Every finding on record at Crowley County Nursing Center

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 on two of four halls and in one of one dining room.Specifically, the facility failed to:-Ensure staff donned (put on) the appropriate personal protective equipment (PPE) for a resident requiring enhanced barrier precautions (EBP) when obtaining vital signs; -Ensure vital signs equipment was sanitized between resident use; and,-Ensure staff performed hand hygiene while providing meal assistance. Findings include: I. EBP failures A. Professional reference Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), 4/2/24, was retrieved 6/9/26. It read in pertinent part, EBP expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact 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 EBP 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, undated policy was provided by the nursing home administrator (NHA) on 6/4/26 at 4:15 p.m. It read in pertinent part, Enhanced barrier precautions (EBP's) are utilized to prevent the spread of multi-drug resistant organisms to residents. EBP's employ targeted gown and glove use during high contact resident care activities when precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity. EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices. EBP's remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. C. Observations On 6/1/26 at 1:45 p.m. an unidentified certified nurse aide (CNA) entered a resident's room on Hall A who was on EBP. The CNA did not don PPE before obtaining the resident's vital signs. -The unidentified CNA failed to don PPE for a resident who was on EBP. On 6/2/26 at 9:00 a.m. during medication pass licensed practical nurse (LPN) #1 entered a resident's room on Hall D, who was on EBP related to an indwelling device. When LPN #1 entered the room she did not don PPE. She had a blood pressure machine that she placed next to the resident's bed. With bare hands she placed the blood pressure cuff on the resident's bare arm touching the resident's skin with her hands. LPN #1 leaned on the bed rail with her bare arm while the resident took their medications. -LPN #1 failed to don PPE for a resident who was on EBP. D. Staff interviews LPN #1 was interviewed on 6/2/26 at 9:30 a.m. LPN #1 said she did not don PPE when she obtained the blood pressure and administered medications to the resident on EBP because they were to only wear the PPE when they changed the resident's catheter. LPN #2 was interviewed on 6/3/26 at 8:25 a.m. LPN #2 said when a resident was on EBP it was because the resident had a catheter, an intravenous (IV) device, or a wound that would be open to the potential for germs to enter their body. She said it was to protect the resident and staff from passing on germs to others. She said obtaining a resident's blood pressure who was on EBP would be considered direct contact because you would be touching the resident and the equipment would need to be sanitized after use. CNA #1 was interviewed on 6/3/26 at 10:10 a.m. She said a gown and gloves were supposed to be worn when they were providing direct care or emptying catheters for a resident that was on EBP to prevent spreading germs. CNA #2 was interviewed on 6/3/26 at 1:15 p.m. She said when a resident was on EBP they were to don PPE prior to entering the room when they were providing direct care to the resident, such as incontinence care, bathing, or emptying catheters. She said the PPE was removed in the room and hands were to be washed. The director of nursing (DON) was interviewed on 6/4/26 at 9:00 a.m. She said any resident who had an open wound that required a dressing change should be placed on EBP. E. Facility follow-up On 6/2/26 the DON provided documentation of an inservice on enhanced barrier precautions for all departments. Twenty staff attended. The education included: Enhanced Barrier Precautions (EBP) expand the use of personal protective equipment (PPE) to include the use of gown and gloves during high-contact resident care activities -- activities that provide opportunities for the transfer of MDROs to staff hands and clothing. EBP requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or transmitting an MDRO. This includes: residents known to be infected or colonized with an MDRO; residents with an indwelling medical device including central venous catheter, urinary catheter, feeding tube , tracheostomy/ventilator status; and, residents with a chronic wound, regardless of their MDRO status. Additional comments included for staff to perform hand hygiene and don appropriate PPE (gowns/gloves) when required for all care provided, especially when touching a resident. II. Vital sign failures A. Facility policy and procedure The Infection Control Equipment Sanitation policy, revised 3/12/18, was provided by the NHA on 6/4/26 4:15 p.m. It read in pertinent part, Procedure: Blood pressure cuffs, pulse oximeter (to measure oxygen saturation), stethoscopes, and