 7/15/2020 at 12:05 p.m., 7/15/2020 at 12:29 p.m., 7/17/2020 at 10:24 a.m., 7/17/2020 at 10:31 a.m., 7/20/2020 at 9:07 a.m., 7/20/2020 at 10:12 a.m., 7/21/2020 at 8:57 a.m., 7/21/2020 at 1:58 p.m., 7/22/2020 at 8:32 a.m., 7/23/2020 at 11:43 a.m., 8/7/2020 at 11:49 a.m. and 8/8/2020 at 10 a.m. The call log reported the aforementioned calls lasted 13, 24, 1, 6, 7, 8, 1, 13, 14, 1, 2, 2, 4 and 1 minute consecutively. The SSA acknowledged that these were the only time interpretation in a language Resident #2 understood occurred. A review of the hospital discharge record dated 6/28/2020 recorded Resident #2's weight as 57 kilograms (KG) which is equivalent to 125.66 Lbs. There was nothing in the hospital record that documented Resident #2 had [MEDICAL CONDITION] in his bilateral lower extremity (BLE). A review of Resident #2's vitals revealed his weight was documented as 118.4 pounds (Lbs) using a chair scale on 7/10/2020 (admission weight). It further revealed Resident #2 weighed 108.9 Lbs using mechanical lift on 7/17/2020. In addition, a weight of 105.6 Lbs was recorded for the resident on 7/30/2020 and 8/6/2020 (means of measurement was omitted in the record) A review of Resident #2's nutrition care plan initiated 7/14/2020 (four days after admission) documented Resident #2 had a potential and /or was at risk for inability to maintain his Nutrition due to (d/t) cardiovascular accident ([MEDICAL CONDITION]), humerus fracture (fx), dementia, [MEDICAL CONDITION] (HLD), [MEDICAL CONDITION] (AFIB), limited mobility, advanced age and hypertension (HTN). The goal portion of the nutrition care plan documented Resident #2 would maintain his nutritional status through the review date. He will experience weight loss/fluctuations related to resolving [MEDICAL CONDITION]. The intervention portion of the nutrition care plan documented to observe/document/report as needed (PRN) any sign/symptom (s/sx) of dysphagia, pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Furthermore, it documented to observe/record/report to medical director (MD) PRN s/sx of malnutrition emaciation, cachexia, muscle wasting, significant weight loss. In addition, it documented to provide and serve diet as ordered, to monitor intake and record per (q) meal. To monitor and record weight per facility guidelines, to provide and serve supplements as ordered, to provide food in a form that is acceptable and culturally acceptable (Resident #2 likes Italian food). Registered dietitian (RD) to evaluate and make nutritional recommendations as needed. Finally, it documented Resident #2 required 1:1 feeding, he was dependent on eating. A review of the nutrition progress note dated 8/6/2020 at 5:09 p.m. documented Average per oral (PO) and oral nutritional supplement (ONS) intake is extremely sporadic 25-100%; resident had been refusing his house supplement at breakfast and lunch but completing 75-100% at dinner. Resident #2 did have recent significant weight (wt) loss -13 (-11%) over last month since admission that was anticipated related to (r/t) resolving [MEDICAL CONDITION] & nursing noting resident was weighted using a different method after leaving admission COVID isolation room and admission weight may be inaccurate. The resident had an initial weight loss of 9.5 lbs which is 8.0% in one week and from 7/10/2020 to 7/17/2020 and an additional 3.3 lbs weight loss from 7/17/2020 to 7/30/2020. There was no weight obtained 7/24/2020. A re-weight was not completed each time the resident lost weight to determine whether the resident had true weight loss or it was an inaccuracy in the scale. Overall, the resident lost 12.8 lbs since his admission to the facility which was an 11% weight loss. The resident was on a supplement, however additional nutritional interventions were not implemented and evaluated when the resident continued to have weight loss each week. Skin assessments: A review of the hospital referral document from 6/28/2020 did not reveal an order for [REDACTED]. Nursing daily skilled charting dated 7/11/2020 at 12:35 pm reported the resident's skin was intact and there were no changes to the resident's skin integrity An head to toe skin assessment dated [DATE] (a day after resident's admission) reported the resident had no skin issue. The same assessment dated [DATE] and 7/25/2020 reported the resident's skin was intact. V. Family interview The resident family member was interviewed on 8/6/2020 at 2:03 p.m. when the family member visited the facility. The family member described the resident as a strong and agile individual for his age. He said the resident could do most of his activities of daily living (ADLs) with no/to limited assistance. He said the resident was able to independently walk on the stairway in the house, he needed help setting up meals but could feed himself. The family member added that the resident got in and out of the bathroom independently/required assistance sometimes. The family member said the resident urinated on the bathroom floor at home and slipped. He said the resident recovered well from the injury before he was discharged to the facility. He said on admission, he (family member) made the facility aware of the resident's needs. He said he emphasized the resident needed an interpreter, and that the facility acknowledged and guaranteed to make provision to accommodate the resident. He said the facility called him on multiple occasions to report that the resident had a fall. The family member said he interviewed the resident and was made aware that when the resident used his call light system to call for help, nursing staff responded to the call light but for the language barrier and lack of understanding of the resident's expressed needs, they would turn off the call light and walked out of the resident's room. The family member said, the resident reported that he fell because he attempted to care for himself. (Cross-reference F689) He said the staff member whom the facility relied on for interpretation did not speak the same language as the resident. He said Resident #2's health deteriorated because of lack of access to an interpreter. He emphasized the resident's lack of ability to communicate his needs had frustrated the resident and had led to him to feeling abandoned and in a state of mental breakdown. He said the resident now required hospice service that could have been prevented if the facility had adequately accommodated the residents needs. The family member said he was worried the resident had lost weight because the facility could not understand the resident when he communicated his meal preference and had not eaten well enough since his admission. The family member said he communicated the resident's meal preference to the facility as Italian meal. He said the meal preference was not accommodated as he had spoken to the resident and had also observed the resident got the same meal as the other population of residents at the facility. He emphasized that instead of accommodating the resident's meal preference, the facility placed the resident on oral nutritional supplement which the resident often declined. The family member identified CNA #2 as the individual whom the facility relied upon to interpret the resident conversation. He (family member) spoke briefly in Italian/Albanian to CNA #4 when the CNA exited the facility to access his car, and the CNA said he did not understand a complex statement spoken in the aforementioned languages. After the brief conversation, Resident #2's family member stated he faulted the facility's reliance on CNA #2 as a translator. He said CNA #2 could not even interpret How are you doing? which was what he asked in Albanian. VI. Resident interview Resident #2 was interviewed on 8/10/2020 at 1:47 p.m., with a translation service via telephone. The phone interview was conducted with facility staff (CNA #8) present and the entire conversation was done while the phone was on speaker phone. The interpreter spoke in Armenian language (the initial care planned language for the resident). In an attempt to speak to the resident in the aforementioned language, the interpreter identified the resident was not speaking Armenian but instead he spoke Albanian/Italian. She connected the call with an Albanian/Italian speaking translator. The translator then asked Resident #2 his name, what time of the day it was, how staff cared for him and finally, how the resident felt about his overall care. The resident responded coherently stating his name, the time of the day (afternoon) and also said staff walked out on him when he called for help. He reported a staff shoved food deep in his throat which caused him to throw up. The resident also reported that one of his fall resulted from nursing staff letting go of his hands when he attempted to stand. VII. Staff interviews CNA #4 was interviewed on 8/6/2020 at 10:23 a.m. He said he had worked with the resident on each of the shifts he came to work for approximately five weeks now. He said resident was able to use his call light. He said when he responded to the resident's call light, he was unable to understand the needs expressed by the resident. He said as most staff of the facility, he took it that the resident was confused and he would turn off the resident's call light and ensure the resident's call light is placed within the reach of the resident and that his bed was in a low position before he exited the room. The CNA said he was assigned as a one-on-one caregiver to the resident because the resident has had multiple falls since his admission to the facility. He acknowledged that language barrier made it difficult to address the residents needs. He said body language was what he utilized to have a peripheral understanding of some limited needs of the resident. He said he was not made aware to use a translation line or communication board with the resident. CNA #2 was interviewed on 8/6/2020 at 11:21 a.m. He said he was sometimes assigned to care for Resident #2 because he spoke three languages. He listed the languages he spoke as Spanish, Catalan and English. He said he was aware Resident #2 understood and communicated in Italian language, He clarified that his understanding was that Italian language had some input of Spanish and thus, he was able to pick some lines from what Resident #2 communicated. CNA #2 acknowledged he was not a satisfied interpreter. He said when he worked the shift, he was called to help interpret what the resident said. He said he had no idea how the resident was managed when he was away. He said the resident family member had a write up on a board which the resident read and helped calm the resident down when he is agitated but due to room change, the write up was misplaced and had not been found. Social services director (SSD), social services assistant (SSA) and DON were interviewed on 8/10/2020 at 11:25 a.m. The SSA said when a resident newly admitted to the facility she went over the referral packet and reviewed the diagnoses, medications and needs. Then they will meet with family, friends, guardians for needs and complete assessments for future plans and needs. She said when a resident was non-english speaking, the tool they used is family and language line. The DON, SSD and SSA said the information for the language line was posted at the nurse's station and CNA's who were one-on-one with the resident had a copy of the language line in their possession at all times. SSA said she completed the communication assessment and found out the resident spoke Italian and Armenian but spoke primarily Italian. She said the son was the best contact and the one who knew his needs best. She said she used the family member as an interpreter and she used the language line two days after. She said the language interpreter only understood a few words out of the resident's sentences. She said she would rely on Resident #2's family member for interpretation because the hospital did not have much luck with communicating with the resident. She said Resident #2's family member would call him once a day or every other day to speak with him. She said if they had any concerns she would bring her cell phone to the room to help with communication. She said Resident #2's family member would express frustration as he could not visit in the beginning, he was upset that he could not sit in the room with the resident for long hours while he spoke with him on the phone. The family member was also worried he could not eat enough, physically getting weaker. The DON went in Resident #2's room on 8/10/2020 at 11:36 a.m. At the time, CNA #8 who was one-on-one with Resident #2 was interviewed. He said he tried to use the google translation application to interpret what the resident said. He does not think that the app made sense of what the resident said. He said the resident does talk, but that he mumbled and that might affect the effectiveness of the google translation application. He said in his five weeks of working with the resident, he had not been made aware to use a language line or communication book with the resident. He said he only got the translation line information transferred through text message few minutes prior to the interview. He said he had not been trained on how the language line was to be utilized. Resident #2 was interviewed on 8/10/2020 at 1:47 p.m. with (name of company) translation service via telephone. The phone interview was conducted with facility staff (CNA #8) present and the entire conversation was done while the phone was on speaker phone. The interpreter spoke in Armenian language (the initially care planned language for the resident). In an attempt to speak to the resident in the aforementioned language, the interpreter identified the resident was not speaking Armenian but instead he spoke Albanian/Italian. She connected the call with an Albanian/Italian speaking translator. The translator then asked the resident of his name, what time of the day it was, how staff cared for him and finally if the resident felt he was being abused. The resident responded coherently stating his name, the time of the day (afternoon) and also said staff walked out on him when he called for help. He reported a staff shoved food deep in his throat which caused him to throw up. The resident also reported that one of his fall resulted from nursing staff letting go of his hands when he attempted to stand. The DON was interviewed on 8/10/2020 at 12:17 pm. She acknowledged that the revision to the care plan above which addressed the the real language spoken by the resident was done because the facility agreed that they had care planned the wrong language for the resident. The aforementioned information of possible abuse was brought to the attention of the DON and the NHA on 8/10/2020 at approximately 2:02 p.m. and the NHA immediately reported to the State Survey Agency and likewise commenced and investigation into the alleged abuse. The nursing home administrator (NHA) and DON were interviewed on 8/11/2020 at 12:35 p.m. The DON said she had been the interim DON since late June, 2020. The NHA said he had stepped in as the NHA the week of the survey. He The NHA said he could not speak to the deficient practice prior to his arrival but would assist as able in the investigation. They acknowledged the staff had not provided consistent monitoring and communication for Resident #2. The NHA said the staff were aware Resident #2 could not speak English and the staff should have utilized every tool to communicate with the resident. He said Resident #2's cognition was poor at times, but could use gestures to communicate. They acknowledged Resident #2 could not see or point to the printed communication tool which staff used in the room. The NHA said while the staff attempted to utilize the interpreter line on 8/10/2020 (for the first time) they found out the resident had trouble understanding and he showed signs of dementia. They said moving forward they had a care conference with Resident #2's family and hospice about Resident #2's change in condition. They started education regarding use of the language line with the appropriate language the resident was used to. The NHA said they would continue to contact the son to interpret and use the resident's hand gestures to communicate and update the care plan.

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents, affecting one (#2) resident reviewed out of the eight sample residents. The facility failed to implement interventions timely and follow implemented care plan interventions for Resident #2 who was admitted as a known high fall risk with a history of falls, dementia, unspecified left humerus fracture, muscle weakness, abnormalities of gait and mobility. The resident fell within days of being admitted , experienced multiple falls which the facility implemented one-to-one staff to be with Resident #2. The staff member left Resident #2 during this time and this failure contributed to Resident #2 falling and sustaining a head injury which required being sent to the hospital and requiring sutures, more than first aid. Furthermore, fall assessments were not completed upon admission and the resident had multiple falls furthering his decline. Additional failures which added to failures of quality of care (cross-reference F684), the staff failed to effectively communicate with the resident. The resident tried to care for himself due to the communication barrier and interventions not being followed, as the staff did not understand the resident's expressed needs in his language. Findings include: I. Failure to ensure fall intervention were in place timely and followed A. Facility fall policy The Fall Management policy, revised in July 2017 was provided by the director of nursing (DON) on 8/10/2020 at 3:30 p.m. The document read, The facility assists each resident in attaining/ maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/ or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A care plan is developed and implemented, based on this evaluation, with ongoing review. An additional Fall Management policy, which was revised in November 2017 was provided by the DON on 8/10/2020 at 3:37 p.m. The document recorded practical guidelines for newly admitted residents and read A proactive approach will be taken for newly admitted residents with regards to fall risk. Newly admitted residents will be considered at risk for falls until they are reviewed by the interdisciplinary team. It further enumerated that: -Upon admission, the admitting nurse will complete the Fall Risk User Defined Assessment (UDA), the nursing initial plan of care, address risk factors related to the resident in the plan of care and implement appropriate interventions as identified. -The kardex will be updated to reflect the resident's risk status and individualized fall risk interventions -If the resident is determined to be at high risk, then the resident is referred to rehabilitation services. -The resident and the resident's representative are provided education on fall risk and interventions in place to reduce the potential for falls. -Residents will be assessed quarterly, annually and with significant change using the Fall Risk UDA. The care plan is updated as appropriate. The document listed the facility's procedure in the event of an actual fall and documented in pertinent part The IDT reviews all resident falls within 24-72 hours at the IDT meeting to evaluate circumstances and probable cause for the fall. The IDT will complete the interdisciplinary post fall review. The IDT designee will discuss recommended significant changes to the care plan to minimize repeat falls with the resident and/ or resident's representative. The care plan will be reviewed and/ or revised as indicated. Care Kardexes are updated as appropriate. B. Resident #2's status prior to admission The referral note dated 6/28/2020 documented the attending physician reported a [DIAGNOSES REDACTED]. No loss of consciousness. laceration to the left post parietal area. Cognition at baseline per family member. small right frontal subarachnoid hemorrhage. The precaution portion of the note also documented Resident #2 was Albanian speaking only. Had dementia and falls, left [MEDICAL CONDITION] upper extremities. Prior level of function portion of the note reported Family member states he assists resident with dressing and bathing. resident is able to step over shower ledge and walks in home independently at times. The resident has had falls. Family member present as much as possible, but the family member is struggling to care for him. Resident is independent for self feeding after setup using the right upper limb (RUL) only. Family member reported the resident got up at night, urinated on the bathroom floor then slipped. The living situation portion of the note reported resident lives with family member in house with stairs to enter. The resident had walk-in shower, no chair, hand held shower head. -This note indicated the facility was aware this resident was a high fall risk prior to being admitted to the facility. A review of the hospital referral document from 6/28/2020 did not reveal an order for [REDACTED]. C. Resident #2's status Resident #2, over [AGE] years old, was admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. -The resident [DIAGNOSES REDACTED]. The 8/4/2020 minimum data set (MDS) assessment coded the resident as moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident has had a fall in the last month prior to admission. The resident has had a fracture related to a fall in the 6 months prior to admission. The resident has had two or more falls since admission. He has had one fall since admission which resulted in minor injury. No pain experience was recorded. The resident did not reject evaluation or care. The resident required two persons physical assistance with transfer. He required extensive assistance of one person with bed mobility, dressing, eating, toilet use and personal hygiene. D. Observation Resident #2 was observed on 8/6/2020 at 10:44 a.m. lying in his bed. The resident had a certified nurse aide (CNA) #4 who was providing one-on-one (1:1) care in the room with him. The resident had a bruise to his right eye which was red and dark purple/black in color and an undressed stitches to the upper corner, just above his right eyebrow. The resident waved and spoke in a language (unknown). His gesture suggested he was greeting. There was nothing suggestive of the resident having a communication deficit. -At 3:35 p.m. observed Resident #2 awake in his wheelchair with his lunch tray on the bedside table in front of him. Resident #2 had a bruise with a laceration above his right eye. CNA #4 was sitting in a chair in front of him encouraging him to eat. CNA #4 said it had been his fourth time working with the resident. Resident #2 was speaking an unknown language, and CNA #4 said he had an App (application) on his phone which was supposed to detect what the resident was trying to say. He said the App was in Italian. CNA#4 said there was a Health Care Communication Board under Resident #2's food tray. The Health Care Communication Board had colored various pictures of items including signs of pain, food/fluids, family, clothes, equipment, and activities. CNA #4 said that was the first time he had seen the communication form and believed it was provided by the therapy department; however he did not attempt to use it. He said the App was not detecting what the resident was saying only words, so he was not sure what the resident wanted. He said the resident would point using hand gestures to communicate. He said the resident would shake his head no and put his hand up when he did not want anything to eat or drink, point to his brief if he needed to be changed and point to the bed when he wanted to lie down. The room did not have any other personalized activities in the room. The resident continued to yell out in his language, then CNA #4 pointed to the resident's bed and assisted him back to bed. (Cross-reference F684) E. Record review A review of the resident's care plan revealed the facility failed to initiate fall interventions for the resident until three days after admission. The fall care plan, initiated on 7/13/2020 with a revision date of 8/11/2020 documented Resident #2 was a high risk for falls related to (r/t) confusion, deconditioning, gait/balance problems, incontinence, new admission, unaware of safety needs. The care plan documented Resident #2 had a fall on 7/10/2020 (admitted ) and twice on 7/22/2020. The goal of the care plan documented Resident #2 would be free of falls through the review date. It also reported that Resident #2 will not sustain serious injury through the review date. In addition, goals of the care plan documented the resident's risks and injury potential will be minimized through the next review date. The fall intervention documented 1:1 staffing to monitor the resident for safety; To ensure all the resident's personal items in reach while in bed; Staff to anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; The resident needs prompt response to all requests for assistance; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; and ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. -Even though the resident had 1:1 (one-to-one) staffing to monitor resident for safety, resident continued to fall, and one-to-one was implemented for a little time after the resident would fall. The fall incident reports for Resident #2 were provided by the DON on 8/10/2020 at 2:48 p.m. There was no incident report provided for the fall sustained by the resident on 7/10/2020. A review of the resident's medical record on 8/11/2020 revealed a fall assessment was not completed for the resident since admission. A change of condition assessment was documented on 7/10/2020 at 8:43 p.m. The situation, background, assessment, recommendation (SBAR) summary reported the resident vital signs (blood pressure (BP), pulse (P), temperature (T), weight (W) and oxygen intake (O2 sat) at room air were within the normal range/limit. The RN assessment/ licensed practical nurse (LPN) appearance of the resident's portion of the SBAR reported What I think is going on with the resident is: New admit, history (Hx) of falls, dementia. Additional Nursing Notes as applicable: Evaluated by (name of RN). No injuries noted. Placed with 1:1 CNA. Family/Health Care Agent Notified: Message left at (cell number) on face sheet at 7/10/2020 at 5:50 p.m Primary care clinician (PCC) notified on 7/10/2020 at 5:45 p.m. Nursing daily skilled charting dated 7/11/2020 at 12:35 pm reported the resident's skin was intact and there were no changes to the resident's skin integrity. An head to toe skin assessment dated [DATE] (a day after resident's admission) reported the resident had no skin issue. The same assessment dated [DATE] and 7/25/2020 reported the resident's skin was intact. -These skin assessments indicate the injuries Resident #2 sustained were after admission A follow up note for the above mentioned fall dated 7/22/2020 at 9:42 p.m. documented monitoring resident for fall, no fall this shift. The resident alert, one-on-one with the resident all night. A change of condition assessment was documented on 7/22/2020 at 12:16 a.m. The SBAR summary reported the resident vitals signs (same as above) were within the normal range/limit. The RN/LPN assessment portion of the report documented What I think is going on with the resident is: I thought resident got out of bed himself due to his poor safety awareness, resident is not aware of his limitations. Bed was in low position, call light was within reach, resident did not use his call light. Additional Nursing Notes as applicable: Res. was found lying on the mat by bed side by resident care staff (RCS), called this writer, getting to the resident's room, found him lying on the mat by bed side, assessment done by the RN, resident was helped back in bed, no sign and symptom (S/S) of pain at this time, neuro assessment initiated, comfortable in bed will continue to monitor. Family/Health Care Agent Notified: family member called on 7/22/2020 at 6:00 a.m. PCC notified on 7/22/2020 at 1:00 a.m. The fall report dated 7/22/2020 at 2:15 pm documented under the incident description portion of the report that Resident #2 was found on the floor mat, no injury. Bed in low position, call light was within reach. Resident did not use the call light button. Resident description portion of the report documented No change noted from residents base line, no sign and symptoms of pain noted. Although the care plan documented the resident fell twice on 7/22/2020 (see above), there was just one change of condition assessment and one incident report of the resident's medical record. An head to toe skin assessment dated [DATE] reported for the first time that the resident had existing bruises and existing abrasions. The site, type, length and width portion of the skin assessment recorded for the first time that the resident sustained [REDACTED]. It also recorded the resident has scabbed areas to his right shin which measured 14 cm in length and 2 cm in width. The assessment recorded the resident sustained [REDACTED]. Further description of skin issues portion of the assessment also recorded for the first time that Both bruises were fading. Area to R shin was multiple scabbed areas (had upon admission). The assessment recorded NO for the question Nail cleaned and trimmed. A fall incident dated 8/1/2020 at 6:30 a.m. documented under the incident description portion of the report that Resident #2 was found on the floor by his CNA. Resident was lying on the floor in the room very close to his bed. He did not hit his head and there was no injury observed. Bed in low position, call light was within reach. Patient did not use the call not use call light button. Resident description portion of the report documented Resident was unable to give description. Immediate action taken portion of the report documented Resident was helped off the floor by three or more staff members including a registered nurse (RN). RN did the first skin assessment, his vitals were obtained, and a sitter was asked to stay with him, he was given a cup of water which he refused. His doctor and family member was later informed. Although he had no injury, but since the fall was unwitnessed, neuros were being observed. Resident was alert and oriented x 1-2 which is his baseline. Intervention, designate 1:1 on schedule. Staff education in regards to following care plans. A fall incident dated 8/1/2020 at 8:00 a.m. documented under the incident description portion of the report that Resident #2 was found on the floor by a nurse. He had a skin tear to upper side of his left eye. He was sent to the hospital for evaluation and treatment. Resident description portion of the report documented Resident was unable to give description. Immediate action taken portion of the report documented Resident was helped off the floor by three to four (3-4) staff members including an RN. His vitals were obtained and resident medical doctor (MD) and family member were informed. Resident was sent to the hospital for evaluation and treatment. The progress note documented on 8/1/2020 at 7:20 a.m. reported Found resident sitting on the floor at 6:30am. it's in draw site. No injury when check body. No abnormal neurologic sign, no limited ROM when compared to his base. Started neuro V/S. Asked help for looking for a sitter to Charge nurse, text message to DON. Agency CNA and (name of staff) helped resident clean and support. Monitored resident condition continuously. A change of condition assessment was documented on 8/1/2020 at 7:24 a.m. The SBAR summary reported the resident vitals signs (same as above) were within the normal range/limit. The RN/LPN assessment portion of the report documented What I think is going on with the resident is: He's acting confused Additional Nursing Notes as applicable: He fell at 6:30 a.m. during morning report. Family/Health Care Agent Notified: family member called on 8/1/2020 at 8:15 a.m. PCC notified on 8/1/2020 at 8:05 a.m. The progress note documented on 8/1/2020 at 8:30 a.m. reported Resident fell again at 7:50 a.m. Right (Rt) eyebrow area laceration 4.5 cm (centimeters) x 2 cm, bleeding with redness Rt. eye around. pupil reflex active, No limited ROM when compare his baseline, no abnormal neurologic sign. Cleaned wound with wound cleanser, pat dry then cover with gauze then secured with tape, called medical director (MD) then notified resident condition, received order of transfer to hospital for evaluation. Informed family and DON. His family member wants to talk to the manager, informed the manager about it. -This fall the resident sustained [REDACTED]. He received stitches to his right eyebrow. (see below) A review of Resident #2's medical record revealed the facility failed to document the facility's decision to move Resident #2 closer to the nursing station for a closer supervision. There was no documentation of the facility's rationale for declining to ensure the resident continued to be on one-on-one supervision as his fall care plan directed. There was no amendment to the care plan which reversed the one-on-one supervision initiated for the resident on 7/13/2020. The head to toe skin assessment dated [DATE] reported for the first time that the resident had existing skin tear in addition to bruising and abrasion mentioned above. The site portion of the assessment reported for the first time that the resident sustained [REDACTED]. The assessment recorded for the first time that the resident had a scab to the frontal part of his right knee and a surgical incision to the back of his head. The progress note documented on 8/1/2020 at 12:42 p.m. reported Resident came back from the hospital at 12:10 p.m. His Rt. eyebrow area sutured (9 stiches) covered by gauze, no bleeding sign from wound, Started neuro vital signs (V/S), no abnormal neurologic sign/ limited range of motion (ROM) when compared with his baseline. Called MD and family, informed resident came back to the facility. Sitter in the resident side. Monitored resident condition continuously. F. Disciplinary action report for staff for failure to follow one-to-one for Resident #2 A disciplinary action record signed on 8/5/2020 was provided by the director of nursing (DON). The document reported that On 8/1/2020, employee pulled 1:1 care giver out of Resident #2's room to work the floor. Resident fell twice and was sent to emergency room (ER). Resident is careplanned to be a one-on-one at all times. Care plan was not being followed and the resident was injured. Care plan is to be followed at all times. An additional disciplinary action record that had the employee, supervisor and witness signatures and date portions of the document blank was provided by the DON on the same day as above. The document reported that On 8/1/2020, a resident had two falls, there were no incident reports completed. SBARS were filled out. On 8/1/2020, another resident roommate (RM) had his bilateral lower extremities dressings removed but not put on, nursing staff found him without a dressing on but it was documented that the dressing was completed. -This indicated the facility falsified documentation. G. Staff interview LPN #1 was interviewed on 8/10/2020 at 12:55 p.m. She said all residents were assessed for fall risk on admission, quarterly and with any changes in condition. She said all falls were reviewed by an interdisciplinary team (IDT) that developed interventions and updated the care plans. She reviewed fall assessment on admission for Resident #2 and stated it was not completed. She said based on the admitting history, such as the history of falls, unstable gait and use of medications, the resident should have had a fall assessment completed with him. She said it was not part of her responsibilities to review assessments. Registered nurse (RN) #3 was interviewed on 8/11/2020 around 9:43 a.m. She said all residents were assessed for fall risk on admission and after a fall. She said the accurate fall assessment would trigger a care plan for falls which did not happen with Resident #2. She said all falls were reviewed during an IDT meeting and care plan updates were a team effort. She said Resident #2 was placed one-on-one supervision following his fall on 7/10/2020. She said the resident was moved closer to the nursing station for a closer supervision. She said the resident went to the hospital and the facility did not place him back on the one-on-one supervision until after his recent fall on 8/1/2020. She reviewed the residents medical record and acknowledged there was no documentation on when the resident was moved closer to the nursing station. She also acknowledged that there was no amendment to the care plan which reversed the one-on-one supervision initiated for the resident on 7/13/2020. She said she would bring the observation to the attention of the facility's administration. The nursing home administrator (NHA) and DON were interviewed on 8/11/2020 at 12:35 p.m. The DON said she had been the interim DON since late June 2020. The NHA said he had stepped in as the NHA the week of the survey. He said he could not speak to the deficient practice prior to his arrival but would assist as able in the investigation. The NHA said 1:1 intervention was likely not the appropriate intervention with managing Resident #2's falls. He said 1:1 intervention should have been provided and care planned as needed. He said 1:1 intervention was not a long term intervention and should have only been utilized for agitation or just while he was in quarantine, until they established the resident's baseline. They acknowledged the laceration with stitches to the back of Resident #2's head was not assessed properly as the facilities first documentation was on 8/1/2020; and they were not sure if it had from his fall on 7/30/2020. He said prior to admission they were aware the resident had falls likely due to dementia. He said he could not speak to the reasoning of incomplete skin assessment and they had started education with licensed staff on shift for completion of skin assessments. The interim director of nursing (IDON) was interviewed on 8/11/2020 at 10:40 a.m. She acknowledged that Resident #2 did not have a fall intervention on admission. She said nursing staff documented an intervention in the resident's progress note when the resident fell on [DATE] (day of admission). She said a baseline care plan was to be completed within 48 hours of a resident's admission. She said the care plan should at least address the immediate needs of the resident. She said nursing staff were responsible for creating the care plan and that she would want to see a fall intervention in place because Resident #2 had a prior history of frequent falls. She acknowledged a one-on-one fall intervention was put in place for Resident #2's on 7/13/2020 (three days after his first fall at the facility). She also acknowledged that the incident reports provided revealed the resident was found on the floor in his room by himself on the four different occasions he had a fall after the one-on-one intervention was put in place. She said care plans were updated by the unit manager after each fall with additional intervention and CNA and nurses were responsible to make sure care planned interventions were carried out. The DON said she would educate nursing staff on the need to adhere and follow through with care planned interventions going forward. .

Based on observation, interviews, and record review, the facility failed to provide necessary care and services for two (#1 and #5) of 14 sample residents to maintain the residents' highest practicable level of well-being. (Cross-reference F514) Specifically: Resident #1 had a chronic infection in her left knee. The facility's failures in providing care and treatment for [REDACTED]. -First, when Resident #1's left knee infection worsened 5/17/17, placing the resident at risk for bacteremia [MEDICAL CONDITION] and causing the resident severe pain, fear, and anxiety, the resident's change of condition, as evidenced by elevated laboratory results, was not promptly communicated to her primary practitioner, her worsening infection and associated increase in pain were not monitored and addressed and new wound orders were not obtained and implemented. -Second, the on-going and projected treatment plan to address Resident #1's chronic knee infection was neither adequately communicated nor coordinated among her multiple practitioners, creating delay in the implementation of her treatment plan and in relief of her severe left knee pain. Resident #5 had orders for the facility to schedule an appointment with a specialist. The facility failed to timely coordinate this appointment, contributing to a delay in the resident receiving treatment for [REDACTED]. The findings include: I. Immediate Jeopardy A. Findings triggering Immediate Jeopardy Observation, interviews, and record review on 5/24/17 and 5/25/17 revealed Resident #1 had a chronic infection in her left knee. Record review revealed that on 5/17/17, Resident #1's left knee infection deteriorated, with the resident exhibiting signs and symptoms of a worsening or new infection, including increased pain, purulent drainage from the wound, white blood cell and [DIAGNOSES REDACTED] values outside the resident's baseline, increased heart rate and body temperature, and a decrease in blood pressure. The facility failed to ensure the resident's laboratory values, indicative of infection, were timely communicated to the resident's primary care physician (PCP/MD #1) and her primary practitioner, nurse practitioner (NP #1), failed to monitor the resident's left knee infection for additional changes after 5/17/17, failed to address the resident's increased, severe pain and anxiety, and failed to follow up on the wound physician's orders [REDACTED]. Record review and interviews revealed Resident #1 was being followed by four specialists (two orthopedic surgeons, a wound specialist, and an infectious disease specialist) in addition to her PCP (MD #1) and NP #1. Record review and interview revealed Resident #1's on-going and projected care was not adequately communicated and coordinated among the specialists, and not all documentation from the specialists was available in Resident #1's chart, contributing to the breakdown of communication of information regarding management of the resident's chronic left knee infection. B. Imposition of Immediate Jeopardy On 5/25/17 at 10:27 a.m., the nursing home administrator (NHA) was informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure following Resident #1's change of condition on 5/17/17 and the lack of communication and coordination in the resident's on-going and projected plan of care as set forth above, created a situation of immediate jeopardy for serious resident harm. C. Facility Response and Removal of immediate jeopardy: On 5/25/17 at 4:05 p.m., the vice president of clinical services (VPC) submitted the following abatement plan (draft 3). The plan read: Dear Sir/Madam: Please accept the following immediate actions taken as the facility's plan of abatement for the Immediate Jeopardy findings under F309. -- The facility's Medical Director has been notified of the situation found to represent Immediate Jeopardy for resident #1 and his recommendations have been noted in the resident's file. -- The DON (director of nurses) will review all of resident #1's notes with the primary care physician noting any recommendations/orders in the resident's file. -- The wound care specialist has been contacted and an order requested to complete a culture of resident #1's wound, if indicated. -- The HIM (health information manager) will obtain all progress notes for the past sixty (60) days from all providers involved with the care of resident #1 and these documents will be provided to the attending physician and filed in the resident's medical record. The request for records will be made today and all efforts will be made to have these records in-house by 6/2/17. After 6/2/17, the HIM will go to the provider's office to retrieve the records, if necessary. -- Resident #1 has been placed on contact isolation precautions until the medical provider has determined (if) isolation protocols are not indicated. -- All residents have been evaluated by the DON to determine if any other residents require isolation precautions. -- The DDCS (division director of clinical services) provided the information that the DON, ADON (assistant director of nursing) and SDC (staff development coordinator) were to use for training facility nursing staff. These nurse managers then started inservice education related to infection control policy for all nursing staff. Nursing staff will be re-educated on infection control processes prior to beginning their next scheduled shift. SBAR (a notification tool standing for situation, background, assessment, and recommendation) and wound assessment education will be provided by the DON/designee with all licensed staff on duty. This education will continue as licensed nursing staff report for duty until all staff are re-trained prior to working their next scheduled shift. -- The DON received education from the DDCS regarding policies related to change of condition. Nursing staff will be educated per DON/designee on needed actions to be taken when a resident change of condition is noted. Education will begin with all on duty licensed nurses. The remainder of the licensed nursing staff will receive education prior to working their next scheduled shift. DON/designee will review changes of resident conditions daily for appropriate nursing interventions. -- The HIM conducted an audit of all resident appointments for the past thirty (30) days to ensure all notes related to these visits are in the facility and available in the resident's medical files. All efforts will be made to obtain any missing notes by 6/2/17. After 6/2/17, the HIM will go to the providers office to retrieve the records, if necessary. -- The Nurse Practitioner ordered new stat lab orders for resident #1. The primary physician will be notified via phone of the results when available. -- The chain of notification for resident #1 is that nursing staff are to call the (physician group) provider for change of condition and labs. -- Resident #1's preference regarding returning to the hospital for further treatment has been documented in the medical record. -- An assessment of Resident #1's wound has been completed by a Registered Nurse and documented in the resident's file. -- All current wound assessments have been reviewed to validate proper documentation is present. -- The care plan for Resident #1 will be updated on 5/25/17 to reflect all current needs. The DON or designee will provide specific training to nursing staff related to the care plan needs of Resident #1 beginning 5/25/17. All nursing staff will receive this training prior to providing care to this resident on an ongoing basis. -- A new pain assessment has been completed for Resident #1. -- Resident #1's room has been deep cleaned per (contracted cleaning housekeeping company) policy and procedure. On 5/25/17 at 4:27 p.m., the NHA and VPC were notified the immediate jeopardy had been lifted effective 4:05 p.m.; however, based on observation, interviews, and record review, deficient practice remained at a G level (harm that is isolated). II. Resident #1 A. Resident Status 1. Resident #1, age under 60, was admitted to the facility on [DATE]. According to the May 2017 computerized physician orders [REDACTED]. 2. According to the minimum data set (MDS) assessment dated [DATE], the resident was cognitively intact with a brief interview for mental status (BIMS) of 14 out of 15. She demonstrated inattention, which fluctuated in severity. She experienced pain almost constantly, which sometimes made it difficult for her to sleep or limited her activities. At the time of the assessment, the resident did not have any open [MEDICAL CONDITION], burns, skin tears, or moisture associated incontinent [MEDICAL CONDITION], although she had dressings and ointments ordered. 3. Interviews with licensed practical nurse (LPN) #2 on 5/23/17 at 7:24 p.m., the DON on 5/24/17 at 7:17 p.m., NP #1 on 5/25/17 at 10:45 a.m. and Resident #1's PCP (MD #1) on 5/25/17 at 11:45 a.m., revealed the resident has had a chronic knee infection for several years. According to LPN #2, the resident's infection was due to a joint replacement that had become infected. The DON said the resident was being seen by four specialists: The facility wound physician (MD #2); an infectious disease specialist (IC); and two orthopedic surgeons (MD #3 and MD #4); however her PCP (MD #1)'s NP (NP #1) was most familiar with Resident #1's case. Interviews and record review further revealed the resident had been receiving an antibiotic, [MEDICATION NAME], 100 milligrams twice a day, with a start date of 12/1/15 for the infection in her knee joint. According to NP #1, the resident's knee infection fluctuated in severity but had been stable on the antibiotic. 4. Observation and resident interview a. Resident #1 was interviewed in her room on 5/24/17 at 6:00 p.m. She expressed pain and fear of losing her left leg. Resident #1 said her left knee had been infected for a long time but had recently opened up. She said the knee hurt and said the pain was often at a 10 out of 10 (on a scale of 0-10, 10 being the worst pain), especially when she moved. She said the dressing needed to be changed frequently because the wound soaked through dressings and it was uncomfortable when the dressing was wet. Resident #1 said she was frightened by how the knee looked and smelled and by the amount of drainage, and she said the facility had often told her that if the infection got bad, it (her leg) would have to be cut off. She said her mother had gotten her in to see a doctor who was going to replace the infected joint and put antibiotics in the knee which she said she wanted to do. However, she was unsure what follow-up had been done for her to have this procedure. During the interview, the resident repeatedly stated she was afraid of losing her leg. b. An observation of the resident's left knee, conducted 5/24/17 at 6:26 p.m., indicated the presence of infection. Specifically: Resident #1 was observed on 5/24/17 at 6:26 p.m. when LPN #2 changed a dressing change on the resident's left knee. The outside of the dressing was soiled with a yellow/orange drainage on the front, approximately 2 (two) inches in diameter. The resident verbalized that the dressing was wet, and said it needed to be changed. The LPN cut through the gauze, and removed the outer layer of gauze. A border foam cushion with a hole around the resident's kneecap was revealed with additional gauze secured with surgical tape. The gauze was saturated with a yellow/green discharge and a purulent odor was present. The LPN began to remove the tape, and the resident gasped and remarked that it hurt. The LPN apologized, and removed the border foam, which was observed to also be completely covered with a yellow/green discharge to the degree that the discharge dripped off the border foam. As the LPN removed the foam, a large amount of the yellow/green discharge flowed down the resident's leg from her knee and formed a puddle on the floor. The resident's knee and the surrounding skin were red, with a large swollen area, approximately 15 cm (centimeters) x 15 cm, above and to the left of the resident's kneecap. Immediately below and to the left of her kneecap was a quarter sized indentation, which appeared to be approximately a cm deep. At the bottom of the indentation was a small pinpoint opening which was draining fluid. The indentation and the skin immediately surrounding it were a dark purple color. B. Failure to assess, monitor, address and communicate a significant change in condition identified 5/17/17, including severe pain and anxiety. 1. Facility Policy The facility's skin management policy, as provided by the HIM on 6/1/17, read in pertinent part, that residents with impaired skin integrity should have the appropriate interventions to promote healing. 2. Professional References According to the Center for Disease Control and Prevention (CDC), the symptoms [MEDICAL CONDITION] include fever, [MEDICAL CONDITION](high heart rate), extreme pain or discomfort, and a decreased blood pressure. The Center for Disease Control and Prevention,[MEDICAL CONDITION] Questions and Answers, (2017), https://www.cdc.gov/sepsis/basic/qa.html (6/8/2017). 3. Documentation 5/17 and 5/18/17 that the chronic infection of Resident #1's left knee had worsened. a. A SBAR dated 5/17/17 at 5:52 p.m. indicated Resident #1 complained of increased pain in her infected left knee. The assessment noted the resident was pale, had a rapid heart rate, a reduced blood pressure, and a fever. The note indicated the concern had begun earlier that day and had worsened. The note indicated the resident was receiving [MEDICATION NAME] for an infection. The note read the resident's most recent blood pressure was 100/60, her pulse was 148 beats a minute, and her temperature was 100.3. She displayed a decrease in mobility from her baseline. The note indicated the resident appeared to be showing signs of increased infection as evidenced by pain, [MEDICAL CONDITION](rapid heart rate), [MEDICAL CONDITION] and fever, and indicated a request for a hospital transfer was in process. The note indicated the resident's PCP (MD #1), was notified of the resident's condition at 6:00 p.m. A note by MD #1 dated 5/17/17 revealed the resident was seen for fever and [MEDICAL CONDITION] The note indicated the resident's shin and above her knee were red, but the knee was covered by a bandage. The note did not indicate the physician had observed the wound. Per MD #1 interview on 5/25/17 at 11:45 a.m., the MD ordered a consult with MD #2 (facility wound physician). A note by MD #2 (facility wound physician) dated 5/17/17 read Resident #1's left knee wound was 1.1 x 0.8 cm with heavy purulent drainage, and was dressed with silver alginate and border foam and a dry protective dressing. The MD indicated the silver alginate and dry protective dressing to the area should continue. The note further indicated a deep wound culture had been performed and [MEDICAL CONDITION] was a potential infectious organism. b. In response to the above findings, MD #1 ordered, by telephone on 5/17/17, that the resident's rapid heart rate was to be treated with 12.5 mg of [MEDICATION NAME] (a medication to slow and strengthen the heart rate) and the following labs were to be drawn: A complete blood count (CBC), a complete metabolic panel (CMP), an ESR (erythrocyte sedimentation rate, used to diagnose acute infection), and a CRP (C-reactive protein, which indicates nonspecific [MEDICAL CONDITION] responses). The labs ordered 5/17/17 and drawn on 5/18/17 indicated the presence of an infection, and demonstrated a deterioration from baseline values. -A CBC dated 5/18/17 indicated an increase in the resident's white blood count and [DIAGNOSES REDACTED]s, neither of which had been out of the reference range on her previous labs (3/28/17). The resident had a white blood count of 16.60 thousand per cubic millimeter (k/mm3) with a reference range of 4.00 to 11.50 k/mm3 and a previous value of 9.4 k/mm3. She also had a [DIAGNOSES REDACTED] count of 13.1 k/mm3, with a reference range of 1.6 to 7.9 k/mm3 and a previous value of 5.6 k/mm3. The percentage of [DIAGNOSES REDACTED]s compared to other white blood cells increased from 59.2% to 78.6%. (An increase in [DIAGNOSES REDACTED]s may indicate acute infections. See: htttps://medline plus.gov) -The resident's erythrocyte sedimentation rate was 82 millimeters per hour mm/hr, with a reference range of 0 to 15. There was no previous ESR available in the chart. (An elevated ESR indicates an [MEDICAL CONDITION] response consistent with infection, among other things. See https://labtestsonline.org/understanding/analytes/esr/tab/test/) -The numerical value of the resident's c-reactive protein (CRP) was not specified on the 5/18/17 lab, instead the results indicated the level was above 26.8 milligrams per deciliter (mg/dl), with a reference range of less than 1.0. Her previous CRP was 49.72 milligrams per liter (mg/L) on 1/11/17 (equivalent to 4.972 mg/dl). (An elevated CRP is also indicative of an [MEDICAL CONDITION] response. See http://www.medicinenet.com/c-reactive_protein_test_crp/article.htm) 4. Failures related to changes documented 5/17/17 a. Failure to ensure prompt communication of lab reports, demonstrating a deterioration from baseline values, to Resident #1's practitioners, MD #1 and primary practitioner NP #1. Record review revealed the resident's abnormal lab values were faxed to MD #1, but not NP #1, her primary practitioner, even though interviews with LPN #2, MD #1, NP #1, and the facility VCP, revealed Resident #1's lab values on 5/18/17, along with her signs and symptoms on 5/17/17, indicated the infection in the resident's left knee was worsening and/or representative of a systemic infection, and the daily administration of [MEDICATION NAME] was ineffective in treating her infection. Record review: A note on the bottom of Resident #1's lab reports, ordered 5/17 and drawn 5/18/17 indicated the reports were faxed to the physician's office, not phoned in to ensure the physician's receipt of lab results. Review of nursing progress notes revealed no documentation of follow up with MD #1 to confirm the physician was aware of Resident #1's abnormal lab values, and there were no additional orders received until 5/24/17 (start of survey). Interviews: LPN #2, Resident #1's nurse, was interviewed on 5/24/17 at 7:24 p.m. about the events on 5/17/17. She said the resident had an increase in pain and vital signs, signs and symptoms which were a departure from her baseline and indicated the left knee infection was potentially worsening. The LPN said she had concerns the resident might be [MEDICAL CONDITION] (a systemic [MEDICAL CONDITION] response to infection, in which there is fever, [MEDICAL CONDITION]. She said she had filled out an SBAR, and had called and left a message about her concerns with the resident's physician, who had ordered labs. The LPN said the labs had also been a departure from the resident's baseline, and said she had sent the information to the physician, but had not been given any orders related to treatment or further monitoring of the resident. She did not indicate she had contacted the resident's physician for follow up orders when none were received. The facility VPC (vice president of clinical services) was interviewed on 5/25/17 at 11:25 a.m. He said Resident #1's labs reports and vital signs on 5/17 and 5/18/17 indicated a systemic infection. MD #1, Resident #1's PCP, was interviewed on 5/25/17 at 11:45 a.m. She confirmed she saw Resident #1 on 5/17/17, but did not observe the left knee as it was covered with a bandage. She said the efficacy of antibiotics in treating Resident #1's knee infection was monitored through bloodwork; an increase in white blood cells could mean the antibiotics were no longer working. She confirmed she had received a fax containing the lab reports, but was unable to state when she received the fax or state what her communication with the facility had been regarding the reports. She said the facility does not always call with abnormal lab values but would instead fax them. NP #1, Resident #1's primary practitioner, was interviewed on 5/25/17 at 10:45 a.m. She, too, said signs that Resident #1's infection was worsening and required different treatment could be if the resident developed a fever, or a rapid heart rate, or a change in her blood pressure. She also said lab values that were a departure from baseline, especially an increase in white blood cells, could indicate the presence of a worsening infection. The NP said she had not been made aware of the lab values drawn 5/18/17, even though she had been following the resident, and said she had not observed the resident's knee following her change in condition on 5/17/17. b. Failure to assess and monitor the local and systemic status of Resident #1 after 5/17/17 and failure to provide expected treatment to the knee. Record Review: Review of nursing progress notes from 5/17/17 to 5/25/17 revealed no documentation in the nursing notes that Resident #1's left knee was monitored for swelling, [DIAGNOSES REDACTED], temperature, pain or drainage. Review of the nursing progress notes from 5/17/17 to 5/25/17 revealed no assessments of the resident's left knee or skin after 5/17/17. Review of the resident's record revealed no vital signs documented between 5/17/17 and 5/25/17. Review of the resident's CPO revealed no order for Resident #1's wound as written in MD #2's note on 5/17/17 (silver alginate and dry protective dressing) and therefore, no documentation the order was being implemented. Interview: Resident #1's wound physician (MD #2) was interviewed on 5/25/17 at 1:15 p.m. He said the status of Resident #1's infected knee would be best monitored by objective measures including, in addition to a white blood count, vitals and tracking the size of the area and the nature and quantity of the drainage. The facility VPC was interviewed on 5/25/17 at 11:25 a.m. He said once the specific order had been provided by the wound physician regarding treatment of [REDACTED].#1) for inclusion on the resident's treatment administration record. He confirmed there was no evidence this had been done or the silver alginate applied. He confirmed documentation of nursing assessment and monitoring of the resident's condition were not present in the resident's record. He said he would have expected to see monitoring of the resident's status after her change in condition. c. Failure to address Resident #1's pain, fear, and anxiety See SBAR notes above (resident complaining of increased pain), Resident #1's interview above on 5/24/17 at 6:00 p.m. (rating her pain often at the highest level of 10 and repeatedly expressing fear of losing her leg), and her response to the dressing change at 6:26 p.m. (gasping as dressing removed). LPN #2 stated no new orders were received on 5/17/17, and review of nursing progress notes from 5/17/17 to 5/25/17 revealed no change in the resident's MEDICATION ORDERS FOR [REDACTED]. d. Facility failure to adequately communicate and coordinate Resident #1's on-going and projected treatment plan among her multiple practitioners. Interviews and record review revealed a lack of communication and coordination among the resident, her multiple practitioners, and her family about her on-going and projected treatment plan. In addition, notes by the resident's practitioners were not always available in the record for review and to facilitate coordination of Resident #1's care. (Cross-reference F514) 1. LPN #2, Resident #1's nurse, was interviewed on 5/23/17 at 7:17 p.m. about the resident's treatment plan. She said she was under the impression the resident's leg would be amputated. She said she believed the resident had seen an orthopedic surgeon the morning of 5/17/17, but said the notes from the surgeon were not in the resident's record and as a result, had not been available to MD #1, who the LPN called following the resident's change in condition on 5/17/17. The LPN said MD #1 had wanted to wait until she received the consult from MD #4 before determining how to proceed. She confirmed there was no documentation the facility followed up to obtain the consult notes. 2. Resident #1 was interviewed on 5/24/17 at 6:00 p.m. See above; Resident #1 said her mother had gotten her in to see a doctor who was going to replace the infected joint and antibiotics in the knee, which she wanted to do. However, she was unsure what follow up had been done to for her to have this procedure. Subsequent interview with Resident #1's family member on 5/30/17 at 8:56 a.m. revealed s/he said s/he had been trying for several months to have a second orthopedic surgeon to evaluate Resident #1's knee to determine whether there were other treatment options than amputation. S/he said the resident would require two surgeries, one to treat the infection, and another to replace the joint. 3. The DON was interviewed on 5/24/17 at 7:17 p.m. The DON said the leg needed to be amputated, but the resident refused. The DON said the resident had seen MD #4 (orthopedic surgeon) on 5/17/17 for a second opinion after MD #3 (orthopedic surgeon) recommended amputation of her leg. She said the resident had verbally told the facility staff that MD #4 was comfortable replacing the joint, but that she (the DON) did not believe this was so because the resident was not always a reliable historian. Although the DON did not have documentation of the consult with MD #4 at the time of the interview, the consult note was provided to the surveyor on 5/25/17. It confirmed Resident #1 had been seen by MD #4 for a consultation regarding an infected left knee prostheses. The note cleared the resident for a replacement of the infected hardware and an antibiotic spacer to treat the infections. This note had not been available to facility staff or any of the resident's other practitioners from 5/17/17 to 5/25/17. (Cross-reference F514) 4. NP #1, Resident #1 primary practitioner, was interviewed on 5/25/17 at 10:45 a.m. She confirmed the resident had seen a second orthopedic surgeon on 5/17/17, but said she was not aware of the recommendation that the hardware in the resident's knee be replaced and an antibiotic spacer inserted, and as a result, she had not initiated any pre-operative tests or labs. She said the resident had a number of specialists consulting, but the information from those consults were not in the resident's medical record to inform her of their decisions. (Cross-reference F514) 5. MD #1, Resident #1's PCP, was interviewed on 5/25/17 at 11:45 a.m. She said the resident had had told her that the left knee would be replaced. 6. MD #2 (facility wound physician) was interviewed on 5/25/17 at 1:16 p.m. He said 5/17/17 was the first time he had seen Resident #1. He said the resident had septic arthritis. He said he understood the resident left leg would be amputated and the antibiotics were palliative. He said he did not understand what his role in the resident's treatment was, because the resident had an orthopedic surgeon on board for the wound. He said he was not aware the orthopedic surgeon also had seen the resident on 5/17/17. MD #2 said he was unable to access the facility's computer system and had been unable to find any documentation or medical records from any of the specialists the resident had seen. He said that as a result, it had been difficult to determine how best to treat the wound, or even if it would be appropriate for him to treat the wound. He said based on his exam, the leg would require amputation, but ultimately that decision was best made by the orthopedic surgeon. 7. The VPC was interviewed on 5/25/17 at 11:25 a.m. He confirmed Resident #1's care team did not have any physicians taking a leading role, and said he would expect the facility to coordinate care. He said it was also his expectation that all documentation be present in the chart so each consulting physician had access to all the information needed to make an informed decision. 8. As of 5/25/17, there was no recent documentation in the resident's record from the infectious disease specialist (IC) or the original orthopedic surgeon (MD #3). (Cross-reference F514) D. Summary Resident #1 had a chronic infection in her left knee. When Resident #1's left knee infection worsened 5/17/17, placing the resident at risk for bacteremia [MEDICAL CONDITION] and causing the resident severe pain, fear, and anxiety, the resident's change of condition, as evidenced by elevated laboratory results, was not promptly communicated to her primary practitioner, and her worsening infection, and associated increase in pain and anxiety were not monitored and addressed. Moreover, Resident #1's on-going and projected treatment plan to address her chronic knee infection was neither adequately communicated nor coordinated among her multiple practitioners, creating delay in the implementation of her treatment plan and in relief of her severe left knee pain. III. Resident #5 A. Resident status Resident #5, age under 60, was admitted to the facility on [DATE]. According to the CPOs, the resident's [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the resident was demonstrated moderate cognitive impairment with a BIMS of 10 of 15. A CPO dated 4/27/17 indicated the resident needed to be scheduled for a consult with a specialist for the [DIAGNOSES REDACTED]. B. Resident Interview Resident #5 was interviewed on 5/31/17 at 10:45 a.m. He said he had resided in the facility for a month. He said he had been admitted so he could receive a medication for his [MEDICAL CONDITION]. He said in order to get the medication, he needed to be referred to a specialist. He said the facility had been aware of his need for a referral at his admission a month ago, and he still did not have the referral. He did not know what efforts the facility had made to get the appointment, and as a result of not having the appointment, he had been unable to obtain his liver medication. C. Staff Interview The assistant director of nursing (ADON) was interviewed on 6/1/17 at 3:26 p.m. She said she and the transportation manager were responsible for coordinating appointments. She said over the previous several days, the facility had been attempting to set Resident #5's appointment, but had run into difficulty with the physician's office. She said she had attempted to fax the necessary paperwork every day for the previous two days. She said she was unsure what had been done in an attempt to set the appointment, and that this was usually done by the transportation manager. She said the transportation manager had left and was unavailable for interview. She confirmed there was no documentation in the resident's medical record to demonstrate prior attempts to set the appointment, or follow up on the initial order dated 4/27/17. She said the facility would confer with the transportation manager to see what documentation he could provide. The DON was interviewed on 6/1/17 at 6:00 p.m. She stated she had not been able to locate additional documentation related to the resident's referral to a specialist in order to receive his medication for [MEDICAL CONDITION]. She said she would provide any documentation she found by the close of business on 6/2/17. D. Record review A nursing note dated 5/31/17 at 9:29 a.m. indicated an information sheet had been faxed to a l(TRUNCATED)