treatment scissors - wipe with cavicide (disinfectant) wipes, place in the appropriately numbered basket, and allowed to air dry for a minimum of 2 minutes before the next use. B. Observations On 6/1/26 at 9:00 a. m. an unidentified male resident was seated near the nurses' station and an unknown staff member obtained his blood pressure placing the cuff on his bare arm. The staff member did not sanitize the vital signs machine before or after obtaining the blood pressure then placed the machine against a wall near the nurses' station. On 6/1/26 at 1:45 p.m. an unidentified CNA, used a vital signs machine that was near the nurses' station to take a residents vital signs. Without sanitizing the machine, she entered a resident's room on Hall A, who was on EBP to take their vital signs. The unidentified CNA did not sanitize the machine prior to use and obtained a blood pressure on the bare arm of the resident. The unidentified CNA exited the room with the vital signs machine, did not sanitize it, and placed it next to the wall near the nurses' station. On 6/2/26 at 8:50 a.m. LPN #1 was observed during medication pass administering medications to a resident on Hall D. LPN #1 removed a pulse oximeter from the pocket of her uniform top, she did not sanitize it, and placed it on the resident's finger. After the oxygen saturation reading was obtained LPN#1 did not sanitize the device and placed it back into the pocket of her uniform top. On 6/2/26 at 9:00 a.m. during medication pass LPN #1 used a stethoscope that had been hanging around her neck and placed the diaphragm (chest piece) on the antecubital (inner bend of elbow) space on the resident's right arm and obtained the blood pressure reading. LPN #1 then placed the stethoscope back around her neck without cleaning the diaphragm. C. Staff interviews LPN #1 was interviewed on 6/2/26 at 9:30 a.m. She said the blood pressure cuff and vital sign equipment needed to be sanitized after each resident use. The DON was interviewed on 6/4/26 at 9:00 a.m. The DON said she filled the role of the infection preventionist. She said when staff were caring for a resident on EBP, and having direct contact with them, such as wound care, catheter care, and obtaining vital signs they were to don the appropriate PPE-gowns and gloves. She said the vital signs machines were to be sanitized between resident use. She said if nurses used their own stethoscope or pulse oximeter, those items should be cleaned as well and not placed around their neck or in the pocket of their uniform top. III. Hand hygiene failures A. Professional reference According to The CDC Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 6/8/26 from https://www.cdc.gov/cleanhands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings. B. Observations On 6/1/26 at 8:36 a.m. in the main dining room several residents were finishing their breakfast meal. Three unidentified residents were sitting at one table in the main dining room receiving meal assistance from an unidentified CNA. The unidentified CNA was wearing a pair of disposable gloves, and was observed providing bites to each of the three residents. -The CNA did not perform hand hygiene between offering bites of food to each resident. During a continuous observation of the lunch meal in the main dining room on 6/1/26, beginning at 11:40 a.m. and ending at 12:40 p.m., the following was observed: At 12:19 p.m. Resident #26 received his lunch meal tray. Resident #26 grabbed his fork and began placing food on his fork using his fingers before using the fork to feed himself. At 12:20 p.m. Resident #5 was served his lunch meal tray. CNA #3 sat down between Resident #5 and Resident #26 and began helping Resident #5 cut his food. At 12:26 p.m. CNA #3 was assisting Resident #26 by offering him bites of his food using his silverware. At 12:27 p.m. CNA #3, using the same hand, used Resident #5's spoon to cut up his fruit before handing him his spoon so the resident could continue feeding himself. At 12:28 p.m. CNA #3 used the same hand to continue to offer bites of food to Resident #26. CNA #3 stood up, walked over to another table where there was a bottle of hand sanitizer and sanitized her hands before sitting in another seat next to Resident #26 to get into a better position to help with his meal assistance. -CNA #3 did not perform hand hygiene between offering bites of food to each resident, and no hand sanitizer was available at the table for CNA #3 to use. C. Staff interview The DON, who also acted as the facility's infection preventionist was interviewed on 6/4/26 at 12:55 p.m. The DON said facility staff performed hand hygiene upon entry into the dining room and should perform hand hygiene before sitting down to assist residents with meals. The DON said staff members should only assist one resident at a time and should perform hand hygiene between residents if they do need to switch between assisting two different residents.