Based on record review and staff interviews, the facility failed to ensure post fall assessments and neurological checks were appropriately completed in accordance with professional standards of practice, for nine (#15, #18, #13, #5, #4, #7, #19, #8 and #9) residents of 15 residents reviewed for falls and accidents. Specifically, the facility failed to complete fall assessments and monitoring, including the neurological assessments, after residents experienced unwitnessed falls or witnessed falls in which they hit their head. The facility's assessment and monitoring failures after resident falls presented a situation of immediate jeopardy with the potential for serious harm. The findings include: I. Immediate Jeopardy A. Findings triggering immediate jeopardy Record review and interviews with staff, health professionals, and residents demonstrated the facility did not have an effective system in place to ensure residents who sustained an unwitnessed fall, or a witnessed fall in which they hit their head, were assessed appropriately; furthermore, the facility failed to consistently monitor residents' neurological status after the fall as expected per facility policy. The following staff interviews revealed the facility was aware of the need for an registered nurse (RN) for immediate assessments; however, they did not staff appropriately to provide the necessary level of care to meet the residents' needs. -Licensed practical nurse (LPN) #4 was interviewed on 2/28/17 at 4:10 a.m. She said she was aware there needed to be a registered nurse (RN) in the building at all times and to provide assessments. She said the facility regularly did not staff an RN for the night shift. -The director of nursing (DON) was interviewed on 2/28/17 at 12:29 p.m. She said the facility needed an RN in the building because of emergencies and they had skilled level residents (skilled level indicating residents needing frequent monitoring and receiving a higher level of care and treatment). - The DON was interviewed on 3/1/17 at 2:45 p.m. She said she could not guarantee if there would be an RN scheduled for the building at all times. - LPN #1 was interviewed on 3/1/17 at 7:25 p.m. She said there should always be an RN in the building to assess and help with situations that would come up. She said she had been working in the facility for four years and had always known there should be an RN in the building at all times. B. Imposition of immediate jeopardy On 3/1/17 at 6:56 p.m., the nursing home administrator (NHA) and the director of nursing (DON), were informed by the Colorado Department of Public Health and Environment (CDPHE) the facility's failure to have a registered nurse (RN) complete initial fall assessments, and the failure to initiate neurological checks, created a situation of immediate jeopardy for serious resident harm. C. Facility response and removal of immediate jeopardy On 3/2/17 at 3:15 p.m., the facility submitted the following plan (draft #4) to remove the immediate jeopardy. The plan read: Abatement Plan to Remove Immediacy Corrective Action: -The facility began immediate education to licensed nursing staff regarding the completion of neuro (neurological) checks and to be initiated immediately with any fall. The DON will be notified immediately of the fall and the results of the nursing assessments. The licensed nursing staff will monitor the resident each shift for 72 hours for any latent change of condition, any identified change of condition the MD and family will be notified. Identification of Others: -The facility is conducting an audit of fall occurrences from January 1, 2017 until 3-1-17 of current residents that sustained a fall in the facility. If any residents is (sic) identified as having sustained a fall; neurological assessments will be audited for completeness, timeliness and accuracy. If any residents neurological assessments are identified as missing components, a new neurological assessment will be completed by a RN to determine if resident is at baseline. If a resident is not at baseline the physician will be notified of the findings. Systemic Changes: -On 3-1-17 the facility began education to licensed nursing staff on completing neurological assessments post fall that includes; completion, timeliness, and accuracy, initiated immediately with a fall. The DON will be notified immediately of the fall and the result of the assessments. The licensed nursing staff will monitor the resident each shift for 72 hours for any latent changes of condition, and identified change of condition the MD and family will be notified. All licensed staff present on 3-1-17 after 6 PM were educated that evening. All oncoming staff is being educated at the start of their shift. This education will be ongoing for licensed nursing staff to include newly hired licensed nursing staff to become part of the orientation process. Monitoring: -The facility will conducted an Ad Hoc QAPI (quality assurance performance improvement) committee meeting to include the facility Medical Director and determine its corrective actions to ensure that the deficient practice has been corrected and will not recur. The facility will audit all resident with a fall occurrence daily (Monday-Friday) at the Morning IDT (interdisciplinary team) meeting and by the MOD (manager on duty) on the weekends and holidays, for neurological assessments completeness, timeliness and accuracy for 1(one) month, then weekly for 2 (two) months, then monthly for 3 (three) months. If the audits identify the neurological assessment(s) have not been completed, DON and/or designee will provide on the spot education to the nursing staff. All resident falls will be reviewed at the weekly At Risk Review meeting. Results of the audits will be forwarded to the Administrator for review and then forwarded to the monthly facility Quality Assurance Committee Meeting. The facility DON or designee will be responsible for sustained compliance. This Plan of Correction is in progress on 3/1/17 and the facility is requesting that the immediacy be removed. On 3/2/17 at 3:15 p.m., the NHA, DON and regional nurse consultant were notified the immediate jeopardy had been removed. However, based on record review and interviews, deficient practice remained at a E level (potential for more than minimal harm at a pattern). II. Facility policy The facility policy titled, Fall Management, last revised 8/12, provided by the NHA on 3/2/17 at 1:49 p.m. documented in pertinent part: If a fall occurs, the IDT conduct an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. When a fall occurs, assess resident for injury. -Resident with potential head injury 1. Complete all items listed under Fall event 2. Complete the Neurological Record per instructions. A copy of the neurological record was provided by the facility. The form noted the facility used the Glascow (sic) coma scale (see description below in professional references).The form noted an initial assessment, then neurological assessments for every 15 minutes x 4, every 30 minutes x 6, every hour x 5, every four hours x 4, then every eight hours for the remaining 48 hours, totaling 72 hours of observation. Every noted time had areas for documenting the following: eyes opening, best motor response, best verbal response, an assessment of the pupils, and vital signs. The facility's policy titled Incident/Accident reporting for residents last revised 2/17, provided by the NHA on 3/2/17 at 1:49 p.m., documented, in part, that relevant facts regarding the incidents are recorded in the progress notes (electronic health record). Relevant facts may include, but are not limited to, the location the resident was found, assessment conducted, care provided and follow up care. III. Professional reference According to Sir Graham Teasdale, The Glasgow Structured Approach to Assessment of the Glasgow Coma Scale, 2014, http://www.glasgowcomascale.org/ (3/17), The timing and frequency of assessment that are appropriate varies according to the stage after onset of the impairment of consciousness and the pattern in any previous observations of a patient. Observation should begin as soon as possible after onset of the impaired consciousness in order to guide initial management and to establish a baseline against which to interpret later findings. Observations initially should be repeated frequently to establish if the patient is stable or to detect any trends of improvement, or of deterioration from developing complications. When a stable pattern emerges as time passes, the frequency can be reduced. The Licensed Practical Nurse Scope of practice as listed by the Department of Regulatory Agency, (May 2015) reads in pertinent part: The Nurse Practice Act defines the scope of practice of the licensed practical nurse (LPN) as that which is taught in schools of practical nursing in Colorado at this time. The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition which are then reported to the RN or MD for further or 'full' assessment. According to Potter, Perry, Stockert and Hall, Fundamentals of Nursing, 8d. ed., Elsevier Mosby, St. Louis, Missouri, 2013, p. 371, Falls result in minor to severe injuries such as [MEDICAL CONDITION] or head trauma that result in reduced mobility and independence and increase the risk for premature death. According to The American Association of Neurological Surgeons, [MEDICAL CONDITION] 2017, http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Traumatic%20Brain%20Injury.aspx (3/17): Deaths from head injuries account for 34 percent of all traumatic deaths. Beginning at age 30, the mortality risk after head injury begins to increase. Persons age 60 and older have the highest death rate after TBI ([MEDICAL CONDITION]), primarily because of falls, which have a rising incidence in this age group. IV. Resident specific findings A. Resident #15 Resident #15, age 49, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 2/1/17 minimum data set (MDS) assessment, the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. No mood or behavior symptoms were noted. She required supervision with set up only with all activities of daily living (ADLs). She was receiving a scheduled pain medication regimen. She had no fall since admission or since the prior assessment. The care plan, initiated 2/28/17, last revised on 3/1/17, identified the resident was a fall risk due to the [DIAGNOSES REDACTED]. The interventions included to keep the call light at resident's reach, make sure the resident had non-skid footwear and monitor for falls/injury and notify the physician. According to the situation, background, assessment and recommendation (SBAR) communication form, dated 1/7/17, the resident slipped and fell on the floor in the small dining room. She tried to catch herself with her right hand and hit the left side of her face and head (the SBAR did not indicate if she struck her head on an object or the floor). Interventions were neurological assessment checks 15 minutes for the first hour, then 30 minute checks until the end of the shift. The form noted the resident appeared 'in some pain.' The assessment and the appearance of the resident was signed as completed by the licensed practical nurse (LPN). The nursing progress note dated 1/7/17 at 5:04 p.m. documented the following vital signs: 12/29/16 (the vitals automatically pulled from the last available recorded set, indicating they were not obtained on 1/7/17), B/P (blood pressure) 113/88, Pulse (P) 86, type was regular, Respiration (R) 18, Temperature (T) 98.2 (Tympanic) and Oxygen saturation (O2) 98 % RA (Percentage, Room Air). The physician in charge notified at 1/7/17 at 4:30 p.m. According to the SBAR communication form, dated 2/14/17, the resident was found (down) on sidewalk across from facility this pm (evening). It was unknown where resident was going. This writer walked across (street) to see what had happened and then noticed (resident) lying on right side on sidewalk. Laceration noted to right side of eye with bruising. 911 was called by passing motorist. Resident stated she had been consuming alcohol. Resident was taken to hospital via EMS (emergency medical services) staff. The assessment and the appearance of the resident was completed by the LPN. The nursing progress note, SBAR summary dated 2/14/17 at 8:13 p.m. documented the resident appeared to have increased confusion r/t (related to) voicing that she had consumed alcohol. The resident left the building without signing out and it was unknown where resident was going. The nursing progress note dated 2/15/17 at 2:52 a.m., documented the resident returned to the facility without an [MEDICAL CONDITION] and no fracture. The resident was noted to have soft tissue swelling, bruising around both eyes and sutures to the right eye area. Record review revealed there were no RN assessments or neurological checks completed following either of the resident's falls. B. Resident #18 Resident #18, age 81, was admitted into the facility on [DATE]. According to the face sheet, the [DIAGNOSES REDACTED]. According to the 2/15/17 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of ten out of 15. No mood or behavior symptoms were noted. She required supervision with bed mobility, toilet use and grooming. She required extensive assistance with transfers. No fall was noted since admission or the prior assessment. The care plan, initiated 2/28/17, identified the resident was at risk for falls related to the [DIAGNOSES REDACTED]. According to the SBAR communication form, dated 1/21/17, the resident hit the right side of her head against the doorframe while rising from the toilet. No swelling or bruising was noted at the time. Skin remains intact. MD (physician) notified. Will continue to monitor. The assessment and the appearance of the resident was completed by the LPN. The nursing progress note, SBAR summary type dated 1/21/17 at 10:00 p.m., documented vital signs of 1/21/17, BP 110/62, P 62 - regular, R 16, T 98.8, Tympanic, O2 sat 97.0 RA (room air). Will continue to monitor. Record review revealed the facility failed to ensure a RN completed an initial assessment and initiated neurological checks immediately after the resident hit her head on the doorframe. C. Resident #13 Resident #13, age 58, was admitted [DATE]. According to the face sheet, the [DIAGNOSES REDACTED]. According to the 1/30/17 MDS assessment, the resident had severe cognitive impairment with a BIMS score of five out of 15. No mood or behavior symptoms were noted. He required limited assistance with bed mobility. He required extensive assistance with toilet use, grooming and supervision with transfers. No falls were noted since admission or the prior assessment. The care plan, initiated 12/3/15 and last revised 9/19/16, identified the resident was at risk for falls due to balance problems, unsteady gait, [MEDICAL CONDITION]'s disease and a history of falls. The intervention included proper footwear, increasing staff rounding and encouraging the resident to slow down his walking pace. The review of the nursing progress note, SBAR summary type dated 2/3/17 at 11:21 a.m., revealed resident moved from couch to floor. Neurological checks were noted as an intervention. The nursing progress note dated 2/4/17 at 9:59 p.m., documented, resident continues on fall F/U (follow/up). Record review revealed the facility failed to ensure a RN completed an initial fall assessment and initiated neurological checks immediately after the resident was found on the floor. D. Resident #5 Resident #5, age 53, was admitted on [DATE]. According to the face sheet, the [DIAGNOSES REDACTED]. According to the 12/22/16 MDS assessment, the resident had intact cognition with BIMS score of 14 out of 15. No mood or behavior symptoms were noted. She required supervision with all ADLs. She had a fall history on admission but no falls since she was admitted in to the facility. The care plan, initiated 2/28/17 identified the resident was at risk for increased potential for falls due to [DIAGNOSES REDACTED]. The intervention included to encourage the resident to ask for assistance with all transfers and mobility, staff to use a gait belt with all transfers and mobility, monitor for any falls/injury, and notify the physician as needed. According to the SBAR communication form dated 1/13/17, the resident was found on her left side on the floor in front of her W/C (wheelchair) by her bed. The resident stated was trying to transfer from the bed to her W/C, the W/C moved, and she slid down. The assessment and the appearance of the resident were completed by the LPN. The nursing progress note, SBAR summary type of 1/13/17 at 3:00 p.m., documented States feels sore from the fall. Requested PRN (as needed) pain medication. According to the SBAR communication form dated 1/14/17, the resident was found on the floor in her bathroom on her right side in front of her toilet. The resident was trying to hold onto the toilet bar but missed the bar and slid down. The physician and the DON were notified. The resident was her own responsible party. The assessment and the appearance of the resident were completed by the LPN. Review of the nursing progress notes dated 1/14/17 at 10:45 p.m., 1/15/17 at 6:17 a.m. and 1/15/17 at 10:47 a.m., revealed the resident received the following pain medications. Tylenol ES (Extra strength) 500 mg (milligram) by mouth every 6 (six) hours PRN for pain, and [MEDICATION NAME] HCL 50 mg tablet by mouth every 8 (eight) hours PRN for pain and discomfort. A nursing progress note, SBAR summary type of 2/4/17 at 4:00 p.m., documented the resident had no complaint of pain or injuries at this time. Will continue to monitor vitals. The primary care clinician was documented as notified. The assessment and the appearance of the resident were completed by the LPN. There was no documentation in the progress notes and SBAR communication form on 2/4/17 available that described why the resident was being monitored, or to which SBAR this was a summary. The initial SBAR was requested but not provided by the facility. A nursing progress note dated 2/5/17 at 5:48 a.m., documented, monitoring resident (sic) for recent fall, no bruise, no swelling noted, medicated for pain with good effect. A nursing progress note dated 2/5/17 at 9:22 p.m., documented, resident on fall F/U with no injury observed. Requested for PRN pain medication with positive result. The director of nursing (DON) was interviewed on 3/1/17 at 7:05 p.m. She said there was no documentation regarding resident #15's incident on 2/4/17. She said she would find the SBAR communication form and neurological assessment. However, these documents were not provided throughout or after the survey. Record review revealed the facility failed to ensure a RN performed an initial assessment and initiated neurological checks for falls on 1/13/17, 1/14/17 and 2/4/17, or completed SBAR communication form for the incident on 2/4/17. E. Resident #4 Resident #4, age 49, was admitted on [DATE]. According to the 2/17 computerized physician orders [REDACTED]. According to the 2/6/17 MDS assessment, the resident had no cognitive deficit with a BIMS score of 15 out of 15. He required supervision for transfers and locomotion on and of the unit. He utilized a wheelchair for ambulation and had range of motion impairment to both sides of his lower extremities. This resident was documented to have one fall without injury. According to a post fall review dated 1/7/17 at 4:30 a.m., the resident fell . No initial SBAR communication form and progress note was in the resident's chart. On 1/9/17 at 10:32 p.m. (two days after his fall) a note made by the LPN documented the following information on the SBAR summary report; blood pressure 148/80, pulse 88, respirations 20 and the resident's temperature was 97.2 Fahrenheit (F). Resident was non-compliant, asked resident to wait for this nurse to help him. The 1/9/17 post fall review documented the resident was found sitting on the floor by the electric wheelchair and stated he slipped. Record review revealed the fall was unwitnessed; however, no neurological assessments were provided by the facility when requested. The SBAR summary report indicated the LPN taking care of this resident when he fell documented the initial assessment immediately after the resident fell . There was no RN assessment documented immediately after the fall and no documentation neuro checks were initiated. F. Resident #7 Resident #7, age 105, was admitted on [DATE] and readmitted on [DATE]. According to the 2/17 CPO, [DIAGNOSES REDACTED]. According to the 2/20/17 MDS assessment, the resident had short-term and long-term memory problems so no BIMS was completed. He required extensive assistance with transfers and locomotion on and off the unit. He utilized a wheelchair for ambulation and was documented to have range of motion impairment to one side of his lower extremities. This resident was not documented to have any falls since the prior assessment date of 11/21/16. The 1/13/17 SBAR communication form and progress note documented the following information: The resident noted on floor in front of bed sitting. Per resident, I slid to the floor. Denies hitting head no injury. Bed in the low position call light within reach. Resident did not call for assistance. Denies pain at this time. Neuro (neurological) intact. Resident with skid free socks on. The note was signed by a LPN. The 1/13/17 SBAR summary note documented: resident blood pressure was 110/62 at 4:04 a.m., pulse 68, respirations 18 and temperature was 96.2 .slide out of bed to the floor. Addition nursing notes as applicable-neurological assessment initiated. Notwithstanding above reference to neuro checks, no neurological assessments were provided by the facility when requested. The SBAR communication form and progress note indicated the LPN taking care of this resident when he fell did the initial assessment after the resident fell . There was no documentation of a RN assessment immediately post fall for the resident. No post fall review was provided by the facility to confirm the interdisciplinary team (IDT) reviewed this resident post fall and monitored the resident's condition to ensure the continued care was appropriate. G. Resident #19 Resident #19, age 58, was admitted on [DATE]. According to the 2/17 CPO, [DIAGNOSES REDACTED]. According to the 2/15/17 MDS assessment, the resident had minimal to no cognitive deficit with a BIMS score of 14 out of 15. He required extensive assistance with transfers and locomotion on and off the unit. He utilized a walker and wheelchair for ambulation and had a range of motion impairment to one side of his upper extremity. This resident was documented to have one fall without injury. On 2/10/17 at 2:10 a.m. an SBAR communication form and progress note documented the following, resident noted to be on floor in bathroom. Per resident, I fell out of bed and crawl (sic) to the bathroom. Denies hitting head, denies pain, neuro intact, call light on bed, bed in low position. The resident's blood pressure was documented as 100/62, pulse 68, respirations 18 and the temperature was 97.6. The neurological assessments provided for the fall on 2/3/17 showed a LPN initiated the neurological assessment and completed the initial assessment after the resident fell . There was no indication of a RN assessment immediately following the resident's fall. H. Resident #8 Resident #8 was admitted on [DATE]. According to the 2/17 CPO, [DIAGNOSES REDACTED]. According to the most recent MDS dated [DATE], the resident was cognitively intact scoring 15 out of 15 on his BIMS. She was noted to have one fall. Record review revealed an IDT post fall review, dated 1/30/17. The review included the following documentation: Unwitnessed fall on 1/27/17 1910 (7:10 p.m.); no injury .Resident was found on the floor leaning against the wall, stated that she was trying to make her bed; ext(ensive) assist. The record did not contain an assessment of the fall (SBAR communication form) or progress notes pertaining to this fall incident. Therefore, there was no documentation a RN completed an initial assessment of the resident after the resident was found on the floor. The Glascow Coma Scale/Pupil Response Evaluation form indicated neuro checks were not started until two hours after the fall occurred. I. Resident #9 Resident #9 was admitted on [DATE]. According to the 2/17 CPO, [DIAGNOSES REDACTED]. According to the most recent MDS dated [DATE], the resident was cognitively intact scoring 12 out of 15 on their BIMS. The resident was noted to have one fall. Record review revealed an IDT post fall review, dated 1/30/17. The review included the following documentation: Date and Time of Fall: 1/27/17 1515 (3:15 p.m.) . Resident found sitting on the floor between his wheelchair and the bed, stated that he was attempting to transfer from bed to his wheelchair. The record did not contain a SBAR assessment of the fall or progress notes pertaining to this fall. Therefore, there was no documentation a RN completed an initial assessment of the resident after the resident was found on the floor. There was no documentation neuro checks were done following this incident. V. Interviews Registered nurse (RN) #1 was interviewed on 3/1/17 at 7:21 p.m. She said for all falls, whether witnessed or unwitnessed, the RN would assess the resident for injury and interview the resident to determine the root cause of the fall. The RN would initiate the neurological checks for falls, which lasted for 72 hours. She said the responsible party and the physician in charge would be notified. The RN would complete the SBAR and document in the progress notes. She said if there were any injuries, the staff would provide first aid and get an order for [REDACTED].>RN #3 was interviewed on 3/1/17 at 7:23 p.m. She said she was a RN so she would do the initial assessment if a resident fell in the facility. She said she expected the LPN who worked in the building to get her or another RN in the building if a resident fell . She said LPNs were not supposed to do the initial assessment. LPN #1 was interviewed on 3/1/17 at 7:25 p.m. she said when a resident falls in the facility, she gets the RN to do the initial assessment of the resident. She said she had been working at the facility for four years and she said it had always been policy for the LPN to get the RN when a resident fell . She said neurological assessments would be done on residents that had unwitnessed falls. LPN #3 was interviewed on 3/1/17 at 7:27 p.m. She said if a resident was found on the floor by an aide and called her to the resident area, she would check the resident first and call for a RN to assess the resident. She said after the RN assessment, the RN would initiate neurological assessments for unwitnessed falls for 72 hours. She also would notify the responsible party, call the physician and start an SBAR form, fill out the incident report and document in the progress notes. LPN #5 was interviewed on 2/28/17 at 1:10 p.m. She said the LPN always needs to get a RN if a resident fell so the RN could do the initial assessment of the resident. The DON was interviewed on 3/1/17 at 12:15 p.m. she said the only incident she was involved with was the one for resident #5 but she did not do a notation in the resident's chart. She confirmed a RN had not assessed all residents (noted above) immediately after their falls. The DON was interviewed again on 3/1/17 at 2:25 p.m. She said that for every fall, a nurse was supposed to start neuro checks immediately and complete a SBAR assessment. Each fall was supposed to be reviewed by the IDT, and the care plan updated as needed. She did not know the reason initial fall assessments by a RN and neuro checks were not completed for residents as revealed in the record reviews above.

Based on observations, record review, resident and staff interviews, the facility failed to ensure precautions were in place to prevent an accident with injury for two (#1 and #3) residents, out of 15 residents sampled for falls, out of 25 total sample residents. Specifically, the facility failed to ensure staff followed the precautions to prevent an accident with injury during transfers for resident #1 and #3. The facility's failure to use appropriate fall precautions contributed to resident #1 sustaining an arm fracture during a transfer. The findings included: I. Facility policy The facility's Fall Management policy, dated August 2012, included the following documentation: -Upon admission, the admitting nurse will complete the Fall Risk Assessment. The nurse will also complete the initial care plan and address risk factors to the resident on the plan of care and implement appropriate interventions as identified. -Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks. -The At-Risk Review committee members will review weekly all residents with falls for documentation, compliance, and interventions. After the At-Risk Review meeting, the IDT (interdisciplinary team) will perform the follow-up items assigned as indicated by the review. II. Facility in-service A staff education log was provided by the nursing home administrator (NHA) on 2/28/17 at 11:19 a.m. The education was titled, Resident transfer, and was conducted on 1/3/17. In pertinent part it read, Obtain information about the level of assistance required for the resident. Obtain assistance when required. Eg. Two person assistance. III. Resident Failures A. Resident #1 1. Resident Status Resident #1, age 61, was admitted on [DATE] and readmitted on [DATE]. The resident was discharged to the hospital 1/15/17 and returned 1/21/17. According to the 2/17 computerized physician orders [REDACTED]. According to the 10/31/16 (prior to his 1/15/17 discharge to the hospital) minimum data set (MDS) assessment, the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance with a two-person physical assist during transfers. 2. Injury during transfer 1/15/17 a. Record review A Situation, Background, Assessment and Recommendation (SBAR) Communication form dated 1/15/17 documented resident #1 transferred with a sit to stand lift, felt something pop in his right arm, and was experiencing pain of 10 out of 10 (10 being the worst pain). The licensed practical nurse (LPN) assessed the resident for right arm pain and requested an x-ray. The resident reported he could not use his right arm. The physician and family were notified. The nursing progress note dated 1/21/17 documented the resident returned from the hospital. He was alert, with a sling to the right arm with staples in place. A review of the hospital record revealed the resident had a right humerus fracture and radial nerve palsy. Right orifice of humerus procedure performed (the upper arm was broken and a surgical repair was performed). Treatment included Physical Therapy, gentle range of motion (ROM) with the right shoulder but non-weight bearing. Care plan review revealed the resident's plan for potential injury due to the resident's inability to self-transfer, weakness, impaired mobility and Parkinson's [DIAGNOSES REDACTED]. Interventions included extensive assistance with transfers of two people with a mechanical lift, to provide a sit to stand lift to/from toilet, to/from chair and to/from bed. PT/OT (Physical therapy/Occupational therapy) PRN (as needed) and use a calm approach when using the lift. b. Resident Interview The resident was interviewed in his room on 2/28/17 at 9:00 a.m. and again at 1:35 p.m. He said that on 1/15/17, the aide transferring him was not paying attention to what she was doing. The aide was a part-time employee and worked two jobs. He said the aide was using a sit to stand lift for the transfer. The aide raised the handle part of the sit to stand lift too high while transferring him, and he told the aide to stop but she was not listening. His right shoulder snapped, causing him pain to his right shoulder. He said the certified nurse aides (CNAs) had been using the (full mechanical) lift to transfer him since he fractured his arm. He said since he returned from the hospital, two CNAs use the (full mechanical) lift to transfer him but, sometimes, there was only one CNA because they were either working short or not enough aides were on the floor. He said he felt safe with two-persons assisting him with transfers using the mechanical lift. 3. Observations of unsafe transfer On 2/27/17 at 5: 19 p.m., resident #1 was observed being transferred from his bed to his wheelchair by CNA #10. Half way through the transfer, the resident was left in the sling, hanging on the mechanical lift. The CNA left the resident in that position in bed to look for a second CNA to help with the transfer. The resident was not secured while the CNA left the room. A second CNA was brought into the room and both CNAs were observed completing the transfer of the resident from the bed to the wheelchair. 4. Staff interview On 2/28/17 at 1:55 p.m., the director of nursing (DON) was interviewed. She said the resident had a [DIAGNOSES REDACTED]. She said the incident could have been avoided if the CNA transferring the resident asked for an assistant. She said that if every staff had proper training on the use of the mechanical lifts, maybe the CNA would know not to self-transfer with a mechanical lift. She said the incident was avoidable. She said moving forward, an in-service would be conducted for all the staff to prevent a future occurrence. 5. Facility follow up On 3/3/17, after survey exit, the facility faxed an in-service training log provided by the facility's therapy staff. It was documented on 1/23/17 that the facility therapist provided an in-service regarding the use of mechanical lift for resident #1 after his injury. It did not address the need for two staff and noted, staff to use (mechanical lift) for transfers - to position right arm appropriately and to adhere to non-weight bearing status. B. Resident #3 1. Resident Status Resident #3 was admitted on [DATE]. According to the 2/17 CPO, [DIAGNOSES REDACTED]. According to the 2/6/17 MDS assessment, the resident had severely impaired cognitive skills for daily decision-making. No mood or behavior symptoms were noted. She required extensive assistance for transfers. The care plan, initiated 12/16/15 and revised 10/10/16, identified the resident was at risk for falls related to poor safety awareness, dementia, history of falls, and gait/balance. Interventions included a fall mat on the floor next to her bed, extensive assistance of one staff, and gait belt use for safety with transfers and ambulation. A physician note, dated 1/13/17, read, in pertinent part, She speaks no English but is back up during (the) day wheeling through halls. The record indicated the resident had an unwitnessed fall out of her wheelchair onto the floor in the dining room on 1/28/17. There were no apparent injuries noted. 2. Observations The following observations were made on 2/28/17: -At 7:10 a.m. the resident was observed being pushed at a fast pace from her room to the dining room by CNA #4. There were no leg rests on the wheelchair, and the aide did not ask the resident to lift her feet. The resident's feet were observed to brush the floor during her wheelchair transfer to the dining room. -At 8:09 a.m. the same aide again pushed the resident in her wheelchair back to her room without first ensuring the resident's feet were lifted so as to not touch the floor. -At 8:13 a.m. the aide was observed to transfer the resident from the wheelchair to her bed. A gait belt was not used during the transfer. There was no fall mat on the floor. 3. Staff interviews CNA #4 was interviewed on 2/28/17 at 8:46 a.m. She said she frequently cared for the resident. She said the resident usually self-propelled while in her wheelchair, but sometimes staff pushed her to and from the dining room. Training for staff in wheelchair management had not been provided over the past year. She further stated she had not observed a fall mat in the resident's room for two months and said she used a gait belt for transfers if she felt the resident was weak. The physical therapist (PT) was interviewed on 2/28/17 at 10:01 a.m. She said nurse aides were supposed to use a gait belt for every transfer with resident #3 because the resident did not position herself properly. She acknowledged she had previously seen nurse aides transfer the resident without a gait belt. The DON was interviewed on 2/28/17 at 9:00 a.m. and on 3/1/17 at 2:22 p.m. She said interventions listed on the resident's falls care plan, including the use of a gait belt for transfers and a fall mat on the floor, were supposed to be implemented on a consistent basis. VI. System Failures The DON was interviewed on 2/28/17 at 9:00 a.m. and on 3/1/17 at 2:22 p.m. She said not all nurse aides received training in the use of mechanical lifts for transfers over the past year. She said training in the proper use of wheelchairs had not been provided for nursing staff over the past year. She said the staff development coordinator (SDC) was responsible for setting up the training schedule and, currently, the SDC position was vacant. The MDS Coordinator (MDSC) was interviewed on 3/2/17 at 9:35 a.m. He said the facility had a weekly At-Risk Review Committee that reviewed weights. The Committee did not review falls and accidents. The Health Information Coordinator (HIC) was interviewed on 3/2/17 at 9:39 a.m. She said she attended the At-Risk Committee every Tuesday, along with the administrator, dietitian, and nursing staff. The Committee reviewed weights. Falls were not reviewed by the Committee. The medical director (MD) was interviewed on 3/2/17 at 11:46 a.m. He said that during the facility's monthly QAPI (quality assessment and performance improvement) committee meetings, a verbal discussion took place regarding falls occurring in the facility. The expectation was that nursing staff was knowledgeable in all types of transfers, including mechanical lift transfers. If it was identified that one nursing staff member did not use a lift in a safe and correct manner while transferring a resident, all nursing staff were supposed to be in-serviced right away to ensure that safe procedures were followed for all transfers, including those which involved the use of various mechanical lifts. The nursing home administrator (NHA) and HIC were interviewed on 3/1/17 at 5:30 p.m. They said that since the last recertification survey in July 2016, one action plan (performance improvement plan - PIP) was developed by the QAPI Committee. No action plans were developed to address the quality deficiencies - including falls - which were cited in the July survey.

Based on interviews and record review, the facility failed to protect residents including one (R69) of 22 sampled residents from abuse. Cross Reference F225 and F226. Resident (R) 69 alleged to facility staff on 6/25/16, Registered Nurse (RN) 20 abused and neglected him; even though the police, the Social Worker (SW) and the Director of Nursing (DON) were aware of what happened, there was no evidence the facility identified the abuse and neglect allegation, investigated the allegation, protected the residents during the investigation or followed their own policy and procedures. RN20 remained on the current staffing schedule and continued to work with R69 until 7/12/16, when he went home sick. The facility's failure to recognize resident abuse and timely respond to R69's allegations of abuse created a situation of Immediate Jeopardy. Findings include: I. Imposition of Immediate Jeopardy The District Director of Operations (DDO - who was also the Acting Administrator) and the Interim Director of Nursing (IDON - who was also the Regional Nurse) were notified of the Immediate Jeopardy on 7/13/16 at 9:36 a.m. II. Facility Response and Removal of the Immediate Jeopardy On 7/13/16 at 7:45 p.m., the facility provided an acceptable plan of removal which included: -all alert interviewable residents were interviewed to determine whether other residents had any issues with staff regarding abuse and whether the residents knew who they should contact in the event abuse occurred; -the nurse who was identified in the alleged abuse allegation was suspended as well as the Director of Nursing, Administrator and Social Service Director; -all staff that were present on the day, evening and night shifts were re-inserviced regarding the facility's Abuse policy; -the facility determined which staff were not present for the inservice (approximately 45 of their 100 employees) and contacted them by telephone to inform the employees they would have to receive inservice education regarding the facility's Abuse policy before they would be allowed to work in the facility and the administrative staff changed the security codes on all the doors so previous employees could not enter the facility other than through the front door during normal business hours and per the doorbell during the evening and night hours. On 7/13/16 at 7:45 p.m., the District Director of Operations and the acting Director of Nursing (DON) were notified that the above plan was accepted and the immediate jeopardy was removed. However, based on interviews and record review, the deficient practice remained at an E level, a pattern with the potential for more than a minimal harm. III. Expectations Review of the facility's policies and procedures revealed a document entitled, Abuse & Neglect Prohibition dated June 2013 which provided the following information: Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. The facility does not allow involuntary seclusion. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. Fundamental information Some residents may be abusive or abrasive toward staff and/or visitors. A resident's actions may be a result of the aging process, certain illnesses or because the resident is unhappy with his or her current situation. Employees should be aware of the potential for hostile responses for residents and report such incidents to their immediate supervisor for their own protection . Investigation The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. The facility will report such allegations to the state, in accordance with state regulation. The facility will report all investigation findings to the state in accordance with state regulations. The facility will investigate all patterns, trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property, identified through analysis conducted by the QAPI (Quality Assurance and Performance Improvement) Committee, with intervention, reporting, or policy/procedure modification conducted as appropriate. Protection The facility will protect residents from harm during the investigation . Documentation Incident/Accident Report for Residents (Briggs) Inservice (sic) Report (Briggs) Concern Report (Briggs) Concern Report Log (Briggs) IV. Allegation of Abuse - Investigation Failures Review of the medical record revealed R69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 4/13/16 quarterly Minimum Data Set (MDS) assessment revealed the facility coded R69 as understood, understands others, independent with activities of daily living (ADL), in chronic pain and he was coded a 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he was not cognitively impaired. An interview with R69, who was seated in his room on the South unit, on 7/12/16 at 11:00 a.m. revealed he was fearful for himself and other residents in the facility. R69 stated RN20 withheld R69's pain medications in retaliation when R69 filed complaints about the facility practices. R69 added, approximately 3 weeks prior (in late June), RN20 refused to give R69 medications timely and RN20 stated, You white Americans need to get out of the way and let the Muslims run this facility. You are going to see how I can shoot my gun. Per R69, he and RN20 had many altercations in the past, but this time the police were called. R69 added, when the police entered his room after the altercation between himself and RN20, they just searched his room for weapons and then they left the facility. R69 stated he did not know why RN20 called the police, he stated, I should have called the police on him, not the other way around. R69 stated he told the facility staff he did not want RN20 assigned to his care in the future. However, he stated staff ignored his request and RN20 had been scheduled to work on the South unit the whole month of July 2016. R69 stated, today RN20 was in R69's room and tried to give R69 medications. R69 said, I told him, 'no way, you are not supposed to be anywhere near me.' Review of the Incident Log(s) dated 1/1/16 through 7/12/16 revealed there was no documentation relative to R69's allegation of potential abuse and neglect. Review of the Behavior Monitoring Schedule dated 6/25/16 revealed at 1:00 p.m. during RN20's shift, R69 was verbally abusive toward staff. Per the documentation R69 was, verbally abusive and physically threatening with an AK-47 (a rifle) which per the documentation, was kept two houses down from this facility. Per the documentation, R69 stated, immigrants are terrorists and you idiot from Somalia - I am going to kill you! The behavior monitoring sheet was signed by RN20. An interview with the SW (also SW34) and the DON (also RN81) on 7/12/16 at 11:45 a.m. revealed they were in the facility on 6/25/16 when the altercation began between R69 and RN20. SW34 stated R69 came to her because RN20 refused to give him his medications. SW34 stated when she and R69 were on their way to the nursing unit to discuss the matter with RN20, R69 told her RN20 said, You white Americans need to get out of the way and let the Muslims run this facility. You are going to see how I can shoot my gun. They said the SW, the DON, R69 and RN20 were at the nursing unit discussing the situation, when RN20 picked up the telephone and called the police. When asked why RN20 called the police, the SW and the DON stated they were unsure. When interviewed about what the police did when they arrived at the facility, the SW and the DON said they were unsure. The DON and the SW stated the police did not file a report but the detective stated, Make sure you keep these two people separated. The SW and DON said they did not complete a thorough investigation or follow the facility's Incident & Accident form or the Abuse and Neglect Prohibition policies and procedures. Review of the July schedule revealed RN20 was scheduled to work on the South unit, (the unit where R69 resided) on the following days:-7/1 through 7/3/16 from 6:00 a.m. until 2:30 p.m. -7/6 and 7/7/16 from 2:00 pm until 10:30 p.m. -7/8 through 7/12/16 from 6:00 a.m. until 2:30 p.m. Review of the 7/12/16 schedule on 7/12/16 revealed RN20 was scheduled to work on the South unit from 6:00 a.m. until 2:30 p.m.; however, per the documentation on the schedule, RN20 was Moved to North (unit) at 10:30 a.m. Observation of the North unit on 7/12/16 at 11:30 p.m. revealed RN20 was not present. Per interview with Licensed Practical Nurse (LPN) 9 at that time, RN20 went home sick. RN20 was not available for interview. Review of the Kronos Punch Detail (time cards) revealed RN20 clocked in and worked on the days as scheduled; 7/1-7/3/16 and 7/6-7/12/16. Further review of the time cards revealed RN20 worked 6/24-6/28/16; during the 6/25/16 altercation with R69. An interview with the Interim Administrator (employee 75) on 7/12/16 at 12:00 p.m. revealed she was the SW at this facility until just a few months ago. The Interim Administrator stated the previous Administrator was re-assigned to another facility and she was the Interim Administrator until the facility could find a replacement. The Interim Administrator stated she was not immediately informed of the altercation between R69 and RN20 on 6/25/16, but she was aware R69 and RN20 had altercations in the past. She said, a few days before the altercation on 6/25/16, R69 and R20 had another altercation and she (the Interim Administrator) called the police and left a message. The Interim Administrator stated the police did not return the call, and she did not follow up on the altercation. She said she did not investigate the alleged altercation, she did not complete an incident report, she did not suspend anyone pending outcome of an investigation and she did not interview all the parties involved. However, she was aware the police recommended to keep R69 and RN20 apart. The Interim Administrator stated she was unware RN20 was scheduled to work on the South unit, until today (7/12/16). She said when she realized RN20 was scheduled to work on the South unit, she immediately took him off the unit and sent him to the North unit. The Interim Administrator stated the facility did not complete any incident reports relative to R69's or RN20's actions, they did not investigate the alleged altercations, they did not suspend RN20 pending the outcome of the investigation, and they failed to ensure R69 and the other residents were safe from physical and verbal abuse while an investigation was conducted; the facility failed to follow their abuse policy and procedures. An interview with the DDO on 7/14/16 at 10:00 a.m. revealed R69 and RN20 had another altercation on 7/1/16, however, the facility did not document the altercation on the behavioral monitoring sheet, they did not complete an incident report, they did not investigate the allegation, and they did not protect other residents pending outcome of the investigation. The DDO confirmed the facility did not follow the abuse and neglect policy and procedures when they failed to complete a thorough investigation for each allegation and suspend the appropriate employees pending the outcome of the investigation.

Based on interviews, record review, and review of policies and procedures, the facility failed to operationalize their Abuse & Neglect Prohibition policy and procedure which affected residents including one (R69) of 22 sampled residents. Resident (R) 69 alleged to facility staff on 6/25/16, Registered Nurse (RN) 20 abused and neglected him; even though the police, the Social Worker (SW) and the Director of Nursing (DON) were aware of what happened, there was no evidence the facility identified the abuse and neglect allegation, investigated the allegation, protected the residents during the investigation or followed their own policy and procedures. RN20 remained on the current staffing schedule and continued to work with R69 until 7/12/16, when he went home sick. The facility's failure to operationalize their abuse prevention policies created a situation of Immediate Jeopardy. Findings include: I. Imposition of Immediate Jeopardy The deficient practice resulted in an Immediate Jeopardy (IJ) situation that was conveyed to the District Director of Operations and the Interim Director of Nursing on 7/13/16 at 9:36 a.m. II. Facility Response and Removal of the Immediate Jeopardy On 7/13/16 at 7:45 p.m., the facility provided an acceptable plan of removal which included: -all alert interviewable residents were interviewed to determine whether other residents had any issues with staff regarding abuse and whether the residents knew who they should contact in the event abuse occurred; -the nurse who was identified in the alleged abuse allegation was suspended as well as the Director of Nursing, Administrator and Social Service Director; -all staff that were present on the day, evening and night shifts were re-inserviced regarding the facility's Abuse policy; -the facility determined which staff were not present for the inservice (approximately 45 of their 100 employees) and contacted them by telephone to inform the employees they would have to receive inservice education regarding the facility's Abuse policy before they would be allowed to work in the facility and the administrative staff changed the security codes on all the doors so previous employees could not enter the facility other than through the front door during normal business hours and per the doorbell during the evening and night hours. On 7/13/16 at 7:45 p.m., the District Director of Operations and the acting Director of Nursing (DON) were notified that the above plan was accepted and the immediate jeopardy was removed. However, based on interviews and record review, the deficient practice remained at an E level, a pattern with the potential for more than a minimal harm. III. Expectations Review of the facility's policies and procedures revealed a document entitled, Abuse & Neglect Prohibition dated June 2013 which provided the following information: Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. The facility does not allow involuntary seclusion. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. Fundamental information Some residents may be abusive or abrasive toward staff and/or visitors. A resident's actions may be a result of the aging process, certain illnesses or because the resident is unhappy with his or her current situation. Employees should be aware of the potential for hostile responses for residents and report such incidents to their immediate supervisor for their own protection . Investigation The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. The facility will report such allegations to the state, in accordance with state regulation. The facility will report all investigation findings to the state in accordance with state regulations. The facility will investigate all patterns, trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property, identified through analysis conducted by the QAPI (Quality Assurance and Performance Improvement) Committee, with intervention, reporting, or policy/procedure modification conducted as appropriate. Protection The facility will protect residents from harm during the investigation . Documentation Incident/Accident Report for Residents (Briggs) Inservice (sic) Report (Briggs) Concern Report (Briggs) Concern Report Log (Briggs) IV. Abuse allegation - Investigation Failures Review of the medical record revealed R69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 4/13/16 quarterly Minimum Data Set (MDS) assessment revealed the facility coded R69 as understood, understands others, independent with activities of daily living (ADL), in chronic pain and he was coded a 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he was not cognitively impaired. An interview with R69, who was seated in his room on the South unit, on 7/12/16 at 11:00 a.m. revealed he was fearful for himself and other residents in the facility. R69 stated RN20 withheld R69's pain medications in retaliation when R69 filed complaints about the facility practices. R69 added, approximately 3 weeks prior (in late June), RN20 refused to give R69 medications timely and RN20 stated, You white Americans need to get out of the way and let the Muslims run this facility. You are going to see how I can shoot my gun. Per R69, he and RN20 had many altercations in the past, but this time the police were called. R69 added, when the police entered his room after the altercation between himself and RN20, they just searched his room for weapons and then they left the facility. R69 stated he did not know why RN20 called the police, he stated, I should have called the police on him, not the other way around. R69 stated he told the facility staff he did not want RN20 assigned to his care in the future. However, he stated staff ignored his request and RN20 had been scheduled to work on the South unit the whole month of July 2016. R69 stated, today RN20 was in R69's room and tried to give R69 medications. R69 said, I told him, 'no way, you are not supposed to be anywhere near me.' Review of the Behavior Monitoring Schedule dated 6/25/16 revealed at 1:00 p.m. during RN20's shift, R69 was verbally abusive toward staff. Per the documentation R69 was, verbally abusive and physically threatening with an AK-47 (a rifle) which per the documentation, was kept two houses down from this facility. Per the documentation, R69 stated, immigrants are terrorists and you idiot from Somalia - I am going to kill you! The behavior monitoring sheet was signed by RN20. An interview with the SW (also SW34) and the DON (also RN81) on 7/12/16 at 11:45 a.m. revealed they were in the facility on 6/25/16 when the altercation began between R69 and RN20. SW34 stated R69 came to her because RN20 refused to give him his medications. SW34 stated when she and R69 were on their way to the nursing unit to discuss the matter with RN20, R69 told her RN20 said, You white Americans need to get out of the way and let the Muslims run this facility. You are going to see how I can shoot my gun. They said the SW, the DON, R69 and RN20 were at the nursing unit discussing the situation, when RN20 picked up the telephone and called the police. When asked why RN20 called the police, the SW and the DON stated they were unsure. When interviewed about what the police did when they arrived at the facility, the SW and the DON said they were unsure. The DON and the SW stated the police did not file a report but the detective stated, Make sure you keep these two people separated. The SW and DON said they did not complete a thorough investigation or follow the facility's Incident & Accident form or the Abuse and Neglect Prohibition policies and procedures. Review of the July schedule revealed RN20 was scheduled to work on the South unit, (the unit where R69 resided) on the following days:-7/1 through 7/3/16 from 6:00 a.m. until 2:30 p.m. -7/6 and 7/7/16 from 2:00 pm until 10:30 p.m. -7/8 through 7/12/16 from 6:00 a.m. until 2:30 p.m. Review of the 7/12/16 schedule on 7/12/16 revealed RN20 was scheduled to work on the South unit from 6:00 a.m. until 2:30 p.m.; however, per the documentation on the schedule, RN20 was Moved to North (unit) at 10:30 a.m. Observation of the North unit on 7/12/16 at 11:30 p.m. revealed RN20 was not present. Per interview with Licensed Practical Nurse (LPN) 9 at that time, RN20 went home sick. RN20 was not available for interview. Review of the Kronos Punch Detail (time cards) revealed RN20 clocked in and worked on the days as scheduled; 7/1-7/3/16 and 7/6-7/12/16. Further review of the time cards revealed RN20 worked 6/24-6/28/16; during the 6/25/16 altercation with R69. An interview with the Interim Administrator (employee 75) on 7/12/16 at 12:00 p.m. revealed she was the SW at this facility until just a few months ago. The Interim Administrator stated the previous Administrator was re-assigned to another facility and she was the Interim Administrator until the facility could find a replacement. The Interim Administrator stated she was not immediately informed of the altercation between R69 and RN20 on 6/25/16, but she was aware R69 and RN20 had altercations in the past. She said, a few days before the altercation on 6/25/16, R69 and R20 had another altercation and she (the Interim Administrator) called the police and left a message. The Interim Administrator stated the police did not return the call, and she did not follow up on the altercation. She said she did not investigate the alleged altercation, she did not complete an incident report, she did not suspend anyone pending outcome of an investigation and she did not interview all the parties involved. However, she was aware the police recommended to keep R69 and RN20 apart. The Interim Administrator stated she was unware RN20 was scheduled to work on the South unit, until today (7/12/16). She said when she realized RN20 was scheduled to work on the South unit, she immediately took him off the unit and sent him to the North unit. The Interim Administrator stated the facility did not complete any incident reports relative to R69's or RN20's actions, they did not investigate the alleged altercations, they did not suspend RN20 pending the outcome of the investigation, and they failed to ensure R69 and the other residents were safe from physical and verbal abuse while an investigation was conducted; the facility failed to follow their abuse policy and procedures. An interview with the DDO on 7/14/16 at 10:00 a.m. revealed R69 and RN20 had another altercation on 7/1/16, however, the facility did not document the altercation on the behavioral monitoring sheet, they did not complete an incident report, they did not investigate the allegation, and they did not protect other residents pending outcome of the investigation. The DDO confirmed the facility did not follow the abuse and neglect policy and procedures when they failed to complete a thorough investigation for each allegation and suspend the appropriate employees pending the outcome of the investigation.