Based on observation, interviews, and record review the facility failed to ensure that residents received proper treatment and assistive devices to maintain hearing abilities for one (#31) of four residents reviewed for hearing services out of 23 sample residents.Specifically, the facility failed to ensure Resident #31's missing hearing aids were replaced in a timely manner.Findings include:I. Resident #31A. Resident statusResident #31, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the June 2026 computerized physician's orders (CPO) diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side.The 4/29/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15.The MDS assessment indicated the resident had difficulty hearing and did not have hearing aides.-However, record review revealed the resident required hearing aides, but they were missing (see record review and interview below).B. Resident interview and observationResident #31 was interviewed on 6/1/26 at 2:07 p.m. At the time of the interview, she was not wearing hearing aids. The resident said her hearing aids were lost some time ago. She said she had not received an update on getting new ones. She said without them she missed parts of conversations and had trouble hearing the television. She said she really wanted to get them back. C. Record reviewResident #31's hearing care plan, initiated 3/5/26, revealed the resident had impaired hearingand her bilateral hearing aids were missing. The care plan indicated she had hearing evaluations with audiology 3/20/23 and 2/26/26. The care plan revealed the medical necessity certification form to obtain new hearing aids through post eligibility treatment of income (PETI) was submitted to the facility corporate business office on 3/3/26. Review of Resident #31's electronic medical record (EMR) revealed the following;A physician's order, dated 5/4/24, indicated staff were to assist the resident with placing the hearing aids in the morning. The physician's order indicated it was on hold.The audiologist's hearing evaluation report, dated 2/26/26, indicated Resident #31's left ear had moderate hearing loss in the low pitches that decreased to a severe hearing loss in the high pitches which could cause general conversation, loud speech, and some environmental sounds to be very soft or entirely inaudible. The note documented speech understanding might be particularly troublesome when trying to communicate in the presence of background noise, if the speaker was at a distance, or when the conversation was not face-to-face. The right ear had mild hearing loss in the low pitches decreasing to a severe hearing loss in the high pitches. The audiologist documented that the resident had bilateral hearing aids and the resident reported the current hearing aids were lost. The audiologist indicated new hearing aids would need to be ordered. The note documented the resident reported more trouble hearing and was concerned that her hearing had changed. The note documented recommendations included bilateral amplification. The note documented the resident was not provided a hearing amplification device.The annual care conference summary, dated 4/29/26, indicated the resident had bilateral hearing aids and the facility was waiting on the PETI approval for new hearing aids.-However, on 3/11/26 a letter was submitted to the facility that indicated payment for new hearing aids had been denied. The social services progress note, dated 1/27/26, documented the audiology company indicated that for the PETI to be submitted Resident #31 would need another hearing evaluation. That evaluation was scheduled for 2/26/26.The social services progress note, dated 2/4/26, documented the resident's hearing aids were missing and she had a hearing aid evaluation scheduled for 2/26/26. The resident was in need of a new evaluation per the PETI guidelines for processing of payment for the hearing aids.The social services progress noted, dated 4/30/26, documented that Resident #31's hearing was impaired, and the facility was waiting on PETI approval for new bilateral hearing aids even though the facility had received a payment denial letter on 3/11/26 that indicated the request for PETI nursing facility services had been denied related to the hearing aids having been replaced on 10/17/24 and per state rule hearing aids could only be replaced every five years. -Review of Resident #31's electronic medical record (EMR) did not reveal any further documentation regarding the replacement of Resident #31's hearing aids.II. Staff interviewsThe social services director (SSD) was interviewed on 6/3/26 at 3:30 p.m. She said when a resident's hearing aids went missing in the facility, the staff looked for them. She said she would then meet with the management team to decide what to do, whether to replace them or try to get them paid for through the PETI process. The SSD said the central business office processed the PETI form requests. She said the nursing home administrator (NHA) was ultimately responsible for deciding whether to pay for the replacements or not. She said she should have followed up on the status of Resident #31's hearing aid replacements after she documented the 4/30/26 progress note. The NHA was interviewed on 6/3/26 at 4:30 p.m. She said when a resident's hearing aids were lost in the facility the process was started to see if they could get them paid for through the PETI process. The NHA said if the request was denied then the facility was responsible for payment and replacement of the hearing aids. She said once the denial was received the SSD was supposed to request an invoice from the audiology company for the cost of the replacements. The NHA said once the central office received the invoice then the replacement hearing aids would be purchased. She said the ball was dropped and she had not been made aware of Resident #31's missing hearing aids. She said the SSD should have followed up frequently on the status of the PETI request to eliminate any unnecessary delays.