Based on resident and staff interviews, and record review, the facility failed to have evidence an allegation of abuse/ neglect involving one (R69) of 22 sampled residents was thoroughly investigated, timely reported, and steps were taken to protect this resident and other facility residents from potential abuse. On 7/12/16 at 11:00 a.m. R69 stated he was fearful for himself and other residents in this facility. R69 stated one Registered Nurse (RN) 20 had withheld his pain medications in retaliation for reporting some of the unbelievable situations in this facility. R69 added approximately 3 weeks prior, in late June, RN20 refused to give him his medications timely and he stated, You white Americans need to get out of the way and let the Muslims run this facility. You are going to see how I can shoot my gun. R69 stated the facility did not ensure R20 was removed from his unit and was not assigned to his care. R69 stated today, 7/12/16, RN20 was in his room and tried to give him his medications. R69 said, I told him, 'no way, you are not supposed to be anywhere near me.' Record review and interview revealed the above incidents were not timely reported, timely or thoroughly investigated, did not lead to the implementation of protective measure by the facility to prevent further abuse. The facility's failures created a situation for residents of immediate jeopardy for serious harm. Findings include: 1. Imposition of Immediate Jeopardy On 7/13/16 at 9:36 a.m., the District Director of Operations and the acting Director of Nursing (DON) were informed by the Healthcare Management Solutions (HMS) the facility failures in reporting, investigating the alleged abuse allegations and resident protection during the investigation left facility residents vulnerable to further abuse and created a situation of Immediate Jeopardy for serious harm. II. Facility Response and Removal of the Immediate Jeopardy On 7/13/16 at 7:45 p.m., the facility provided an acceptable plan of removal which included: -all alert interviewable residents were interviewed to determine whether other residents had any issues with staff regarding abuse and whether the residents knew who they should contact in the event abuse occurred; -the nurse who was identified in the alleged abuse allegation was suspended as well as the Director of Nursing, Administrator and Social Service Director; -all staff that were present on the day, evening and night shifts were re-inserviced regarding the facility's Abuse policy; -the facility determined which staff were not present for the inservice (approximately 45 of their 100 employees) and contacted them by telephone to inform the employees they would have to receive inservice education regarding the facility's Abuse policy before they would be allowed to work in the facility and the administrative staff changed the security codes on all the doors so previous employees could not enter the facility other than through the front door during normal business hours and per the doorbell during the evening and night hours. On 7/13/16 at 7:45 p.m., the District Director of Operations and the acting Director of Nursing (DON) were notified that the above plan was accepted and the immediate jeopardy was removed. However, based on interviews and record review, the deficient practice remained at an E level, a pattern with the potential for more than a minimal harm. III. Expectations Review of the facility's policies and procedures revealed a document entitled, Incident/Accident Reporting for Residents dated June 2013 which provided the following information: Policy All incidents, accidents, and unusual occurrences involving a resident are documented and reported. All incidents that are considered to be, or that have the potential to be, significant and/or serious are reported timely to the facility Administrator (abuse coordinator) and to Risk Management in accordance with any Federal and State law. The facility thoroughly investigates any such incident. Fundamental Information All forms, reports, and data collected for the purposes of identifying potential quality of care issues must be reviewed as part of the Quality Assurance and Performance Improvement (QAPI) process. Definitions Incidents, Accidents and Unusual Occurrences Any event not consistent with routine resident care; Any event reportable to Federal and State agencies accordance with State and/or Federal law; and Any event involving a resident with negative or harmful results or outcomes. Significant/Serious Incidents Incidents that are reported to Clinical Services, Operations, Risk Management, and the Legal Department include, but are not limited to, the following: Assaults/Abuse (verbal, emotional, sexual, physical) between any parties (resident or staff) . Procedure . 3. The facility initiates an investigation for all incidents 4. The facility documents all incidents (Significant/Serious or not) . 5. Completed reports are forwarded to the Administrator and DON for review within 24 hours of the event . Further review of the facility's policies and procedures revealed a document entitled, Abuse & Neglect Prohibition dated June 2013 which provided the following information: Investigation The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. IV. Allegation of Abuse - Investigation Failures Review of the medical record revealed that R69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility coded R69 as being; understood, understands others, independent with activities of daily living (ADL), in chronic pain and he was coded a 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he was not cognitively impaired. An interview with R69, who was seated in his room on the South unit, on 7/12/16 at 11:00 a.m. revealed he was fearful for himself and other residents in the facility. R69 stated RN20 withheld R69's pain medications when R69 filed complaints about the facility practices. R69 added, approximately 3 weeks prior (in late June), RN20 refused to give R69 medications timely and RN20 stated, You white Americans need to get out of the way and let the Muslims run this facility. You are going to see how I can shoot my gun. Per R69, he and RN20 had many altercations in the past, but this time the police were called. R69 added, when the police entered his room after the altercation between himself and RN20, they just searched his room for weapons and then they left the facility. R69 stated he did not know why RN20 called the police, he stated, I should have called the police on him, not the other way around. R69 stated he told the facility staff he did not want either nurse, RN20 or RN66, to be assigned to his care in the future. However, he stated staff ignored his request and RN20 had been scheduled to work on the South unit the whole month of July 2016. R69 stated, today RN20 was in R69's room and tried to give R69 medications. R69 said, I told him, 'no way, you are not supposed to be anywhere near me.' Review of the Incident Log(s) dated 1/1/16 through 7/12/16 revealed no documentation of R69's allegation of potential abuse and neglect. Review of the Behavior Monitoring Schedule dated 6/25/16 revealed at 1:00 p.m. during RN20's shift, R69 was verbally abusive toward staff. Per the documentation R69 was, verbally abusive and physically threatening with an AK-47 (a rifle) which per the documentation, was kept two houses down from this facility. Per the documentation, R69 stated, immigrants are terrorists and you idiot from Somalia - I am going to kill you! The behavior monitoring sheet was signed by RN20. An interview with the SW (also SW34) and the DON (also RN81) on 7/12/16 at 11:45 a.m. revealed they were in the facility on 6/25/16 when the altercation began between R69 and RN20. SW34 stated R69 came to her because RN20 refused to give him his medications. SW34 stated when she and R69 were on their way to the nursing unit to discuss the matter with RN20, R69 told her RN20 said, You white Americans need to get out of the way and let the Muslims run this facility. You are going to see how I can shoot my gun. They said the SW, the DON, R69 and RN20 were at the nursing unit discussing the situation, when RN20 picked up the telephone and called the police. When asked why RN20 called the police, the SW and the DON stated they were unsure. When interviewed about what the police did when they arrived at the facility, the SW and the DON said they were unsure. The DON and the SW stated the police did not file a report but the detective stated, Make sure you keep these two people separated. The SW and DON said they did not complete a thorough investigation or follow the facility's Incident & Accident form or the Abuse and Neglect Prohibition policies and procedures. An interview with the Interim Administrator (employee 75) on 7/12/16 at 12:00 p.m. revealed she was the SW at this facility until just a few months ago. The Interim Administrator stated the previous Administrator was re-assigned to another facility and she was the Interim Administrator until the facility could find a replacement. The Interim Administrator stated she was not immediately informed of the altercation between R69 and RN20 on 6/25/16, but she was aware R69 and RN20 had altercations in the past. She said, a few days before the altercation on 6/25/16, R69 and R20 had another altercation and she (the Interim Administrator) called the police and left a message. The Interim Administrator stated the police did not return the call, and she did not follow up on the altercation. She said she did not investigate the alleged altercation, she did not complete an incident report, she did not suspend anyone pending outcome of an investigation and she did not interview all the parties involved. However, she was aware the police recommended to keep R69 and RN20 apart. The Interim Administrator stated she was unware RN20 was scheduled to work on the South unit, until today (7/12/16). She said when she realized RN20 was scheduled to work on the South unit, she immediately took him off the unit and sent him to the North unit. The Interim Administrator stated the facility did not complete any incident reports relative to R69's or RN20's actions, they did not investigate the alleged altercations, they did not suspend RN20 pending the outcome of the investigation, and they failed to ensure R69 and the other residents were safe from physical and verbal abuse while an investigation was conducted; the facility failed to follow their abuse policy and procedures. An interview with the DDO on 7/14/16 at 10:00 a.m. revealed R69 and RN20 had another altercation on 7/1/16, however, the facility did not document the altercation on the behavioral monitoring sheet, they did not complete an incident report, they did not investigate the allegation, and they did not protect other residents pending outcome of the investigation. The DDO confirmed the facility did not follow the abuse and neglect policy and procedures when they failed to complete a thorough investigation for each allegation and suspend the appropriate employees pending the outcome of the investigation.

Based on observations, record review and interviews the facility failed to provide an effective social service program and resources for five (#14, #53, #94 and #115, and #31) of 32 sample residents. Specifically, the facility failed to provide social service assessments, end of life resources and emotional support, assistance with out of state transfers and tracking of resident personal property. The facility also failed to complete resident pre-admission screenings within the allotted state time line. For resident #53, who was receiving palliative cares, the failures by social service staff made the resident angry, anxious, and "forgotten." Findings: 1. Resident #53 Resident #53, age 49, was admitted to the facility on [DATE] at 5:00 p.m. with the [DIAGNOSES REDACTED]. The resident is currently receiving end of life cares and services. a. Resident Status The resident's minimum data set ((MDS) dated [DATE] documented the following information: Section C- cognitive status indicated that the resident was moderately cognitively impaired. The brief mental status exam (BIMS) was used as the tool to obtain the information. Section G- functional status documented that the resident was totally dependent on staff in all areas of activities of daily living. The computerized physician orders [REDACTED]. A care plan dated [DATE] documented that the resident was care planned for palliative cares. The problem identified was that the resident required support for choices in regards to daily living tasks and end of life issues. -The goal indicated the resident would experience end of life transition with comfort and dignity. -The approaches to achieve the documented goal included the social service department providing emotional support to resident and family as needed. b. Interviews On [DATE] at approximately 4:00 p.m., an interview was held with the resident. The interview revealed the following: - The resident was unaware that the facility social service department was available to assist her and her power of attorney (POA) with information and resources regarding the resident's palliative care. - The resident was unaware who in the facility the social service representative was, and had not met anyone from the social service department since admission on [DATE]. - The resident stated that she had not been offered any services by the social service staff or activity staff. She stated that she kept her room door shut because the hallway noise could get really loud and it was too much for her. - The resident stated that she felt like she was left in her room and forgotten about by the staff of the facility. She further stated that when the certified nursing assistants (CNAs) come in to assist her, she lets them know that she is in extreme pain and asks them to relay the need for provider ordered pain medication to the nurse. The resident stated that sometimes, it would take way too long for the nurse to respond and she would be anxious, angry and "hurting so badly" by the time the staff came in. - The resident was unaware that the social service department could work as a liaison between the resident and the staff and stated that she sure could use that. An interview with the resident's POA and primary caretaker was conducted on [DATE] at approximately 5:00 p.m. The interview revealed the following: - The facility social service department had not made any contact with the resident or the family since the resident had been admitted . - The POA was overwhelmed with all the "details" regarding the resident's end of life wishes and arrangements. The POA was attempting to make funeral arrangements on [DATE], and was told by the mortuary that certain indwelling medical devices would need to be "cut" out of her loved one before the mortuary would receive the body. The POA stated that this was too much for her to deal with and any assistance regarding practices after death at the nursing home would be very helpful for her. - The POA was not sure to whom in the facility to direct multiple questions regarding the resident's cares and needs for end of life arrangements. - The resident's POA had been providing urinary catheters and oxygen cannulas for the resident to the facility. The POA stated that if she had not been supplying catheters for the resident she would have had to be sent out for a catheter change because the facility did not have the proper physician ordered urinary catheters An interview with the director of social services on [DATE] at 1:15 p.m. revealed the following: - She did not know the resident. She was not aware that the resident was [AGE] years old, was end stage life, and on palliative cares. - She had not done any documentation for the resident and had not completed any social service assessments for the resident. - She said, "I do not know anything that is going on with her. I can only do what I know about. I have not met with her and have not done any social services for her." c. Record Review A review of the communication note from the agency supplying the resident with palliative care services indicated the resident was seen and assessed, and the social service department from the facility was to follow up with the resident on [DATE]. However, a review of the resident's record and interview with the facility social service manager (SSM) on [DATE] at 9; 50 am indicated the meeting with the resident on [DATE] did not occur. A review of the communication note from the agency supplying the resident with palliative care services dated [DATE], documented that a note would be left with the SSM regarding the coordination of services for the resident. On [DATE], [DATE] and [DATE], written and verbal requests were made to the facility requesting any and all social service progress notes for the resident. On [DATE] at 3:00 pm, the facility SSM, Assistant Director of Nurses (ADON #1), Director of Nurses (DON) and Regional Consultant (RCD) reported there were neither progress notes nor any assessments available for the resident from the facility social service staff. 2. Resident #14 a. Facility Policy The facility policy entitled "Transfer and Discharge" was requested and received from the Nursing Home Administrator on [DATE] at 3:14 p.m. It read in pertinent part: "Transfer or Discharge 1. Facility assists with preparation and orientation of the resident to ensure safe and orderly transfer or discharge from the facility... Preparation and orientation includes: -Informing the resident where he or she is going; -Taking steps to assure safe transportation; -Involving the resident and family in selecting the new residence; ... -Working with the family to assure that the resident's valued possessions are not left behind... -Making appropriate referrals; ..." b. Resident #14 (closed record) Resident #14, age 92, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident spoke only Russian. Resident Status: The MDS admission assessment, dated [DATE], indicated the resident had adequate hearing, unclear speech, usually understood and sometimes understands others. He scored a ,[DATE] in the Brief Interview for Mental Status (BIMS) indicating he was severely impaired in his cognitive skills. The resident had no medical power of attorney (MPOA) at this time; however, his granddaughter who lived in New York, was pursuing guardianship. Review of a social service note dated [DATE] indicated the resident had family support and lived at the facility with his wife. The social service person stated that a discharge plan was uncertain at this time. The next social service note was dated [DATE] and there was no mention of helping the granddaughter find placement for her grandparents in New York. The note indicated the resident often isolated in his room with his wife. On [DATE], the social worker documented the granddaughter was pursuing guardianship and wanted to move them to a facility in New York. The note read that the granddaughter was working with a colleague to look for appropriate placement. The facility was to work on getting a medical records release signed by the resident. The next social service note was dated [DATE]. It read the granddaughter was trying to find placement in New York for her grandparents. There was no evidence any follow-up with the discharge by social services. Social Service Failures: There was no care plan for discharge to a facility in New York as requested by the resident's granddaughter. The resident's granddaughter was interviewed by telephone on [DATE] at 9:30 a.m. She stated she did not receive any assistance from the facility in finding placement for her grandparents. She stated that her grandfather expired before she could transfer them and she was still looking for placement in New York for her grandmother who only spoke Russian. The newly hired social worker was interviewed on [DATE] at 9:30 a.m. She stated a family member came and took the resident's wife to the funeral and then left. She stated the discharge of the resident's wife needed to be re-evaluated. She was unaware of what if any assistance had been given to the granddaughter to relocate her grandparents. No other social service notes regarding resident #14's plans for discharge were provided by the social worker. 3. Residents #94 and #115 a. Inventory of Personal Effects form The facility's Inventory of Personal Effects form, which was present in some of the residents' charts, included the following instructions: -"Upon admission, identify the resident's personal belongings by indicating quantity of those items listed. Use space allowed to write in additional items as necessary. The original shall be kept in the resident's chart. The copy is given to the resident or resident representative. Update as necessary throughout the resident's stay by using the space provided. Upon discharge, use the "check" columns to indicate that all personal belongings are accounted for." b. Resident #94 Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the annual minimum data set (MDS) assessment, dated [DATE], the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. During an interview with the resident on [DATE] at 9:30 a.m., the resident stated that some of her clothes had gone missing over the past year. The resident said that some of the clothes that had gone missing were labeled while others were not. The resident explained that unclaimed items were brought to the lobby once a month so that residents could claim their personal property. The resident said, "Sometimes I've found my own personal items there. I can't afford to buy new clothes." The resident further verbalized on [DATE] at 11:20 a.m. that she periodically received gifts throughout the year, but that these gifts were not recorded on an inventory form. The resident said, "I got this wooden cane from my support group six months ago. It's special - it could never be replaced." The resident's record lacked evidence the resident's personal property was inventoried and tracked. There was no Inventory of Personal Effects form in the chart. c. Resident #115 Resident #115 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the resident had moderate cognitive impairment with a BIMS score of 8 out of 15. A nurse's note, dated [DATE], read, "Resident A & O x 3 (alert and oriented to person, place, and time), able to make needs known ...Call light within reach but resident will not use call light." The resident's record did not contain evidence the resident's personal property was inventoried and tracked. There was an Inventory of Personal Effects form in the chart, but it was blank. On [DATE] at 11:15 a.m., the resident was observed to be lying on his bed, awake. There was a DVD machine, along with several DVDs, in the top drawer of his dresser. The drawer also contained a blank Inventory of Personal Effects form. The contents of his closet included 10 tee shirts, seven long-sleeved shirts, slacks, and a BiPAP (bi-level positive airway pressure) machine. A nurse, who was present during this observation, communicated, "His wife was supposed to take it (the BiPAP machine) home, but she hasn't yet." The DVD machine and DVDs were not listed on the form. d. Staff Interviews The social services manager (SSM), who began working at the facility three weeks earlier, was interviewed on [DATE] at 1:30 p.m. With regard to residents' personal property, the SSM indicated that Nursing was supposed to complete the Inventory of Personal Effects form for each resident upon admission. The SSM verbalized, "When a resident or their family member brings in an item, they're supposed to go to me or Nursing, but most of them don't do that." On [DATE] at 1:50 p.m., the new social services assistant (SSA) indicated that the facility was implementing a new system for tracking residents' personal property. The SSA said, "We will put out notices to family members, and the CNAs (certified nursing assistants) or the nurses will add (items) to the inventory list. We want to make sure everything is documented so that if anything is misplaced we can get it back to them ..." 4. Resident #31 Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's record contained a nurse's note, dated [DATE], which read, "Res(ident) A & O x 3 (alert and oriented to person, time, and place), able to make needs known. Pleasant and cooperative w/all aspects of care ..." a. Record Review An Inventory of Personal Effects form, dated [DATE], indicated the resident had both upper and lower dentures, with both the "up" and "low" boxes checked off on the form under "Dentures." The undated Resident Care Cardex Worksheet, indicated the resident wore dentures. Under the section "Mouth Care," the space next to Dentures was checked, and a staff member wrote, "Remove in evening at bedtime, clean and store for AM use. Help put in dentures in AM." The resident's record did not contain a dental care plan, or any reference to the resident's use of dentures. On [DATE], a physician from the Dialysis center wrote, "Not wearing lower dentures ...Please call over to (Facility) and see if anything can be done on their end to help with his ill-fitting lower dentures." b. Resident Observation and Interview During an initial interview with the resident on [DATE] at 1:42 p.m., the resident was observed to only be wearing upper dentures. The resident was missing all of his lower teeth. The resident reported that his lower dentures had been missing "for a long time." The resident said, "They (the lower dentures) were thrown out with the bed sheets." The resident further stated, "I have a hard time eating vegetables and potatoes." The resident communicated that a dentist had recently examined him, but that he was still waiting for new dentures. c. Staff Interview On [DATE] at 4:00 p.m., the social services manager (SSM), who started working at the facility three weeks earlier, explained that the resident was seen by a dentist in July to be fitted for dentures, and that an appointment for a second impression was scheduled for the end of August. The SSM confirmed that a dental referral had not been made for the resident until July, eight months after the Dialysis physician brought forth the concern about the resident's lower dentures. The SSM said, "There has been no list for the past six months for who's done what." The SSM further stated, "Dental rounds should be done monthly, and an ancillary care plan should be developed." 5. Pre-admission Screening and Resident Reviews (PASRR) On [DATE], upon entering the facility, a list of residents that had received a level 2 PASRR due to potential mental illness and mental retardation, and the potential need for specialized services was requested. On [DATE] the facility provided a new list that showed residents that had been identified as having mental illness or mental retardation as of this date. The list included ten potential residents with mental illness and one resident with potential mild intellectual disability. The Social Service Director (SSD) was interviewed on [DATE] at 8:05 a.m. The SSD stated the list of residents provided (see above) was incomplete. The SSD, who had been employed at the facility for about a month, acknowledged the list of residents was missing PASRR information and said she had been in contact with the PASRR office. She said the last Social Service employee hadn't been keeping up with PASRR information and a lot of the paperwork for the residents was missing or incomplete. The SSD indicated her review of residents was not complete and she anticipated more residents with missing PASRR information would be found.