Based on record review and interviews, the facility failed to ensure one (#6) of five residents out of 23 sample residents received the nutritional care and services necessary to maintain their highest practicable level of well-being.Specifically, the facility failed to implement effective, person-centered interventions for Resident #6 who was experiencing weight loss.Findings include:I. Facility policy and procedureThe Food and Nutrition Services policy and procedure, revised 2/19/18, was received from the nursing home administrator (NHA) on 6/4/26 at 4:15 p.m. It read in pertinent part, Multidisciplinary staff, including the nursing staff, the attending physician and the dietitian, will assess each resident's nutritional needs, food likes and dislikes, eating habits, as well as physical, functional and psychosocial factors that affect eating and nutritional intake and utilization. Reasonable efforts will be made to accommodate resident choices and preferences. Nursing staff will ensure that assistive devices are available to residents as needed.II. Resident #6A. Resident statusResident #6, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes, anemia, major depressive disorder, generalized muscle weakness, adult failure to thrive, chronic heart failure, pressure ulcer and protein-calorie malnutrition.The 4/16/26 minimum data set (MDS) assessment revealed the resident was cognitively intactwith a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff assistance for most activities of daily living (ADL) and needed setup or cleanup assistance for eating.The assessment documented the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months.B. Resident interview and observationsResident #6 was interviewed on 6/2/26 at 12:07 p.m. Resident #6 said he loved Spanish and Mexican food, coffee, and milk. Resident #6 said he did not like the chocolate flavor of his nutritional supplements, but did like the strawberry and vanilla flavors. Resident #6 said the facility gave him Ensure (nutritional supplement) for protein because he had lost a lot of weight. Resident #6 said he looked at himself and asked himself how he ever got so skinny. Resident #6 said the nursing staff also gave him a straight protein drink (Prostat), which did not taste very good. Resident #6 said he wanted to put weight back on and get his strength back. Resident #6 was observed lying in bed. Resident #6 was visibly emaciated, with each of his arm and finger bones visibly prominent.C. Record reviewThe nutrition care plan, revised 4/19/26, revealed Resident #6 had a nutritional problem due to his diagnoses of diabetes, malnutrition and respiratory failure. Resident #6 experienced a significant weight loss of 6.2% of his body weight in 30 days on 4/19/26. Pertinent interventions included providing Resident #6's diet as ordered, monitoring and recording his intake at each meal, offering whole milk at each meal, providing snacks as ordered, and the registered dietitian (RD) evaluating the resident and making diet change recommendations as needed.Resident #6's weights were documented in the electronic medical record (EMR) as follows:-On 4/3/26, the resident weighed 133.0 pounds (lbs);-On 4/7/26, the resident weighed 132.6 lbs;-On 4/14/26, the resident weighed 124.8 lbs;-On 4/29/26, the resident weighed 116.4 lbs;-On 5/6/26, the resident weighed 110.0 lbs;-On 5/13/26, the resident weighed 116.4 lbs;-On 5/19/26, the resident weighed 119.8 lbs;-On 5/26/26, the resident weighed 117.6 lbs; and,-On 6/4/26, the resident weighed 116.8 lbs.-The resident sustained a 17% (23 lbs) weight loss, from 4/3/26 to 5/6/26, in one month, which was considered severe.-The resident sustained a 12% (16.2 lbs) weight loss, from 4/3/26 to 6/4/26, in two months, which was considered severe.Review of Resident #6's June 2026 CPO revealed the following physician's orders:-Mirtazapine (an antidepressant medication also used to stimulate appetite) 30 milligram (mg) tablets, give 30 mg by mouth at bedtime for major depression, ordered 4/3/26;-Admit to hospice with diagnosis of moderate protein-calorie malnutrition, ordered 4/3/26;-Regular diet, regular texture, regular consistency, ordered 4/3/26;-Obtain weights/vital signs per facility protocol, ordered 4/3/26;-Glucerna (nutritional supplement) two times daily, ordered 4/3/26; and,-Protein oral liquid, give 30 milliliters (ml) by mouth two times a day to help with wound repair to the left foot, ordered 4/10/26.Review of Resident #6's April 2026 medication administration record (MAR), from 4/3/26 through 4/30/26, revealed the following:-Resident #6 refused his Glucerna 24 times out of 53 possible opportunities; and,-Resident #6 refused the protein oral liquid 27 times out of 40 possible opportunities.Review of Resident #6's May 2026 MAR, from 5/1/26 through 5/31/26, revealed the following:-Resident #6 refused his Glucerna 29 times out of 62 possible opportunities; and,-Resident #6 refused the protein oral liquid 57 times out of 62 possible opportunities.Review of Resident #6's June 2026 MAR, from 6/1/26 through 6/4/26, revealed the following:-Resident #6 refused his Glucerna 3 times out of 6 possible opportunities; and,-Resident #6 refused the protein oral liquid five times out of seven possible opportunities.-However, review of Resident #6's electronic medical record (EMR) did not reveal documentation indicating the facility addressed the residents frequent refusals of the oral nutritional supplements. A dietary profile, dated 4/3/26, revealed the dietary manager (DM) met with Resident #6 to assess his dietary preferences. In the food allergies/intolerances section, the DM documented Resident #6 would not answer the question, and it was unclear if Resident #6 did not know the answer or did not want to answer. Resident #6 did not respond when asked about his food likes or dislikes. The DM documented Resident #6 did not respond to most of his questions, and that the DM would try to get more answers from the resident at a later time.-However, review of Resident #6's electronic medical record (EMR) did not reveal any other attempts to assess the resident's food preferences.A progress note, dated 4/10/26 at 10:02 a.m., revealed the facility dietitian recommended Resident #6 receive Megace for appetite stimulation. Resident #6 was on hospice, and when the nursing staff communicated with the hospice staff, it was revealed Megace was not covered by the resident's insurance and the hospice company would not fill an appetite stimulant. The director of nursing (DON) was notified.-However, the facility did not attempt to implement a different nutritional intervention to assist with the resident's weight loss.A progress note, dated 4/10/26 at 11:06 a.m., revealed Resident #6 was seen by a hospice registered nurse (RN) for a follow-up. Resident #6 had poor appetite and abdominal discomfort. The note documented the facility's dietitian requested Megace as an appetite stimulant for Resident #6. The note documented the hospice agency would monitor the resident before moving forward.A progress note, dated 4/12/26 at 2:36 a.m., revealed Resident #6 ate 50% or less for two or more meals in one day. Resident #6 declined all snacks that were offered before bed. Resident #6 drank 25% of his Glucerna with staff encouragement. The note documented staff would continue to offer Resident #6 his preferred foods and encourage increased nutritional intake.A social services note, dated 4/22/26 at 4:31 p.m., revealed Resident #6 participated in his initial care conference. Resident #6's Mirtazapine dose was discussed during the care conference, at which point Resident #6 expressed he did not feel like eating, but said he was motivated to get better. A nutrition note, dated 4/24/26 at 11:21 a.m., revealed Resident #6 was being followed in the facility's nutrition at risk meetings due to being a new admission and having a significant weight loss of 6.2% of his body weight in 30 days. Resident #6 was receiving hospice care. Resident #6's intake of meals ranged from 0 to 25%. Resident #6 had orders for Glucerna twice a day, which was accepted 20% of the time. Resident #6 also had a diabetic ulcer on his left ankle and a pressure ulcer on his left heel which were not improving. Resident #6 would continue to be followed during the nutrition at risk meetings.-However, no new interventions were initiated for Resident #6 despite his low meal and Glucerna acceptance rates.A progress note, dated 4/24/26 at 8:08 p.m., revealed Resident #6 refused his evening Glucerna. Resident #6 told the nurse he knew she put that protein stuff in it, to which the nurse assured the resident she did not put the liquid protein in his Glucerna. The nurse offered to open a new bottle of Glucerna for Resident #6, but the resident refused that as well and said the nurse would put the liquid protein in it when he was not looking. Resident #6 refused the liquid protein and any other snacks.A progress note, dated 4/26/26 at 9:27 a.m., revealed Resident #6 continued to refuse his meals. Resident #6 said he was grossed out by the food and said everything tasted funny. The note documented Resident #6 did not like the taste of the liquid protein and suspected staff of putting it in his food and drinks. The nurse documented she had to make his coffee and show Resident #6 it was free of the liquid protein before he would even take a sip of it.A progress note, dated 4/27/26 at 9:22 a.m., revealed Resident #6 took the liquid protein supplement that morning, but was upset with the nurse. The nurse documented the staff had offered the liquid protein supplement in different juices and drinks but Resident #6 insisted the supplement tasted terrible. Resident #6 was reeducated by the nursing staff on the importance of him taking the supplement to help with his wound healing, but the resident said the supplement was gross and made him feel nauseated.A nutrition note, dated 5/29/26 at 10:57 a.m., revealed Resident #6 was being followed in the facility's nutrition at risk meetings due to his diagnosis of moderate protein-calorie malnutrition and his wounds to his left lower extremity. The note documented Resident #6's trending weight was increasing since his admission. Resident #6 was receiving