Based on observation, interviews and record reviews, the facility failed to ensure three of 32 sample residents (#59, #82, and #112) received the care and services necessary to attain and/or maintain their highest practicable level of well-being. Specifically: -The facility failed to comprehensively assess and monitor the status of resident #59's suprapubic catheter and ensure appropriate care and services were received after the suprapubic catheter had been changed at the facility and when her condition declined. (Cross reference to F322 Tube Feeding) -The facility failed to provide resident #82 the care necessary to prevent falls, communicate to the resident in the language of origin and keep the resident free from unnecessary medications. (Cross reference to F323 Supervision to Prevent Accidents) - The facility failed to ensure resident #112's communication progress notes from the [MEDICAL TREATMENT] center were completed in an accurate and timely manner. (Cross Reference to F327 Hydration) The findings include: A. Resident #59 (closed record) Resident #59, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. 1. Resident status a. The most recent quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was dependent on staff for all activities of daily living, was nonverbal, was always incontinent of bowel, had a supra pubic catheter and was fed by a gastrostomy tube (G or PEG tube). The resident was in a persistent vegetative state. The resident was a full COR. b. The plan of care revealed the resident had a care plan for an indwelling catheter, written on 1/22/13, indicated the resident had a suprapubic catheter (24 French with a 10 cc balloon) related to a [MEDICAL CONDITION] bladder. The goal was the resident's risk from complications from the indwelling catheter will be minimized with interventions in the next 90 days. Some of the interventions were: -Perineal care frequent and as needed, -Monitor lab values as ordered, -Change per physician's orders [REDACTED]. -Notify physician as needed. c. The 6/14 Physician Computerized Orders for the supra catheter included: -TAO around suprapubic insertion site daily until [DIAGNOSES REDACTED] resolved (10/9/12) - Flush Foley with 30 ml Normal saline every shift (10/27/11), -Supra catheter care every shift (4/30/11) -Change dressing to suprapubic catheter with drainage sponge every day as needed and cleanse with wound cleanser (4/30/11) -Change Foley bag every two weeks (2/29/12) -Monitor Intake and Output (10/27/11) -Suprapubic catheter (24 FR/10 ml) change once a month (10/30/12) d. A nurse's note documented on 6/12/14 at 11:30 p.m., "While flushing G tube noticed suprapubic catheter leaking. Suprapubic catheter 22 French with 30 cc balloon inflated changed and resident tolerated well." 6/13/14-There was no documentation of the suprapubic catheter and how it was functioning since the change. There was no documentation of the amount of drainage. 6/14/14-There was no documentation of the suprapubic catheter and how it was functioning and the amount of urine drainage. 6/15/14-There was no documentation of the suprapubic catheter other than it was draining yellow urine with no odor. There was measurement documented of urine since the catheter was changed to ensure it was draining adequately. 6/16/14-The suprapubic catheter was documented as draining amber urine with a slight odor. There was no documentation of the amount of urine for the day to ensure the catheter was functioning properly since the catheter change on 6/12/14. e. The resident was admitted to the intensive care unit at the hospital on [DATE] and diagnosed to be in septic shock. She was found to have a high white count of 20, [MEDICAL CONDITION] the 130's, altered mental status, and fever. The resident's feeding tube, per CT (computerized tomography) scan, revealed "free air along the (feeding tube) site with possible gastric outflow obstruction by the feeding tube balloon ... (with) concern for possible soilage of the peritoneum with gastric contents leading to peritonitis and ascites on the CT scan." (Cross Reference F322 Nasogastric Treatment and Services-Restore Eating Skills) In addition, the hospital record dated 6/17/14, documented the "suprapubic catheter balloon may have entered the urethra with the balloon thought to be inflated within the urethra. There is some mild distention of the bladder still remaining... Mild left-sided hydro[DIAGNOSES REDACTED] without [MEDICAL CONDITION] stone identified on CT scan." In the emergency department (6/17/14), it was noted that the tip of the suprapubic Foley catheter was in the vagina with the balloon inflated. This was removed and replaced "upon arrival to the ICU with the Foley tip readily seen in the vagina. ... The patient does have a supra catheter in place and does have a soaked pad, which is now being changed." The 6/17/14 assessment documented the patient is a "[AGE] year old female, here with septic shock. Source of this is likely her urine, although she may have also infection around the neck of the PEG tube and possibly respiratory component." The 6/17/14 laboratory results included a "UA which appeared turbid, small blood, greater than 500 protein, moderate leukocytes...many bacteria." The hospital record also indicated under "The Impressions" dated 6/18/14, documented acute kidney failure, which is also currently improving, likely cystovaginal fistula with persistent vaginal leak with a suprapubic catheter in place. The facility failed to identify this even when doing frequent perineal care, flushing of the foley with 30 cc every shift, and with suprapubic cath care every shift (see care plan and physician's orders [REDACTED]. Interviews On 8/11/14 at 9:19 a.m., a family member was interviewed. The family member stated the facility would never find issues with the resident on their own; that s/he would need to point things out to them. S/he felt the nurses rarely came into assess her. S/he went on to say the Certified Nursing Assistants (CNAs) would do most of the resident's care, including the catheter and feeding tube care. S/he stated he felt he needed to visit often and at different times, and then they would quickly clean everything up. The DON (Director of Nursing) was interviewed on 8/19/14 at approximately 2:00 p.m. She stated she did not remember having a problem with the resident's catheter leaking. B. Resident #82 Resident #82, age 82, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of the computerized physician orders [REDACTED]. The resident's minimum data set ((MDS) dated [DATE] documented the following: the resident was Spanish speaking. Section B indicated that the resident sometimes missed some part/intent of message. The resident scored a 3/15 on the BIMS testing, a brief mental status exam. A score of 3 indicated severe cognitive impairment. The resident required limited assistance with transfers and locomotion. Review of the resident's care plan dated 5/20/14 revealed that the resident was care planned for falls and communication, the resident was Spanish speaking only. The fall care plan was related in part to a history of previous falls, benzodiazepine use (Klonopin) and a problem with balance and walking. One of the interventions for the resident's fall care plan included: having the resident ask for assistance, despite the resident was documented repeatedly by the facility as Spanish speaking only. The care plan document was void of documentation to indicate that there had been any revision or updates to the care plan despite the resident's documented four falls prior to the target date of 8/20/14. The resident's medical record contained a care plan dated 5/22/14, for the use of [MEDICAL CONDITION] medications. Some of the interventions for the resident included: providing avenues for the resident to express herself and have validated feelings, providing cues as necessary and providing direct communication in a quiet environment to promote understanding. These interventions by the facility did not address the fact that the resident was Spanish speaking only and would not understand nor benefit from the interventions. Another approach documented in the care plan for the use of [MEDICAL CONDITION] medications included review at the psychopharmalogical meetings to evaluate possible med reductions. The care plan had not been updated to document that the facility had made any attempts at a gradual dose reduction for the resident's use of [MEDICAL CONDITION] medications. Both of the resident's [MEDICAL CONDITION] medications were documented on the same care plan. The resident's [MEDICAL CONDITION] medications included two different types of medications and in different classes. The medication [MEDICATION NAME] is an anti-depressant and the medication Klonopin is a benzodiazepine. The medications are in different classes and would require resident education specific to the different classes of medications. One of the approaches documented in the care plan included review at the psychopharmalogical meetings to evaluate possible medication reductions. Record Review: A review of the resident's medical record revealed [REDACTED]. 1. The facility documented that the resident had four falls since admission to the facility. The dates of the falls documented by the facility were as follows: 6/10/14, 6/14/14, 6/18/14 and 7/31/14. Cross reference F323 (Falls) 2. A review of a document titled change of condition medication regiment review report dated 7/9/14 and authored by the facility consulting pharmacist indicated that he was consulting in relation to an increase in falls for the resident. The document indicated that the resident had been noted to be experiencing new onset or worsening of falls, dizziness or impaired coordination. The pharmacist continued to document that the resident was receiving 2 mg of Klonopin which is above the maximum recommended daily dose of 1 mg in for persons over the age 65. The facility did not document the utilization of the report to revise or update the resident's care plan to prevent further falls. 3. There was no documentation in the resident's medical record that the resident was educated in her primary language other than English in regards to the use of a call light, the need to ask for assistance, possible side effects from [MEDICAL CONDITION] medications and with general cares. The education record is void of any documentation to support that the facility attempted to make the process understandable to the resident in her primary language in the attempt to prevent further falls or educate the resident about the side effects of her medications in her primary language. 4. A review of the resident's psychoactive medication consent for the use of the medication Klonopin revealed that the consent had not been signed by the physician as mandated by state law and as indicated on the consent form with the wording "required by state law." 6. A review of the activity progress notes found in the resident's medical record and dated 5/21/14 and 8/17/14 (during survey) documented that the resident was Spanish speaking only and could only make her needs known in Spanish or by using hand gestures. 7. As of 8/18/14 8:00 a.m., there was a large sign in the medication book, under the resident's name, that read "per family request give Klonopin." This document was on the same page as the resident's picture and name. Interviews: An interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON #1) on 8/18/14 at approximately 2:15 p.m. revealed the following: - A resident with a BIMS score of 3 represented severe cognitive deficits. - The DON and ADON #1 would expect that after a resident has a fall witnessed or unwitnessed, the fall would be reviewed by the interdisciplinary team (IDT) and at the morning meeting. After the IDT reviewed the information, the team would make recommendations and update the resident's care plan if needed. - The resident's care plan should provide revisions that minimize the problem area identified by the facility (falls and unnecessary medications) by the next review date. Revisions would be made by reviewing and re-assessing the approaches for the resident. A resident with a history of a fall pattern and multiple falls should be evaluated for new approaches. These would be documented on the resident's care plan. - The resident's provider should be a part of the IDT team and assist the team in developing an effective plan of care to prevent potential future falls. This would include a review of the facility pharmacist's recommendations related to the use of FDA controlled scheduled benzodiazepines used in excess of the federally recommended dosage by the facility. - The resident's language barrier made it difficult to communicate safety awareness to her and any general cares. - The DON stated that she did not know why the resident's language barrier was a hindrance to the resident communicating her needs and receiving cares from the facility because the resident "could just point to what she needed." An interview with the resident care specialist (RSC #2) responsible for the resident's care on 8/14/14 at 3:30 p.m. revealed: - That the resident was Spanish speaking only. She stated that the resident does not speak any English and she points to make her needs known. The resident does not remember how to use a call light or ask for help because she has memory problems. - The Cardex was reviewed and it revealed that in the lower right hand corner the words Spanish speaking only (SSO) were documented. The RSC stated that is how the resident's needs are communicated to other staff. She stated that the staff talks to the resident as if she can understand what they are asking her to do and she can't remember or understand. C. Resident #112 Failure to ensure [MEDICAL TREATMENT] communication forms completed Resident #112, age 51, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the minimum data set ((MDS) dated [DATE], the resident had a brief interview for mental status (BIMS) of 15 indicating he was cognitively intact. Facility Policy and Procedure on [MEDICAL TREATMENT] Care of Residents (in pertinent part): -The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes. -A [MEDICAL TREATMENT] Communication Record is initiated and sent to the [MEDICAL TREATMENT] center for each appointment. Ensure it is received upon return. -Documentation: 1. [MEDICAL TREATMENT] Communication Record 2. Nurses' notes-key documentation elements: -vital signs -intake and output -weight gain or loss, abnormal lab result -[MEDICAL CONDITION] -response to medication or treatment -diet and fluid restriction and response Record review: [MEDICAL TREATMENT] Communication Records: The following dates the resident was scheduled for [MEDICAL TREATMENT]: The following documentation was noted on each date: 6/4/14-faciltiy did not finish the "Specific Pre-[MEDICAL TREATMENT] Information" section, nor sign it 6/6/14-faciity did not complete "Specific Pre-[MEDICAL TREATMENT] Information" section, including vitals 6/9/14-form not found 6/11/14-form complete 6/13/14-form not found 6/16/14-form not found 6/18/14-vitals not taken by facility staff. Form is signed 6/18/14, but facility nurse signed it 6/14/14 6/19/14 or 6/20/14-form not found 6/21/14-a Saturday visit, [MEDICAL TREATMENT] did not complete their portion of the form 6/23/14-facility staff did not complete "Specific Pre-[MEDICAL TREATMENT] Information" section, including vitals 6/25/14-complete form 6/27/14-form not found 6/30/14-form not found 7/7/14-form not found 7/9/14-vitals not taken by facility staff 7/11/14-form not found 7/14/14-form not found 7/16/14-[MEDICAL TREATMENT] did not complete or sign their portion of the form 7/28/14-complete form 7/30/14-form not found 7/31/14-form complete, but the documented date was not a physician ordered [MEDICAL TREATMENT] date 8/1/14-facility staff did not complete the "Specific Pre-[MEDICAL TREATMENT] Information" and [MEDICAL TREATMENT] did not complete any of their section of the form including weights 8/4/14-complete form 8/6/14-form not found 8/8/14-vitals not taken by facility staff 8/11/14-complete form *an undated [MEDICAL TREATMENT] communication form was found in the resident's communication book, but the "Specific Pre-[MEDICAL TREATMENT] Information" section was not filled out, including vitals, a nurse signature, or a date. The [MEDICAL TREATMENT] center also did not date this form. *a second undated [MEDICAL TREATMENT] communication form was found in the resident's communication book, but the facility nurse did not sign or date it, and the [MEDICAL TREATMENT] center nurse also did not sign or date it. Care plans: -A care plan initiated on 5/7/14 read: Receives [MEDICAL TREATMENT] 3 times a week on Mondays, Wednesdays, and Fridays. Access site: [MEDICATION NAME]. Goal: Safe, accurate, appropriate care, assessments and interventions will be provided to improve resident outcomes next 90 days. Approaches: [MEDICAL TREATMENT] communication report is sent to the [MEDICAL TREATMENT] center with each appointment, and return of form is ensured after appointment is completed; VS (vital signs) checked every shift for 24 hours post-[MEDICAL TREATMENT] or per physician's orders [REDACTED]. Interviews: An interview with a registered nurse (RN) #4 was conducted on 8/13/14 at 10:10 a.m. The RN stated that she fills out the [MEDICAL TREATMENT] communication forms in the morning on the resident's [MEDICAL TREATMENT] days. The RN stated that the nurse who was on duty when the resident returned would check for the bruit/thrill. An interview was conducted with the Registered Dietitian (RD) on 8/14/14 at 12:00 p.m. regarding the resident's [MEDICAL TREATMENT] communication forms. The RD stated that she had been recently looking at the [MEDICAL TREATMENT] communication forms and that the [MEDICAL TREATMENT] center had noted concerns about the resident's fluid restrictions. The RD stated that she had been talking to the facility staff about keeping better track of the [MEDICAL TREATMENT] forms and ensuring they were complete. An interview was conducted with a registered nurse (RN) #3 on 8/18/14 at 9:20 a.m. regarding the [MEDICAL TREATMENT] needs of resident #112. The RN stated that the resident went to [MEDICAL TREATMENT] around 10:00 a.m. and get back around 3-4:00 p.m. The RN stated that he fills out the top two sections of the [MEDICAL TREATMENT] communication forms and that the [MEDICAL TREATMENT] center was required to fill out the bottom portion. These completed forms, upon the resident's return, would go into the resident's communication book. An interview with the Director of Nursing (DON) on 8/19/14 at 11:20 a.m. confirmed that the resident's [MEDICAL TREATMENT] communication forms were not completed.

Based on record review and interview, the facility failed to ensure one (#59) out of four residents who were tube fed, out of 32 sample residents, received appropriate treatment and services to prevent complications. Specifically: The facility failed to comprehensively assess the status of the resident's feeding tube when her condition declined, failed to have a resident-specific care plan related to tube feeding monitoring, and a facility clinical practice standard addressing potential mechanical complications of tube feeding, including the signs and symptoms of an improperly positioned feeding tube and how to respond. Resident #59 was admitted to the hospital on [DATE] and diagnosed to be in septic shock. The resident's feeding tube, per CT (computerized tomography) scan, revealed "free air along the (feeding tube) site with possible gastric outflow obstruction by the feeding tube balloon ... (with) concern for possible soilage of the peritoneum with gastric contents leading to peritonitis and ascites on the CT scan." Findings: A. Resident #59 (closed record) Resident #59, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. 1. Resident status a. The most recent quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was dependent on staff for all activities of daily living, was nonverbal, was always incontinent of bowel, had a supra pubic catheter and was fed by a gastrostomy tube (G or PEG tube).The resident was in a persistent vegetative state. b. The plan of care revealed the resident had a care plan for enternal nutrition, rewritten on [DATE], that identified the resident received enteral nutrition related to history of aneurysm. The goal was the resident would receive adequate nutrition to maintain body weight. Interventions included: -Tube feeding as ordered, -Flush as ordered, -Check placement and check residual as ordered, -Change or replace tube as indicated (record review indicated the tube had been changed at the hospital on [DATE]) -Elevate the head of the bed equal to or above 45 degrees, -Monitor tolerance of the feeding, -Monitor stoma site, -Notify the physician as indicated, and -Lab work as ordered. The resident's care plan included no specific information for staff on the signs and symptoms the resident might present if tube feeding complications occurred and included no directive, other than "as indicated," on when to notify the physician. c. The ,[DATE] Computerized physician's orders [REDACTED]. - NPO (nothing by mouth) with [MEDICATION NAME] 1.2 cal at 75 ml/hour for 20 hours. [MEDICATION NAME] was to be administered from 10:00 a.m. to 6 a.m. daily ([DATE]), -30 ml water flush before and after medication administration ([DATE]), -Check tube placement and residual every shift ([DATE]), -200 ml water flush every 4 hours for hydration ([DATE]), and -Monitor Intake and Output. 2. Change of condition [DATE] On [DATE] a SBAR (Situation, Background, Assessment, Request ) Communication Form which was untimed, documented the resident had a low grade fever, bleeding around PEG tube, and decreased bowel sounds but her abdomen was soft and nontender. The Nurse Practitioner (NP) conducted an acute visit the same day. The NP documented the resident had a large amount of dark brown drainage from the PEG tube site during the night. There was no evidence of emesis or diarrhea. The NP wrote, " ... (temp) 99.6... Chest congested upper airway... down arrows (decreased) bowel signs, sl (slight) distention. Large amt (amount) tarry mucous from PEG tube site... Up arrows (increased) area excoriation around PEG with extension L (left) side abdomen. Tender when touched." Orders were written on [DATE] to rule out "infection, ileus, GI (gastro-intestinal) Bleed. CBC (Complete Blood Count), INR (international normalization ratio to check bleeding/clotting), STAT (immediate) 3 way abdomen (x-ray), increase local care to site, and to start skilled charting through [DATE]." Review of the [DATE] x-ray report indicated the PEG tube was over the gastric region and there was slight lower atelectasis. Under the "Impression", it read, "The gastrostomy tube was over the gastric region. If there was a concern of complication, a CT scan (is) recommended." Handwritten on the bottom of the x-ray report was "No new orders, Add CMP (further blood tests) and monitor temp and notify if the resident spikes a temperature. ([DATE] at 8:45 p.m.) No CT scan was ordered. Review of the CBC completed on [DATE] and reported on [DATE] indicated a normal white blood cell count of 7.80 (reference range of 4XXX,[DATE].50), however, the monocytes, a type of white blood cells, were high at 15.5 (reference range 4XXX,[DATE].0). 3. Resident status after [DATE] - Facility Assessment, Documentation and Communication Failures Record review (physician, physician assistant (PA), NP documentation, SBAR forms completed by the facility staff, physician orders [REDACTED]. Although vital signs were consistently taken, the NP repeatedly contacted, and orders for x-rays and blood work implemented, nursing staff failed to comprehensively assess the resident for signs and symptoms of tube feeding complications and communicate all changes in the resident's condition. a. [DATE] An order was written by the NP for a CMP (comprehensive metabolic panel) to be added to the lab draw and to notify physician if the resident would spike a fever (every shift) ([DATE]). On [DATE] at 6:10 p.m., the NP documented to discontinue the previous PEG site care orders and issued new site orders (cleanse the surrounding skin with normal saline, pat dry, apply [MEDICATION NAME] to cover entire area excoriation, change every three days and as needed). Skilled charting was initiated by nursing as directed in the [DATE] NP note (see above); however, the skilled nursing notes did not reveal a focus on signs of PEG tube complications, such as, documentation of bowel sounds, abdominal measurements for distention and/or palpation, tenderness, or include details regarding the tube drainage. Review of the MAR and TAR revealed the order to check residual was marked with staff initials; however, no amount, if any, was documented. Moreover, intake and output, per policy and resident orders (see above), was not documented. b. [DATE] On [DATE] at 10:30 a.m. a telephone order from the NP was written to discontinue the current dressing to the PEG tube site and a new order was written (abdomen and left arm, dry, apply zinc oxide to areas). Another order was written to obtain a 3 way x-ray of the abdomen for PEG placement and check for GI problems/bleed. an order for [REDACTED]. The CBC, completed on [DATE] at 12:16 p.m. and reported to the facility on [DATE] at 2:30 p.m., indicated the monocytes were high at 16 and platelets were high at 513 (reference range of ,[DATE]). A voice mail was left for the physician at [DATE] at 8:30 p.m. (per a handwritten note on the bottom of the lab report). The portable x-ray completed on [DATE] at 1:33 p.m. indicated there were limited views of the abdomen which revealed no obvious free air or air/fluid levels. No ileus or obstructed gas pattern was seen. The "Impression" indicated this was a "Nonspecific Study." Again, a voice message was left for the physician at 3:30 p.m. on [DATE] (per handwritten notes on bottom of the x-ray report.) Skilled nursing notes at 1:30 p.m. documented the resident's vital signs and oxygen saturation levels (temp of 96.3, pulse 96, respirations of 21, blood pressure ,[DATE], 97% at 6 Liter/L) and further noted, "Resident tube site leaking brown fluid around the tube esp (especially) when she coughs..." There was no documentation of an abdominal assessment (bowel sounds or abdominal measurements for distention and/or palpation for tenderness). Skilled nursing notes at 8:00 p.m. again documented the resident's vital signs and oxygen saturation levels (temp of 96.3, pulse 100, respirations of 20, blood pressure ,[DATE], 96% at 6 L) with a note that the resident's peg tube (feeding) "running continuously..." There was no documentation of of an abdominal assessment and no discussion of leaking at the tube site. Further review of the skilled charting and the resident's record failed to reveal any return call by the physician on [DATE], although two voice mails were left. And, although the x-ray report documented limited views of the abdomen and nonspecific results and leaking continued at the feeding tube site, there was no evidence nursing staff contacted the Director of Nursing or Medical Director about the resident's condition or the physician's failure to respond to the voice mails sent that day. Review of the MAR and TAR revealed the order to check residual was marked with staff initials; however, no amount, if any, was documented. There was no documentation that intake and output, per policy and resident orders (see above), were documented. c. [DATE] Skilled nursing notes at 5:00 a.m. [MEDICAL CONDITION] and vital signs (temp of 98.9, pulse 85, respirations of 22, blood pressure ,[DATE], 94% at 6 L of oxygen). There was no documentation of an abdominal assessment (bowel sounds, abdominal measurements for distention, palpation for tenderness) or details regarding the feeding tube and drainage. Skilled nursing notes at 12 noon, documented the resident's vital signs (temp of 97.5, pulse 100, respirations of 21, blood pressure ,[DATE], 94% at 6 L of oxygen) and further documented a rash around peg tube site that spread to left side of (l) left arm... " Documentation further read, "Tube feeding running as there is no residual upon checking..." There was no documentation, however, of a bowel assessment or details regarding the feeding tube and drainage. In addition, no intake and output was documented for the day in the notes, contrary to facility policy (see below) and the resident's orders. d. [DATE] Skilled nursing notes at 5:00 a.m. documented vital signs (temp of 98.3, pulse 91, respirations of 22, blood pressure ,[DATE], 93% at 6 L of oxygen). The note read that the G tube site continued to drain and the rash was still present. The note did not describe the amount or character of the drainage and did not include documentation of a bowel assessment. Skilled nursing notes at 1:30 p.m. documented the resident continued to have increased discharge from the peg tube site, "Also draining what appears to be the tube feeding." The amount of the drainage and the degree of "increase" was not described. The note further read that the NP stated to hold tube feeding for' a few hours and monitor drainage. However, review of the orders revealed no order as how long to hold the tube feeding, and there was no documentation on the MAR that indicated the tube feeding was held. No further assessment related to the PEG tube was recorded, even though the drainage had not only continued, but "increased." The note also read the resident noted to have some labored breathing which decreased [MEDICAL CONDITION] was completed; no respiratory assessment was documented. Another skilled nursing note (no time documented) included vital signs (temp not documented), pulse 64, respirations of 18, blood pressure ,[DATE], oxygen saturation 97% and read that the resident was up in the wheelchair, the tube site "reddened" and the drainage noted as "odorous." This note read that the TF (tube feeding) was "patent and infusing." There was no reference to the NP's directive (see above) to hold the tube feeding to determine whether the NP directive was implemented and then discontinued or not implemented at all. "Odorous" drainage was a new finding; there was no evidence, however, that it was reported to the DON, Assistant DON, or the resident's physician or NP. Another skilled nursing note at 8 p.m. recorded vital signs and included a pulse rate higher than previously (132) and a respiratory rate of of 22 (previously 18). The note further documented the dressing to peg tube site was changed "4 times due to heavy and continuous drainage." There was no notation the DON, Assistant DON, physician or NP were notified at this time of the resident's elevated pulse and respirations and "heavy and continuous" drainage from the PEG tube site. There was no documentation of a bowel assessment (bowel sounds, abdominal measurements for distention, or palpation for tenderness). The next skilled nursing note (no time documented) read that excess residual (60 cc) and increased drainage from the site was relayed on to NP and that tube feeding was held as a result. As this note was untimed, it cannot be determined when the NP was notified. The NP instructed staff to "continue" to hold the tube feeding; however, see above note documented the tube feeding was "patent and infusing." Per the NP, the PA would be in to evaluate the PEG tube. A physician telephone order was written at 9:00 p.m. that instructed staff to continue to hold the tube feeding, to change the PEG site dressing frequently and the PA would be in to see the resident. A SBAR Communication Form and Progress Note dated [DATE] (untimed) was completed and contained some of the following information: The resident had a change in condition with documented fever, absence of bowel signs, hyperventilation and leakage from the PEG tube site. The resident's vitals were documented as temp of 100.8, pulse 56, respirations of 40, blood pressure ,[DATE], 90% at 6 L of oxygen. e. [DATE] Skilled nursing notes (untimed) on [DATE] documented the resident's vital signs (temp of 98.6, pulse 130, respirations of 18, blood pressure ,[DATE], 96% at 6 L of oxygen). Another skilled note at 2:00 a.m. read the resident had a temp of 100.8, and respirations of 40. The MD was notified and the resident was sent to the hospital (5 days after the resident started with increased drainage from the PEG site). 4. Hospital Records Hospital records dated [DATE], indicated the resident had dark brown drainage from the PEG tube site beginning on [DATE] and had continuing drainage from the peg tube site with increased chest congestion and more sedation and fever over the next few days. The resident was admitted to intensive care with the [DATE] CBC revealing an elevated WBC of 20.3 (reference range of 4.0 to 11.0) and [MEDICAL CONDITION] the 130s and became hypotensive. The BUN was 55.4 (reference range ,[DATE]), the creatinine was 3.08 9 (reference range 0.44 to 1.03.) The ,[DATE] physical exam revealed "a PEG tube with significant pus drainage around this and [DIAGNOSES REDACTED] around the PEG tube site."She was admitted with septic shock. The hospital discharge summary read, "...She had a CT scan of the abdomen that showed free air along the PEG site with possible gastric outflow obstruction by the Peg balloon. Surgery readjusted the Peg balloon; however there was concern for possible soilage of the peritoneum with gastric contents leading to peritonitis and ascites on the CT scan. She continued to have [MEDICAL CONDITIONS] physiology. Repeat CT scan had showed persistent peritoneal ascites and signs of peritonitis. Therefore a paracentesis was performed. This grew yeasts..." The resident expired [DATE]. 5. Interviews On [DATE] at approximately 10:50 a.m., the regional nurse consultant, the DON and the Assistant DON were interviewed. The DON stated the NP gave staff orders for labs and x-rays, staff monitored for fever and there was no indication of a fever. She further stated had taken the following steps in addressing the resident's change in condition: -On [DATE], a SBAR communication form was completed and the NP was notified of the resident's change in condition. The NP noted when it (drainage) changed, noted the excoriation around the site and wrote to continue with the treatment. -On [DATE], the NP was notified again. Labs and x-rays were ordered. The reason for the x-ray was decreased bowel sounds; the statement on the report recommending a CT "if there was a concern of complication," referenced gallstones, not the abdomen. The x-ray report showed that there was nothing remarkable on the abdomen. -On ,[DATE] the resident's white blood cells were within the normal range and, per x-ray, there was no ileus or obstructed gas pattern. The RNC said they had not seen the resident's hospital report. On [DATE] at 11:30 a.m., the DON was interviewed again and stated the resident had a bowel movement everyday, [DATE] - [DATE], including on the day she was transferred to the hospital. The DON said this indicated that the resident had bowel sounds 'everyday.' B. Facility Clinical Practice Standard for Enteral Feeding Review of the facility's Clinical Practice Standard for Enteral Feeding, SSP 1101.00, Revised [DATE], revealed it included the following expectations in pertinent part: -Follow orders for the administration of enteral feedings and tube irrigation; -Check for placement prior to feeding and flushes and periodically during continuous feeding; -Monitor for therapeutic efficacy, adverse effects and clinical changes, including weight, hydration, intake and output, and lab values; -Evaluate for intolerance to the enteral feeding (diarrhea, nausea/vomting, constipation, abdominal distention/cramping, dehydration, fluid overload, aspiration, increased gastric residual, hypo/[MEDICAL CONDITION]) -Observe for complication in resident with long-term intubation (for PEG tube, gasric ulceration, skin irritation due to tape, and [MEDICAL CONDITION] infection) -Keep skin around tube clean and evaluate for [DIAGNOSES REDACTED], tenderness and drainage. -Contact physician to discuss and receive orders when complications from or intolerance to feedings and/or inadequate process toward goals is identified. This clinical practice standard was incomplete, as it failed to address complications related to improper placement of the feeding tube, situations increasing the likelihood of improper placement and early signs and symptoms of improper placement such as excessive leakage around the tube. "Excessive leakage around the tube is a complication that can be caused by a variety of factors, including ...mechanical issues." See Simons, Shellie and Remington, Ruth. "The Percutaneous Endoscopic Gastrostomy Tube: A Nurse's Guide to PEG Tubes, MEDSURG Nursing 22, no.2 (2013) ,[DATE].