hospice care. Resident #6's intake of meals averaged 58%. Resident #6 had orders for Glucerna twice a day, which was accepted 25 to 50% of the time and Prostat liquid protein which was accepted 0 to 25% of the time. -However, no new interventions were initiated or discussed for Resident #6 despite his and Glucerna and Prostat acceptance rates.III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/3/26 at 10:56 a.m. CNA #1 said Resident #6 liked Mexican food and always talked with her about it. CNA #1 said Resident #6's appetite depended on the day, and said he was able to feed himself if he set himself up right. CNA #1 said she offered Resident #6 snacks often and when he asked for them. CNA #1 said Resident #6 told her the supplements did not taste very good. Licensed practical nurse (LPN) #2 was interviewed on 6/3/26 at 1:04 p.m. LPN #2 said Resident #6's appetite had not been great but was starting to improve. LPN #2 said Resident #6 was a very picky eater and only wanted Mexican food. LPN #2 said sometimes Resident #6's family brought in Mexican food, or the nursing staff would make food and bring it in. LPN #2 said Resident #6 received Glucerna once a day and usually accepted it well. LPN #2 said Resident #6 liked the chocolate flavor of Glucerna. LPN #2 said Resident #6 also had orders for liquid protein but hated it and refused it quite a bit, even when the nursing staff tried mixing it with apple juice.CNA #2 was interviewed on 6/3/26 at 2:32 p.m. CNA #2 said Resident #6's appetite had improved lately and said he ate well especially when eating Mexican food. CNA #6 said Resident #6 liked chocolate and Oreo cookies.The DM was interviewed on 6/4/26 at 10:45 a.m. The DM said he had started talking with all of the residents about their dietary preferences when he started his position a few months prior. The DM said his meetings with the residents about their dietary preferences had been more informal, and he was starting to document them more in their EMRs as he was not previously familiar with their EMR software. The DM said he had spoken with Resident #6 about his dietary preferences and said the resident enjoyed mandarin oranges, cauliflower, salisbury steak, cottage cheese and fruit. The DM reviewed Resident #6's EMR and said he was not able to find any updated dietary preference sheet for him.The registered dietitian (RD) was interviewed on 6/4/26 at 11:32 a.m. The RD said she had been working with the facility since mid-May 2026 and had not yet reviewed Resident #6's case. The RD said generally any resident experiencing a significant weight loss of greater than 5% of their body weight in one month or 10% over 180 days would automatically be triggered for monthly chart reviews. The RD said the facility also had a nutrition-at-risk committee. The RD said she generally reviewed residents at risk for weight loss at least monthly if not more frequently. The RD said when she reviewed residents for weight loss she would talk with the nursing staff to see what feedback the resident was giving them about their supplements and meals. The RD said sometimes residents did not like the flavor of the supplements they received, or sometimes they did not want to drink their supplements and wanted more food-forward interventions. The RD said if a resident was not accepting their supplements she would discontinue or decrease the supplement they were refusing, because sometimes residents became overwhelmed by the frequency of interventions being offered. The RD said she would meet with Resident #6 to discuss what interventions he wanted to continue with.The DON was interviewed on 6/4/26 at 12:03 p.m. The DON said Resident #6 was admitted to the facility with hospice services and said his appetite was okay. The DON said she had spoken with Resident #6 and asked him if he wanted food from home or Mexican food, so the facility started ordering burritos for him, but the resident said he just felt gross and did not want to eat. The DON said Resident #6's appetite had slowly gotten better and the resident was eating bigger portions and eating a lot of cream of wheat. The DON said Resident #6 was on Prostat to help with wound healing and also received Glucerna. The DON said Resident #6 had gotten better with accepting the Prostat since she educated him on why it was important for him to take. The DON said Resident #6 did not accept the Prostat previously as he did not like it and thought it was not doing anything for him. The DON said the administration had been getting ready to discontinue Resident #6's Prostat order but wanted to sit down with him and explain why it was important for him to give it another try, and said he had been more compliant with accepting it over the last two to three weeks. The DON said Resident #6 liked all the flavors of Glucerna and asked for different flavors each time. The DON said the DM created a baseline care plan with resident's dietary preferences on admission and created a dietary preference sheet for each resident in their EMR.-However, Resident #6's dietary preferences had not been documented after his admission on [DATE].