Based on observation, interviews and record reviews, the facility failed to provide a safe environment for four of 32 sample residents (#14, #28, #82 and #123). Specifically: -The facility failed to implement effective interventions that specifically addressed resident #14's fall risks (severe cognitive impairment, weakness, language barrier) and pattern of falls (unassisted self-transfers).The facility also failed to implement pharmacy recommendations in a timely manner. Resident #14 sustained cuts, bruises, lacerations that required sutures, as well as an acute/chronic subdural hematoma. -The facility failed to adequately and timely address residents #123, #82, and #28's fall risks and keep the residents safe from repeat falls. Findings: A. Facility Expectations 1. Fall Policy A review of the facility fall management policy dated 8/2012 indicated that in the event of a fall, the following things should happen: -The Interdisciplinary team (IDT) team modifies and implements a care plan and treatment approach to minimize repeat falls. The care plan will be reviewed/ revised as indicated. The RCS (resident care specialist) assignment sheets/care kardexes are updated as appropriate. -Each facility is responsible for implementing individualized interventions related to or for each resident's fall risks. -Residents that experience actual falls will be reviewed each week during the at risk review meeting. -The at risk review committee members will review weekly all residents with falls for documentation, compliance and interventions. 2. Staff Interview - Expectations An interview with the Director of Nurses (DON) and Assistant DON #1 on 8/18/14 at approximately 2:15 p.m. revealed that residents are on the falling star program when they have multiple falls. -The DON and ADON would expect that after a resident has a fall, witnessed or unwitnessed, the fall would be reviewed by the IDT and at the morning meeting. After the IDT reviewed the information, the team would make recommendations and update the resident's care plan if needed. -A resident with a BIMS (cognition score) of 3 (or less) represented the resident has severe cognitive deficits. -The resident's care plan should provide revisions that minimize the problem area identified by the facility (falls) by the next review date. Revisions would be made by reviewing and re-assessing the approaches for the resident. A resident with a history of a fall pattern and multiple falls should be evaluated for new approaches. These would be documented on the resident's care plan. -The resident's provider should be a part of the IDT team and assist the team in developing an effective plan of care to prevent potential future falls. -Residents are put on purposeful rounds so that staff can monitor them more frequently. On 8/12/14 at 11:00 a.m. the DON stated the IDT meets every day (when we are here) and reviews all the falls from the previous day and then follow up. If the resident is cognitive, the DON said they ask the resident what happened and do not do an investigation. If the resident is not cognitively intact, the IDT do an accident follow up. B. Residents 1. Resident #14 (closed record), age 92, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident spoke only Russian. a. Resident Status The Minimum Data Set (MDS) admission assessment, dated 5/23/14, indicated the resident had adequate hearing, unclear speech, usually understood and sometimes understands others. He scored a 2/15 in the Brief Interview for Mental Status (BIMS) indicating he was severely impaired in his cognitive skills. -The resident was coded as needing limited assistance of a staff member in all activities of daily living except dressing with which he needed extensive assistance of a staff member. He was occasionally incontinent of bowel and bladder, and used a wheelchair to navigate. He had a fall before admission. The care plan for falls, updated on 6/10/14, indicated the resident was at risk for falls related to his mental status, his recent admission, a history of previous falls, a balance problem with standing and walking, decreased muscle coordination, poor safety awareness, and has had a CVA (stroke). The goal was for the resident to be free from falls related to injury through the next review period of 90 days. Interventions included: --The Falling Star program, --Encourage the resident to ask for assistance, --Ensure and encourage the resident has the proper footwear as indicated and accepted (non skid soles), --Orient resident to his room/environment, --Place call light within reach, --Observe for potential patterns of falls to identify possible causes, --Offer/Assist to toilet frequently and as accepted, --Handwritten comment (not dated) that the resident's tube feeding was changed from continuous to bolus to prevent tripping on the tubing. Resident medications included: -Doxazosin (Cardura), used to treat hypertension, high blood pressure and benign prostatic hyperplasia (enlarged prostate). Doxazosin has side effects that may include dizziness, fatigue, headache, shortness of breath, diarrhea, abdominal pain, edema (fluid accumulation), and low blood pressure. -Venlafaxine (Effexor) 5 mg daily (an antidepressant), has common side effects that may include high blood pressure lack or loss of strength, severe headache, and sweating. -Welchol, 3.75 g daily, a glucose lowering agent. The common side effects may include mild constipation; nausea, vomiting, upset stomach, gas, indigestion; feeling weak or tired; headache; muscle pain; or runny nose, sore throat, flu symptoms. -Zitia 10 mg, a cholesterol lowering drug. Some side effects include muscle pain, tenderness, and weakness, nausea and vomiting. b. Falls Review of SBARs (Situation, Background, Assessment, Request) Communication Forms and Progress Notes, nurses' notes, hospital records, and fall investigations revealed the resident repeatedly fell after transferring and/or ambulating unassisted in and around his room. The facility failed to implement effective interventions that specifically addressed his fall risks (severe cognitive impairment, weakness, language barrier) and pattern of falls (self-transfers from bed and walking unassisted in his room). The facility also failed to implement pharmacy recommendations in a timely manner. 1. On 6/8/14 at 7 a.m., staff witnessed the resident fall to the ground as he was walking and pushing the (feeding) tube machine. Interdisciplinary (IDT) Post Fall Review interventions included: Follow-up with dietary for possible bolus feeding versus continuous feeding and IDT referral to ST (speech therapy). Other interventions documented were to encourage the resident to ask for help in moving the feeding tube machine. 2. On 6/22/14 at 1:30 p.m., the resident was found on the floor in his room, sitting upright with his back against the wall. He sustained a skin tear on the right elbow (2 cm) well approximated, a bruise on the left lateral side 2 x 2 cm, redness on back right side (10 x 5 cm). Neurological checks were started and a physician order [REDACTED]. The report revealed the resident appeared to be walking unassisted in his room. Interventions included orthostatic blood pressure every shift for 72 hours, fall protocol, purposeful rounds, engage the resident in activities, bring the resident to common areas, medication review, physical therapy (PT) to evaluate and treat, and check fasting blood sugar 6/24/14 prior to each bolus feeding for that day only. Review of the 6/14 Medication Administration Record (MAR) revealed documentation of orthostatic blood pressures only on 6/25/14, not the 72 hours as recommended. Review of PT notes revealed a 6/23/14 PT evaluation that read (in part), "the resident was seen by PT not too long ago but was (discontinued) d/t (due to) increase agitation and severe language impairment. Pt however is starting to recognize and is more familiar with caregivers, and his new environment which helps in getting pt to participate and cooperate with given tasks." Therapy was recommended three times a week for four weeks. 3. On 6/25/14 at approximately 6:00 p.m.,the resident was found sitting on the floor near the bed in his room. He received a laceration to the forehead and was sent to hospital for sutures, was admitted , and returned to the facility on [DATE]. A PT note dated 6/25/14 read that the resident was beginning to participate with PT, with increase ability to follow simple consistent commands. However, the resident has no insight for his functional impairments and has been attempting to self transfer and walk on his own, which caused the resident to fall. (Therapy was discontinued on 6/26/14 due to the 6/25/14 fall.) 4. On 6/29/14 at 12:30 p.m., one day after the resident's readmission, he was found on floor by the bed, bleeding from the forehead with a large open laceration above right eyebrow. The resident was sent to hospital by ambulance. The summary of the facility's investigation of the incident revealed the resident had an unsteady gait and poor safety awareness. He had gotten up out of bed with boots on, slipped and hit his head. New interventions included to implement a bed alarm and do purposeful rounds every hour when he returned from the hospital. Hospital records revealed the resident also had posterior interspinous ligamentous injury and subacute subdural hematoma; he was put in a C-collar and admitted to the intensive care unit. The CT scan demonstrated a subacute/chronic subdural hematoma. The MRI demonstrated hematoma in the right anterior paraspinous area of the neck with posterior spinous ligamentous injury and significant spinal canal stenosis. The hospital assessment and plan read, "Falls. Due to recurrent and multiple now with cervical ligamentous injury and subacute subdural hematoma, he is in a C-collar. Question whether these are due to medications such as, finasteride and doxazosin versus possible lower extremity weakness from his cervical canal stenosis versus dis-coordination due to his left middle cerebral stroke. We will need PT/OT (physical and occupational therapy) (to) evaluate the patient. Consider discharge to alternate setting given his multiple falls at his current skilled nursing facility." The resident, however, returned to the facility on [DATE]. He received a chair and bed alarm upon return to the facility and was assessed as a high risk for falls. His care plan was updated on 7/3/14 with additional interventions to: -Encourage resident and assist to attend activities with wife as he allows, -Encourage and assist to be in the common areas with his wife as he allows, -Encourage resident to leave door open except during care so he can be observed by staff as he allows, -Bed alarm to alert staff when resident is attempting to ambulate without assistance since resident will not use call light. -Therapy to evaluate and treat, -Neuro checks every shift for 72 hours to assess for neurogenic changes related to the subdural hematoma, -Hourly purposeful rounds (handwritten) and -Increased activities as resident allows (handwritten). On 7/9/14, the pharmacist reviewed the resident's medications and suggested the Doxazosin, used to treat hypertension, high blood pressure and benign prostatic hyperplasia (enlarged prostate), and Venlafaxine (an antidepressant) be evaluated and if continued a risk/benefit statement be issued. The pharmacist comments included: "Resident was experiencing new onset or worsening of falls, dizziness or impaired coordination as indicated on a change of condition medication regimen review requested by the facility. The use of the following medications has/have been associated with such adverse consequences, potentially affecting coordination: -Doxazosin has been associated with dizziness, syncope, weakness and abnormality of gait. -Venlafaxine has been associated with vertigo, dizziness, and weakness." A physician order [REDACTED]. However, review of the 7/14 MAR, revealed Doxazosin was signed off as given through 7/24/14. 5. On 7/12/14 at 11:30 a.m., the resident had an unwitnessed fall. The resident was found sitting on the floor by the bedside. According to the nurse's note, the resident had been put to bed after breakfast. The bed alarm had sounded. The post fall review indicated the activities staff would be asked to engage the resident more as he allowed, an intervention that was to be initiated after his fall on 6/22/14 and again after his fall on 6/29/14. c. Interviews In an interview with a Resident Care Specialist (RCS?) ?#5 on 8/19/14 at 11:17 a.m., the RCS #5 stated she had taken care of resident #14 and his wife and had helped the resident with bathing, toileting, and dressing. She stated it was hard at first because the resident and his wife did not speak English. RCS? ?#5 said the resident would not use the call light so she would have to go in the room frequently. RCS #5 stated the couple liked to keep their door closed, and staff would have to open it. She added that she downloaded an application on her phone so she could communicate better with the couple and them with her. In an interview on 8/19/14 at 9:30 a.m. with the resident's granddaughter, who was seeking guardianship of her grandparents, the granddaughter said, she was upset that the facility had not moved her grandparents' to a room closer to the nurses' station for more supervision or provide a low bed for him if he continued to get up on his own, which they knew he repeatedly would do.? 2. Resident #82, age 82, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. a. Resident Status A review of the computerized physician orders [REDACTED]. The resident's minimum data set ((MDS) dated [DATE] documented the following: The resident was Spanish speaking. Section B indicated that the resident sometimes missed some part/intent of message. The resident scored a 3/15 on the BIMS testing (a brief mental status exam). A score of 3 indicated severe cognitive impairment. The resident required limited assistance with transfers and locomotion. Review of the resident's care plan dated 5/20/14 revealed that the resident was care planned for falls and communication and for being Spanish speaking only. The fall care plan was related to a history of previous falls, impaired balance, narcotic use, decreased muscle coordination and problem with balance and walking. The facility had identified goals for the resident as being free from falls and related injuries through the next review date of 8/20/14. Some of the interventions for the resident included: Having the resident ask for assistance (although severely cognitively impaired and Spanish speak only) and observing for patterns of potential falls to identify possible causes. b. Falls Medical record review revealed the facility documented the resident had four falls after admission to the facility. The dates of the falls documented by the facility were as follows: 6/10/14, 6/14/14, 6/18/14 and 7/31/14. (1) A review of the SBAR communication form (Situation, Background Assessment and Request) dated 6/10/14 documented that the resident was found on the floor next to her bed. The resident received no injuries. The resident's fall on 6/10/14 was reviewed by the facility DON, Nursing Home Administrator (NHA) and the ADON #1 as indicated on the facility form interdisciplinary post fall review. The document was dated 6/10/14. The summary of the team was to continue the fall protocol and offer the resident bedtime at 7:30 p.m. Another recommendation was to continue safety education. The provider notes dated 6/11/14 and 6/12/14 did not address the fall by the resident on 6/10/14. The provider documented that the resident was ambulating 'well' with her walker and that she had discussed the resident's care with the nursing staff. The SBAR form indicated that the facility had notified the provider of the fall on 6/10/14. (2) A review of the SBAR communication form document dated 6/14/14 documented that the resident was unassisted and alone in the bathroom, lost her balance and fell in the doorway. The resident hit her head per the documentation but no indication of injury. The resident's fall on 6/14/14 was reviewed by the facility DON, NHA and the ADON #1 as indicated on the facility form interdisciplinary post fall review. The document was dated 6/16/14. The summary of the team was to continue the fall protocol and offer the resident the toilet every two hours while awake. (3) A review of the SBAR communication form document dated 6/18/14 documented that the resident was found sitting on the bathroom floor next to the toilet bowl. The resident received injuries to the left elbow with a skin tear measuring 2 cm x 3 cm. The area required first aid treatment by the facility. The resident's fall on 6/18/14 was reviewed by the facility DON, NHA and the ADON #1 as indicated on the facility form interdisciplinary post fall review. The document was dated 6/18/14. The summary of the team was to continue the fall protocol and not to leave the resident alone in the bathroom, keep the resident in common areas so staff could monitor. The provider notes on 6/19/14 indicated that the reason for the provider visit was falls. The document indicated that the resident "continues to fall." The document continued to read in part, "Her balance is impaired and this is showing little improvement with skilled therapies. The resident has zero carryover of safety education. "The language barrier makes it hard to assess, and it is thought she has significant memory impairment. (4) A review of the SBAR communication form document dated 7/31/14 documented that the resident was found sitting on the floor beside her wheelchair. The resident suffered injuries of an abrasion to the left elbow and a bruise to the left upper arm. The area required first aid treatment by the facility. The resident's fall on 7/31/14 was reviewed by the facility DON only. The document called the incident/accident investigation follow up and dated 7/31/14 indicated that the ADON #1 was the only management team to review the fall. The summary of the ADON #1 was to continue the fall protocol and do purposeful rounds and get a bed alarm. A review of the telephone orders obtained for the resident indicated that on 8/9/14 the nursing staff received an order for [REDACTED]. The [DIAGNOSES REDACTED]. (A provider note dated 8/12/14 made no reference to the resident's fall on 7/31/14.) c. Failure to Meet Facility Expectations to Minimize Fall Risks (1) IDT post fall reviews There was no documentation in the resident's medical record that the interdisciplinary team assessed and re-assessed the effectiveness of the recommendations made after each of the resident's falls in order to prevent further falls for the resident. The provider notes documented the resident's inability to understand English and to retain safety awareness specifically. The recommendation of the IDT to "continue safety education," and to allow the care plan directive to "ask for assistance" to remain on the care plan indicated these interventions were not evaluated for effectiveness or resident-specific, given the resident's limited cognitive abilities and language barrier. Interview with the RCS #2 responsible for the resident's care on 8/14/14 at 3:30 p.m. confirmed the resident was Spanish speaking only. She stated that the resident does not speak any English and she points to make her needs known. She also said the resident does not remember how to use a call light or ask for help because she has memory problems. Although review of the resident's kardex revealed it noted the resident was Spanish speaking only, the RSC stated the staff talk to the resident as if she can understand what they are asking her to do and she can't remember or understand. (2) Care plan The fall care plan (see above) was void of documentation to indicate that there had been any revision or updates to the fall care plan although the resident documented four falls prior to the target date of 8/20/14, and a number of recommendations (every two hour toileting, not leaving the resident unassisted in the bathroom, keeping the resident in the common areas, purposeful rounds and bed alarm) had been made by the IDT to minimize the resident's risks. Without adding these interventions to the care plan, there was no assurance these recommendations were communicated to all staff on all shifts. (3) A review of a document titled change of condition medication regiment review report dated 7/9/14 and authored by the facility consulting pharmacist indicated that he was consulting in relation to an increase in falls for the resident. The document indicated that the resident had been noted to be experiencing new onset or worsening of falls, dizziness or impaired coordination. The report indicated possible interactions with multiple medications that the resident was receiving. The facility did not document the utilization of the report to revise or update the resident's care plan to prevent further falls. (4) There was no documentation in the resident's medical record that the resident was educated in her primary language other than English in regards to the use of a call light, the need to ask for assistance with self mobility. The education record was void of any documentation to support that the facility attempted to make the process understandable to the resident in her primary language in the attempt to prevent further falls. The provider (see 6/18/14 note) documented, and the DON and ADON #1 confirmed on 8/18/14 at approximately 2:15 p.m. that the resident's language barrier made it difficult to communicate safety awareness to her. See also RCS #2 interview above. c. Observations On 8/11/14 at approximately 10:00 a.m., the resident was observed in her room. The resident was observed sitting at the sink in her wheelchair and attempting to reach into the sink .The resident was not completely seated in her wheelchair and no staff was in the room at the time. On 8/14/14 at approximately 3:30 p.m. the resident was observed sitting alone in her room. The resident was observed next to her bed. When the surveyor entered the room the resident stated that she was going to bed. The resident's call light was observed on the bed and out of reach of the resident. On 8/19/14 at approximately 1:30 p.m. the resident was observed sitting in her room in her wheelchair. The resident's roommate stated, "I am glad you are here I don't know what she wants but she is trying to get up." The resident's call light needed to activate the staff to respond and assist the resident, was observed out of reach and behind the resident ' s nightstand. 2. Resident #123, age 57, was admitted to the facility on [DATE] from the hospital. The face sheet of the same date indicated the following Diagnosis: [REDACTED]. a. Resident Status The computerized physician orders [REDACTED]. The ancillary orders for the month of August 2014 in the section safety devices/enablers read: -The resident was to have a pillow placed under the mattress edge when the resident was in bed and check the placement every shift for safety. -The resident should have a bed alarm, chair alarm, and the placement of both alarms should be checked every shift related to poor safety awareness. -Safety mats should be placed on the floor on each side of the bed. -The bed was to be in low position and checked every shift. -The resident was to be repositioned every 2 hours and purposeful rounds were to be done every hour and documented on the flow sheet. The minimum data set ((MDS) dated [DATE] documented that the resident had scored 0/15 on the BIMS; a score of 0 is reflective of severe cognitive impairment. The documentation further indicated that the resident had signs of delirium. Section G - functional status, documented that the resident was totally dependent on staff for all cares. The resident's fall care plan dated 5/20/14 documented the resident was at risk/potential for falls and fall related injury. The goal was that the resident would be free of fall related injury through 8/20/14. Interventions included having the resident ask for assist although, per assessment, the resident was severely cognitively impaired (see above). Another intervention was to observe for potential patterns of falls to identify possible causes. The care plan had not been updated or revised despite the documentation of 16 falls for the resident (see below). b. Falls The facility documented that the resident had 14 falls since admission to the facility. The dates of the falls documented by the facility were as follows: 4/18, 5/3, 5/16, 5/21, 5/23, 6/3, 6/19, 6/21, 6/23, 6/25, 6/30, 7/7, 7/15, and 7/25/14. (1) A review of the SBAR communication form document dated 4/18/14 documented that the resident was found on the side of the bed. The resident ' s blood sugar was "48." The resident suffered no injuries. (2) A review of the SBAR communication form document dated 5/3/14 documented that the resident was found on floor face down next to the bed. No injuries were documented. (5) A review of the SBAR communication form document dated 5/16/14 documented that the resident was found on her bottom on the fall mat next to the bed. (6) A review of the SBAR communication form document dated 5/21/14 documented that the resident was found sitting on the floor next to the air conditioning unit. (7) A review of the SBAR communication form document dated 5/23/14 documented that the resident was found sitting on floor next to her bed. (8) A review of the SBAR communication form document dated 6/3/14 documented that the resident was found sitting on floor next to her bed with some parts of her body actually under the bed. (9) A review of the SBAR communication form document dated 6/19/14 documented that the resident was found on the floor on her hands and knees. (10) A review of the SBAR communication form document dated 6/21/14 documented that the resident was found sitting on the floor. (11) A review of the SBAR communication form document dated 6/23/14 documented that the resident was found sitting on the floor. (12) A review of the SBAR communication form document dated 6/25/14 documented that the resident was found on floor. (13) A review of the SBAR communication form document dated 6/30/14 documented that the resident was assisted to the floor. (14) A review of the SBAR communication form document dated 7/7/14 documented that the resident fell face down onto the mat at the bedside. (15) A review of the SBAR communication form document dated 7/15/14 documented that the resident was found lying on the floor. (16) A review of the SBAR communication form document dated 7/25/14 documented that the resident was found on floor beside her bed. c. Facility Response (1) Provider notes The provider notes dated 4/21/14 did not address the fall by the resident on 4/18/14. The provider documented that the resident was ambulating well with her wheelchair and that he had discussed the resident's care with the nursing staff. The SBAR form indicated that the facility had notified the provider of the fall on the date of 4/18/14. The provider notes on 5/7/14 indicated that the reason for the provider visit was hepatic [DIAGNOSES REDACTED]. The SBAR form indicated that the facility had notified the provider of the fall on the date of 5/3/14. The next provider notes in the record were dated 5/23/14 and were specific to the resident's altered mental status. The progress note made no reference to the resident's falls on 5/16, 5/21 and 5/23/14. The SBAR form indicated that the facility had notified the provider of the three falls on the date of the falls. A provider note on 6/4/14 addressed the resident fall specific to that date. The provider note suggested that a medication change might help with the falls that the resident was suffering from. The next provider notes in the record were dated 6/24/14 and were specific to the resident's agitation. The note indicated that the resident had been slightly agitated and had several falls (per SBAR forms above, the resident had nine falls documented by the facility staff). The plan by the provider was an increase in her benzodiazepine which causes sedation and confusion. There was no mention of the lack of effectiveness of the current fall care plan for the resident in the provider progress notes. The last provider note in the resident's medical record was dated 7/30/14. The note did not document any re-assessment of the current fall program in place for the resident. (2) Fall Reviews The resident's falls were consistently evaluated and discussed at the IDT meetings by the facility DON, NHA and the ADON #1 as indicated on the facility form interdisciplinary post fall review. However, the resident's falls were not investigated on an ongoing basis. The recommendations by the IDT committee were often the same and were documented as hospice follow up, neuro checks and continue with the current plan of care. The resident had a total of 14 falls since admission and in a 3.5 month period. At no time did the facility develop a new plan of care to prevent the potential for future falls and injuries related to falls. There was no documentation in the resident's medical record that the interdisciplinary team assessed and re-assessed the effectiveness of the recommendations made after each of the resident's falls in order to prevent further falls for the resident. Finally, ancillary orders (see above) were not obtained until August after the resident had sustained 16 falls. These ancillary orders, moreover, were not added to the care plan to ensure implementation by all staff on all shifts. 4. Resident #28, aged [AGE] years, was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) on 6/28/14 revealed a Brief Interview for Mental Status score of 12 out of 15, indicating mild cognitive impairment. Resident record review indicated the resident had been documented and care planned as developmentally delayed. The resident was also documented to require a one person physical assist for toileting. Review of an incident/Accident Investigation Follow-up revealed: -Date of Incident: 7/17/14. -Description of Incident: Resident ambulates independently with four wheel walker. Was self transferring to toilet, says she lost her balance and found on floor by staff. -Summary of Investigation: Resident independent with four wheel walker, usually accepts with toilet transfers, but is safe with walker. This time she left walker near chair and tried to walk without it to toilet and fell . Complain of pain left hip. X-ray negative. Still complaining of left thigh pain. -Past Interventions Attempted: PT (physical therapy), restorative, ambulative walker, encouraged to request assistance for toileting. -Recommendations: monitor for pain and treatment per orders and results. Monitor for signs and symptoms of injury. Further assess left thigh. PT evaluation