Based on record review, observations and interviews, the facility failed to ensure one (#21) of six residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 23 sample residents.Specifically, the facility failed to identify, implement and care plan interventions for Resident #21 who had a history of trauma and suicidal ideation.Findings include:I. Facility policy and procedureThe Mental Health policy and procedure, revised 2/19/18, was received from the nursing home administrator (NHA) on 6/4/26 at 4:15 p.m. It read in pertinent part, Any member of the facility is allowed to report suicidal comments, ideation or attempts. The charge nurse is responsible for notifying the physician for orders, implementing safety measures, protocol, and charting of steps/actions taken.The Behavioral Health Services policy and procedure, dated 5/22/18, was received from the NHA on 6/4/26 at 4:15 p.m. It read in pertinent part, The facility will ensure that residents' individualized behavioral health needs are met through the resident assessment instrument process. All areas are to be addressed through care plan development and evaluation.II. Resident #21A. Resident statusResident #21, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included major depressive disorder, dementia without behavioral disturbance and suicidal ideations.The 5/13/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. The resident required partial to moderate assistance from staff for most activities of daily living (ADL) and needed setup or cleanup assistance for eating.The assessment documented the resident felt down, depressed or hopeless, felt bad about herself, and had thoughts that she would be better off dead or of hurting herself in some way nearly every day of the two week assessment period.B. Resident interview and observationsResident #21 was interviewed on 6/1/26 at 2:36 p.m. Resident #21 said she wanted to die and said she was tired of the staff pushing her around. Resident #21 said the staff asked her if she wanted to go outside, but she refused. Resident #21 said she did not leave her room and had her meals brought into her room. Resident #21 said she wished she would just die and end her suffering. Resident #21 continued to talk about a truck and her brother, but the conversation was largely unintelligible.Resident #21 became repeatedly tearful and distressed during the interview.C. Record reviewThe grief care plan, initiated 3/5/26 and revised 4/27/26, revealed Resident #21 was grieving the loss of her husband who died in January 2026. Resident #21 was sad because she did not get to say goodbye to him because she was in the hospital. Pertinent interventions included encouraging Resident #21 to attend activities of her choice, encouraging the resident to verbalize her feelings, encouraging the resident to participate in counseling service to work through her grief, providing reassurance and emotional support as needed.The mood and behavior care plan, revised 2/24/26, revealed Resident #21 was dependent on staff for emotional, intellectual, physical and social stimulation due to her decreasing mood and forgetting when/where activities were held. Pertinent interventions included staff conversing with Resident #21 while providing care, approaching the resident calmly and explaining the cares being offered, encouraging ongoing family involvement, ensuring activities Resident #21 attended were compatible with her physical and mental capabilities, inviting and assisting the resident to activities, and offering alternatives to cares.The behavior care plan, revised 6/1/26 (during the survey process), revealed Resident #21 isolated in her room, refused to come out of her room for meals, and refused to take her medications or let nursing staff provide wound care. Resident #21 also made false accusations toward staff due to her dementia and adjusting to living in a nursing home. Pertinent interventions included administering medications as ordered, inviting Resident #21 to food-related activities and offering food or beverages of choice to encourage intake, and providing a calm, quiet atmosphere for eating.The psychosocial well-being care plan, revised 2/24/26, revealed Resident #21 had a potential or actual and/or potential inability to cope with her medical conditions, lifestyle changes and/or limitations in her functional abilities due to her new admission to a nursing facility and loss of independence. Pertinent interventions included introducing Resident #21 to other residents with similar backgrounds or interests, giving the resident opportunity to communicate her feelings regarding her nursing home placement, encouraging family involvement, and encouraging the resident to participate in activities of choice.The suicidal ideation care plan, initiated 6/3/26 (during the survey process), revealed on 5/18/26 Resident #21 responded to a patient health questionnaire (PHQ-9) question which asked if she had thoughts of hurting herself or that she would be better off dead by saying yes. Resident #21 said she would never hurt herself as that was against God and said she did not have a plan or intent. Resident #21's physician and a psychiatrist were both notified, counseling was offered and declined. Pertinent interventions included taking Resident #21 seriously if she made suicidal comments, assessing her cognition and mood, assessing her lethality by asking if she had a plan, encouraging her to express her feelings and listing attentively, offering counciling and monitoring for any further suicidal ideation.