Based on record review and interviews, the facility failed to ensure two of 32 sample residents (#90 and #112) received the care and services necessary to maintain the proper level of fluid intake. Specifically: -The facility failed to identify and assess resident #90's risk for fluid overload, consistently implement orders to address and monitor fluid overload, ensure the collaboration of the different physicians in charge of her care and develop and implement a care plan to mitigate her fluid overload risk. The resident was hosptalized on [DATE] for diuresis, given her weight gain of 20 pounds over the last month with symptoms of shortness of breath and bilateral lower extremity [MEDICAL CONDITION]. -The facility failed to ensure resident #112 received the care and services to maintain fluid restrictions, even though the [MEDICAL TREATMENT] communication forms had repeatedly requested that fluid restrictions be in place, in order to prevent fluid overload. Findings: A. Facility Policy 1. Hydration Management (in pertinent part): -All residents will be assessed by the Registered Dietitian to determine estimated nutritional requirements: kilocalories, protein, and fluids. This will be completed on admission, annually, and when there is a significant change in condition utilizing the Medical Nutritional Therapy Review form. -The Registered Dietitian or Dietary Manager will determine whether nutritional needs are met based on meal observation and intake reports. -Residents on fluid restriction will be monitored to ensure fluids are provided per physician's orders [REDACTED]. -A care plan will be developed or updated to reflect risk factors, measurable goals, and resident specific interventions. 2. Oral Nutrition and Hydration (in pertinent part): -Drinking water is provided to encourage adequate fluid intake. Provide fluids to residents during and in-between meals and during activities as appropriate. Before serving drinking water to the resident, verify that the resident is not NPO (nothing by mouth); is not on restricted fluids; is not on thickened fluids; and can have ice. -Residents may be placed on intake or output monitoring, or both. Intake and/or output measurement is recorded for residents according to the Hydration Management standards. -Document education with the resident and/or family member, and the response and non-compliance with the ordered diet. -If non-compliance continues, frequent counseling with the resident and/or family should be conducted and documented. B. Residents 1. Resident #90 (closed record) Resident #90, age 59, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (Several attempts were made during survey 8/8 - 8/20/14, to locate the resident for interviews, however, these attempts were unsuccessful.) a. Resident Status The 6/28/14 MDS revealed the resident had a brief interview for mental status score of 13/15 which indicated the resident was cognitively intact. The MDS revealed the resident had clear speech, adequate hearing, adequate vision, and no behaviors. The MDS coded the resident as needing limited assistance of the staff member with bed mobility, toileting, dressing, and transferring. The resident was 62 inches tall and weighed 244 pounds. The MDS coded the resident as occasionally incontinent of bowel and bladder. The resident was admitted with a 3/14/14 physician's orders [REDACTED]. The resident was care planned for pain, diabetes, falls, hypertension, [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. The care plan for [MEDICAL CONDITION], dated 5/7/14, included the goal that the resident would not have any complications related to [MEDICAL CONDITION] (such as shortness of breath, weight increase, decreased activity, [MEDICAL CONDITION]) for the next 90 days. The interventions included: -Monitor for shortness of breath, -Monitor for [MEDICAL CONDITION] to lower extremities, -Monitor weight weekly (although daily weights were ordered - see below), -Listen to the lungs with increase weight, shortness of breath, increased [MEDICAL CONDITION]. Listen for crackles as needed, -Notify physician with significant changes, and -Administer medications as ordered. b. Status after admission - facility failures Record review revealed the facility failed to identify and assess resident #90's risk for fluid overload, consistently implement orders to address and monitor fluid overload, ensure the collaboration of the different physicians in charge of her care and develop and implement a care plan to mitigate her fluid overload risk. The resident was hosptalized on [DATE] for diuresis, given her weight gain of 20 pounds over the last month with symptoms of shortness of breath and bilateral lower extremity [MEDICAL CONDITION]. (1) On 3/18/14, the resident visited the physician and medications were changed. The physician documented to continue [MEDICATION NAME] (diuretic) 60 mg twice a day and Zarox (diuretic) 5 mg Monday, Wednesday, and Friday and give an extra dose of 5 mg of Zarox tomorrow (3/19) equaling 10 mg. Review of the MAR revealed 60 mg of [MEDICATION NAME] was given at 8 a.m. and at 2 p.m., verified by initials in the dated squares, on 3/13 through 3/20/14. There was no evidence it was given at 2 p.m. on 3/13/14. On 3/20/14 the diet was clarified and documented as reduced concentrated sweets and low-sodium. The resident was admitted to the hospital on [DATE] due to the chest pain (due to increased fluids secondary to an acute exacerbation of [MEDICAL CONDITION] per hospital record) and readmitted to the facility on [DATE]. The resident, per care plan review (see above), was not care planned for a low sodium diet. (2) On 3/26/14 the resident was readmitted to the facility with orders of daily weights and [MEDICATION NAME] 40 mg, one and one half tablets orally twice a day, however, it was to be held on 3/26 and 3/27/14. In addition, the resident was to take [MEDICATION NAME] (antihypertensive) 3.125 mg, two tablets orally twice a day with meals. This was to be held for a heart rate less than 50 beats per minute. Review of the 3/14 MAR revealed [MEDICATION NAME] was held on 3/26 and 3/27/14 as ordered. However, it was given, verified by initials in the dated squares, only once at 8 a.m. on 3/29 and 3/30/14, instead of twice a day. [MEDICATION NAME] 3.125 mg, two tablets scheduled to be given twice a day with meals, was given twice a day as ordered on 3/27 through 3/30/14. However, it was given once only with the evening meal on 3/31/14, verified by initials in the dated squares. Documented weights were 248.8 pounds on 3/26 and 250.2 pounds on 3/27/14. There was no evidence that her weight was taken on 3/28, 3/29, and 3/30/14 as ordered. On 3/31/14, the resident's weight was documented as 245.4 (pounds). (3) On 4/2/14, the resident had a cardiologist visit. The visit note read, "discussed the importance of maintaining p.o. (oral) fluid intake currently that is less than 2000 ml at her care center; however she may have to decrease that even more." It was also discussed with the resident to minimize her dietary input of sodium and the resident stated she was trying to do this. The physician recommended the resident be seen at least weekly and possibly twice a week by the healthcare provider at the facility to monitor her fluid status and adjust diuretics as needed with follow-up labs. According to the doctor's progress notes, it was discussed and recommended, "... the patient may need a facility with a higher level of care as her status is so tenuous regarding going into heart failure." Despite the cardiologist's recommendation of fluid restrictions on 4/2/14, it was not until 4/10/14, that the Registered Dietitian (RD) documented an update. Contrary to physician orders [REDACTED]. There was no discussion of limiting fluids as the physician recommended on 4/2/14 and no documentation in the record that fluids were being limited. Moreover, the entry on the 4/14 MAR read, "Fluid 2000 ml per day Encourage every shift." The resident, per care plan review (see above) was not care planned for the fluid restriction recommended by the cardiologist. (4) On 4/9/14, the resident had an appointment with a renal physician. On 4/14/14, this physician documented to increase [MEDICATION NAME] to 80 mg every a.m. and 60 mg every p.m. times 3 days, and then resume 60 mg orally twice a day. There was no evidence the facility was restricting the resident's fluids (see MAR entry above). (5) The resident returned to the cardiologist on 4/24/14 and the orders were to increase the [MEDICATION NAME] to 80 mg twice a day, to recheck labs in one week, to decrease fluid limit to 1800 ml daily and "must be given a restricted sodium diet." [MEDICATION NAME] 80 mg was documented as given once on 4/30/14. There was no evidence the resident was visited by the dietitian to instruct her on the low sodium diet (per the medical record copies received from the facility). Review of the 5/14 MAR, revealed [MEDICATION NAME] was documented as given only daily at 8 a.m. on 5/1 through 5/7/14 instead as ordered twice a day on 4/24/14. On 5/13, the cardiologist ordered to continue on [MEDICATION NAME] 80 mg twice a day. Review of the 6/14 MAR, indicated by initials in the dated squares, [MEDICATION NAME] 80 mg was given twice a day from 6/1 through 6/14/14, and given once at 8 a.m. on 6/15/14 and not given on 6/16/14. (6) On 6/18/14, the resident again visited the cardiologist who documented the resident's lab tests were not in range (sodium of 130 -reference range of 135-145; potassium of 5.6-reference range of 3.5-5.50; BUN of 92 -reference range of 7 to 25; and a creatinine of 2 -reference range of 0.4 to 1.5). He documented to discontinue the [MEDICATION NAME] and the potassium. In addition, the cardiologist ordered to redo the "BMP (basic metabolic panel) STAT (immediately) on 6/19/14". However, the facility physician on 6/18/14 ordered the test to be done on 6/23/14. (7) On 6/28/14, the resident's weight was documented as 244 pounds. On 7/1/14, there was no documented weight. On 7/2 her weight was documented as 256.4 pounds, an increase of 12 pounds in 3 days. There was no documented weights on 7/3, 7/7, 7/14 and 7/15/14, despite the order of daily weights. (8) On 7/3/14, [MEDICATION NAME] 80 mg was ordered to be given daily and documented as given on 7/4 through 7/10, although not given on 7/11, and then given 7/12 through 7/17/14. (9) On 7/17/14, the resident was sent to the hospital by the cardiologist with shortness of breath, bilateral foot swelling and 20 pounds weight gain over the past month. She was discharged to another facility on 7/24/14. (10) Review of the meal intake records showed no evidence that the intake of fluids was documented. c. Interviews The Registered Dietitian (RD) was interviewed on 8/14/14 at 11:40 a.m. She stated she comes to the facility on ce a week and spends about 8 to 10 hours per visit. She verified, as she looked through the closed record, there was no evidence of any education of the resident on her diet and her fluid restriction. The RD went on to say that the corporate policy does not instruct them to document the amount of cc's of fluid intake per meal. The RD stated what should happen is a breakdown of cc's for days, evenings and nights for nursing and dietary. She went on to say that the staff should encourage the fluid restriction and that fluid restriction should be care planned. The policy on fluid restriction was requested, however, not received before exit on 8/20/14 or in the days immediately thereafter. The medical director was interviewed on 8/14/14 at 10:41 a.m. He stated the facility cannot do fluid restriction. He went on to say that it is a "resident's right and a resident's choice to have fluids. We cannot force a resident not to drink. The facility should be a homelike environment." He stated, however, "I would expect documentation (to) encourage fluid restriction every shift and that should be in the MARs." 2. Resident #112 Resident #112, age [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) on 5/17/14 indicated the resident's Brief Interview of Mental Status (BIMS) was 15/15, showing no cognitive impairment. Resident Record Review: Review of the August 2014 medication administration record (MAR) revealed an added order of "encourage 1500 ml fluid restriction (240 cc with meal) (300 cc each shift 6-2, 2-10) (180 cc with noc(night) shift" on 8/17/14. The MAR had been noted with 300 cc for the mornings of 8/17/14 and 8/18/14 and initialed or left blank on the other shifts. Review of the August 2014 treatment administration record (TAR) did not reveal any attempts of nursing staff to encourage fluid restrictions as noted in the interviews below. Review of the August 2014 physician's orders [REDACTED]. The dietary order was noted as 'Regular Texture.' Review of the July 2014 MAR and TAR did not reveal any attempts to encourage fluid restrictions. Review of the July 2014 physician's orders [REDACTED]. -A physician order [REDACTED]." -A physician order [REDACTED]." Review of the June 2014 MAR and TAR did not reveal any attempts to encourage fluid restrictions. Review of the June 2014 physician's orders [REDACTED]. [MEDICAL TREATMENT] Communications: [MEDICAL TREATMENT] Communication Records on 5/14/14 documented "Encourage patient to restrict fluid intake, should limit to 1000-1500 ml/day." [MEDICAL TREATMENT] Communication Records on 6/11/14 documented "Please reiterate to patient the importance of watching his fluid intake. He is fluid overloaded, but despite extra treatments, can't go down to EDW (estimated dry weight) due to 3-4 kg weight gain between treatments." [MEDICAL TREATMENT] Communication Records on 6/18/14 documented "Please reiterate fluid restriction. Patient still have 3-4 L fluid gains between treatments. He's 14 kilos over his EDW." A Quarterly Nutritional Status Review on 5/16/14 documented that the resident was on a renal diet and with double portions. The form noted under "Fluid Intake=Encouraged." It did not indicate fluid restrictions. The Progress Note for this date did not mention fluid concerns. Nurse Note on 7/22/14 indicated patient "request hospitalization now. He states 'I will call 911 on my own,' related to shortness of breath and increased weakness. A Resident Transfer Form on 7/22/14 indicated that the resident "requests hospitalization secondary shortness of breath and increased weakness. Patient non-compliant with fluids restriction. No signs of acute distress at the time of transfer." A hospital note indicated that "patient is a [AGE] year old male with a history of [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) on [MEDICAL TREATMENT], diabetes, hypertension, and OSA (obstructive sleep apnea) who presented with SOB (shortness of breath) and volume overload. He initially presented to the ED (emergency department) last night after calling 911 for throbbing CP (chest pain), SOB, productive cough, subjective fevers, and generalized fatigue x 1 day, but was later d/c home with likely [MEDICAL CONDITIONS] and no indications for emergent HD ([MEDICAL TREATMENT]). ACS (acute coronary syndrome) ruled out at that time. AV (arterial venous) fistula placed 3/14, with failure of maturation. The AM (morning) during his scheduled appointment for AVF (arterial venous fistula) repair he was found to be volume overloaded; the procedure was cancelled and he was sent to the ED. A physician progress notes [REDACTED]. A readmit Nutritional Status Review on 7/26/14 after the resident returned from the hospital indicated a fluid intake need of 2400-2880 ml, with recommendations to resume double portions. There was no documentation to indicate fluid restriction concerns. Resident Weights: 4/1/2014-294 5/2/2014-290 6/1/2014-302 6/29/2014-300 8/3/2014-312 -as noted in the interview with the RD below, the current weight gain of 12 pounds in six weeks had not been assessed for potential fluid overload as occurred in July 2014. Care Plans: -A care plan was initiated on 5/7/14 for [MEDICAL CONDITION] related to diabetes, [MEDICAL CONDITION], and high blood pressure. The Goals included: [MEDICAL CONDITION] will be minimized with treatment as ordered by the MD (physician) over the next 90 days. Approaches included: elevate [MEDICAL CONDITION] extremity for at least 30 minutes per day; administer medications for [MEDICAL CONDITION] as ordered by the MD; lay resident down for rest periods as needed, throughout the day; provide appropriate diet to minimize [MEDICAL CONDITION], as ordered by the MD; monitor monthly weight for changes; refer to dietician as needed. - A care plan was initiated on 5/7/14 for at risk for fluid deficit related to three times a week [MEDICAL TREATMENT]. The Goals included: resident will have risk of fluid deficit minimized due to interventions next 90 days. Approaches included: place fluids at bedside in resident's reach; provide 8 ounces of fluids at each medication pass; provide 8 ounces of extra fluids at each meal time; interdisciplinary referral for registered dietitian as needed; notify physician on change of status; monitor lab values and report to MD. - A care plan was initiated on 2/18/14 for potential weight loss/nutritional risk related to assist/ feed self, encourage in fluid status, fluctuates food/fluid intake, chronic disease, [MEDICAL TREATMENT] three times a week which would cause weight to go up and down, weight may fluctuate secondary to [MEDICAL CONDITION], and resident chooses to consume food not on renal diet. The Goals included: weight will be stabilized within weight range 290 to 305 pounds or weight gain 305 to 315 pounds each month through next 90 days. Approaches included: provide renal diet as ordered; offer double portions; offer preferred foods; meal assistance as needed; offer snacks as needed; provide medication as ordered; weights monthly or as indicated and may use [MEDICAL TREATMENT] weight; determine individual likes and dislikes; remind of meal times/locations. This was reviewed and revised on 5/16/14. Documentation summary: The facility failed to show updated care plans that addressed the potential for fluid overload related to fluid intake noncompliance. The resident's nutritional assessments did not document any concerns with fluid restrictions, even though the [MEDICAL TREATMENT] communication forms had repeatedly requested that fluid restrictions be in place. The resident was not properly educated or helped in ways that would make fluid restrictions more manageable. The facility had failed to monitor fluid intakes for the resident at risk, and to ensure that weight gains were not indicators of fluid overload. Interviews: An interview with a registered nurse (RN) #4 on 8/13/14 at 10:10 a.m. revealed that she was not aware that resident #112 was on any dietary restrictions. However, she did state she held his blood pressure medications on his [MEDICAL TREATMENT] dates. An interview with the registered dietitian (RD) on 8/13/14 at 12:15 p.m. revealed that the corporation that owned the nursing home did not require that any resident's fluids be monitored. The RD stated that they make sure that residents get enough to drink. According to the RD, the only exception to this would be if the physician wrote a specific order to monitor fluid intakes. An interview with a certified nursing assistant (CNA) #5 on 8/14/14 at 7:25 a.m. revealed that as far as she was aware, resident #112 was on a regular diet, and that "he eats really well and sometimes gets more, and drinks really well." The CNA was asked if the fluid intakes were monitored, and she said that they mark percentages for food intakes and cc's for fluid intake at the CNA kiosks. The CNA stated she had heard the resident had gone out to the hospital in July but did not know anything about the reason for the hospitalization . An interview with the DON was conducted on 8/14/14 at 7:33 a.m. regarding fluid intake monitoring. The DON stated that the facility did not document fluid intakes unless there was a doctor's order. The DON stated that resident #112 was noncompliant with fluids and food, but that decreased fluids were encouraged. The DON said that even though the resident was encouraged to be on a fluid restriction, they were not keeping track of his actual intakes in order to monitor him. An interview was conducted with the Assistant Director of Nursing (ADON) #1 on 8/14/14 at 7:40 a.m. regarding monitoring fluid intakes. The ADON was asked what would be considered a normal fluid restriction level. Resident #112's documented fluid intake needs of 2400-2800 ml were offered as an example. The ADON stated that it would depend, although the fluid intake needs of 2400-2800 ml seemed a little high. An interview with CNA #3 on 8/14/14 at 8:03 a.m. revealed that the resident sometimes did not eat breakfast, but did eat a good lunch, and liked to take food to [MEDICAL TREATMENT]. An interview was conducted with the facility medical director, DON, and ADON #1 on 8/14/14 at 10:18 a.m. regarding fluid intake and hydration management for at risk residents. The physician stated that the facility did not deprive residents of water and that intake and outputs of fluids were not common practice anymore, and were not that helpful. The physician stated that weights should be used instead. The physician stated that the instruction was to look at skin turgor and to check the state of the tongue. The physician stated that 90% of the history came from the resident, but in this population the CNA was the best historian. The physician indicated monitoring weights for residents that go to [MEDICAL TREATMENT] was difficult. The DON and ADON stated that the facility could not withhold fluids from any residents. If a resident was noted to have fluid restriction needs, the dietary order should have read to "encourage" fluid restrictions. The DON also confirmed that fluid restrictions should be reflected on the care plans if ordered by the physician. The DON also stated that the medication administration record (MAR) should show that the nurses are documenting that they have encouraged fluid restrictions to the resident. The RD was interviewed on 8/14/14 at 12:00 p.m. regarding the resident's fluid intake needs. The RD stated that the resident was noncompliant, and that she did not see anything in the resident's chart to indicate a need for fluid restrictions. The RD confirmed the resident had recently been in the hospital and documented with fluid overload. The RD also confirmed that the resident had gained weight again recently. When asked how she could determine if the resident's current weight gain was from increased food intake or from a potential fluid overload she confirmed that there, "wouldn't be any way to make that determination" and stated "I don't know how to answer that." The RD said that she had seen the [MEDICAL TREATMENT] communication forms that had noted fluid restriction for the resident. An interview was conducted with the resident on 8/14/14 at 1:10 p.m. The resident confirmed that a fluid restrictive diet was encouraged from [MEDICAL TREATMENT], but was hard to be on and he was really looking for more education from someone. The resident stated that he would get a very dry mouth at night and would need something to drink. The resident stated he had not been feeling very good in July and could not get the facility staff to listen to him. He stated he had to call 911 because if he had to wait on them to take him serious "you'd die around here." An interview was conducted with the DON on 8/19/14 at 11:20 a.m. regarding the facility's hydration management policy. The DON stated that the RD would mention any residents of concern. The facility is mostly "focused on fluid deficit." The DON again confirmed that they did not check for fluid intakes if there was no doctor's order. The DON said that the RD would mention people to look at, such as those with a change in condition. When the DON was informed of the resident's recent fluid overload, she stated that those residents were usually [MEDICAL TREATMENT] residents. The DON also confirmed that the resident's [MEDICAL TREATMENT] communication forms were not completed.

Based on observations, record review, resident and staff interviews, the facility failed to ensure that one (#8) of 38 sample residents had routine and emergency dental services. Specifically, the facility failed to ensure recommended follow-up dental services were provided for the resident. The lack of follow-up dental services resulted in the resident experiencing significant mouth pain. Findings include: Sample resident #8, age 91, was admitted to the facility on [DATE]. According to the 11/12 Computerized Physician order [REDACTED]. The 8/4/12 MDS documented the resident had a 14 out of 15 score on the brief interview for mental status. Observations: --On 11/1/12 at 9:30 a.m., the resident was observed to have both upper and lower dentures. The resident lifted her lips up with her hands and showed the surveyor. Resident Interview: --The resident was interviewed on 11/1/12 at 1:20 p.m. The resident stated that she had mouth pain and that both of her upper and lower gums were sore. She stated that it interfered with her eating. She stated that the nurses were getting something from the drug store to help with the pain. The resident stated, "it hurts to bite down." Record Review: --Review of the meal intake records for September, October and November 2012, showed the resident had an average meal consumption of 73% for breakfast, 64% of lunch and 56% of dinner. --The 8/15/12 dental report documented the areas of concern of the " ...broken denture tooth, clinical evidence of very loose upper denture and ill fitting lower denture and clinical evidence of poor bite." --A dental report, dated 10/18/12, documented the resident had a visit related to denture sores. The dentist evaluated and could not find a sore, however, documented the resident dentures were loose. The dentist assured the resident that new dentures would improve the situation. --The 10/29/12, physician telephone order documented, "apply oralgel to mouth and gums per directions on box. Do this prior to meal for sore gums." --The 10/26/12, nurses notes documented, "...c/o (complaint of) mouth pain did assess (assessment) no redness or sore noted. Social service stated that dentures are too big and that dentist has order new ones but delivery date yet. MD (medical doctor) was notified at 1835 regarding pt's mouth discomfort. Will continue to observe. Tylenol 650 mg given with good effect." --The care plan, dated 10/29/12, identified the resident as having sore gums. The goal was for the resident to be free from serious complications related to oral status. Pertinent approaches were to report mouth pain, social service referral for dental exam, oragel used as ordered by the physician. --The 11/2/12, nurses note documented the physician was called regarding the resident's mouth pain. The resident needed new dentures and that the resident "...just wanted something for the pain now ..." --Review of the social service notes dated 5/15/12 to 11/6/12 failed to show documentation regarding the request for new dentures. Interviews: --A licensed practical nurse was interviewed on 11/7/12 at approximately 1:00 p.m. The LPN stated that the resident complained of mouth pain. The LPN stated the resident complained of her gums being sore. She stated that the resident had treatment to aid in the pain. --The resident was interviewed a second time on 11/7/12 at 5:00 p.m. The resident stated her gums remained sore all the time. She stated that she had lost weight and that she was unable to eat. --The social service director (SSD) and the social service assistant (SSA) were interviewed on 11/7/12 at 4:00 p.m. The SSA stated the PETI process was started 8/12. She stated that the resident had been complaining of mouth pain. The PETI process was started to acquire new set of dentures as her current dentures were rubbing as they were too big. She stated that the PETI form was sent back on 8/29/12 due to a lack of a signature. The signature was obtained and was sent back for approval on 9/11/12. The business office received the PETI authorization on 10/1/12. The business office then starts the process of the payment. The SSA stated that it would then take a few months to obtain the money prior to ordering the dentures. --The SSD stated that the facility could request "emergency money" prior to the approval of the PETI to ensure the resident received the dentures timely. However, the SSA was unaware of this procedure. The business office manager (BOM) was interviewed on 11/7/12 at approximately 4:30 p.m. The BOM stated that she did receive the PETI request, however, it would take at least two months for the reimbursement. She stated that she had not received any request for "emergency money" to be obtained to purchase the dentures. The director of nurses was interviewed on 11/7/12 at approximately 4:30 p.m. The DON stated that she was not aware of the recommendations for new set of dentures.