-The suicidal ideation care plan was not initiated until 6/3/26 (during the survey), despite the resident admitting with a history of suicidal ideations and ongoing suicidal statements during the residents stay at the facility.Hospital discharge notes, dated 1/15/26, revealed Resident #21 was admitted to the hospital after a welfare check was conducted when the resident reportedly told her family member she was going to drink bleach. The hospital psychiatrist gathered information from Resident #21's family members and documented the resident had a history of depression as well as several suicide attempts. Resident #21's reported several significant psychosocial concerns including her incarceration, losing custody of her children due to abuse concerns and significant alcohol use throughout her life. The psychiatrist's note revealed Resident #21 had endorsed passive, then active suicidal ideation, then the resident denied any suicidal ideation in the span of one conversation. A social history trauma screening, dated 1/28/26, revealed distressing events in Resident #21's past included serious illness, suicidal ideation and the recent loss of her husband. Resident #21's social evaluation revealed the resident was sad, depressed, emotional and cooperative.A progress note, dated 1/30/26 at 12:05 a.m., revealed Resident #21 told an unidentified certified nurse aide (CNA) that she would miss her very much because she was going to die soon. Resident #21 said she was going to commit suicide, becuase she had no place to live. The CNA told the resident she could live at the facility and the staff would take care of her. Resident #21 thanked the CNA and told her she was glad she could live in the facility, calmed down and went back to sleep. The note documented the nursing staff would continue to monitor Resident #21.-Review of Resident #21's electronic medical record (EMR) did not reveal Resident #21's physician or the social services director (SSD) were notified about the resident's statement of suicidal ideation.A progress note, dated 3/5/26 at 1:50 p.m., revealed Resident #21 had been isolating in her room, eating in her room and refusing to take medications. Resident #21 was tearful and angry. Resident #21 lost her husband in January 2026 while she was in the hospital. Resident #21 did not know where her daughter or sister were which caused her extreme distress. Counseling services were offered and declined. Resident #21's physician recommended having the resident evaluated by a psychiatrist.A progress note, dated 3/26/26 at 9:04 a.m., revealed Resident #21 told her nurse she did not want to take any medications because they did not help. The nurse educated Resident #21 that without her blood pressure medication she could have a stroke, to which the resident responded good, maybe she would just have a stroke and die. Resident #21 said she did not want to take any more medication because she wanted to die. Emotional support was provided, and by the nursing staff, and Resident #21's physician and the facility administration were notified of the resident's statements.A social services note, dated 3/26/26 at 5:56 p.m., revealed the SSD had met with Resident #21 for a one-on-one. Resident #21 became tearful as she talked about her spouse who had passed away in January 2026 and felt sad she did not get to say goodbye to him. Resident #21 also talked about her worries in not knowing where her sister or daughter were. The SSD discussed with the resident that taking her medications would help her feel better, to which the resident said the medications did not help. The SSD asked Resident #21 if she had thoughts that she would be better off dead or thoughts of harming herself, to which the resident said she was about to die and she could just feel it. Resident #21 said she just wanted to go to her house and get her things and she would be ready. Resident #21 denied any active thoughts of harming herself and promised she never would. Resident #21 said she was ready to be with her husband in heaven. The note documented the SSD would continue to monitor Resident #21's mood and behaviors.A progress note, dated 4/3/26 at 11:18 a.m., revealed Resident #21 had an appointment with her physician's assistant. Resident #21 said she wanted to go back to her home city to put her husband's truck in her brother's name, that she would not take any medications, and said she just wanted to die. The note documented the nursing staff would continue to monitor the resident.-Review of Resident #21's EMR did not reveal the SSD or physician was notified about the resident's statement of suicidal ideation. A progress note, dated 4/10/26 at 3:42 p.m., revealed Resident #21 was informed of her psychiatric appointment that day by the SSD. Resident #21 said she probably would not attend the appointment as she was going back to her home in another city. Resident #21 then started getting angry and intermittently crying as she talked about her life circumstances. Resident #21 said she wanted to go to her home city to get her truck back and give it to her nephew. Resident #21 then talked about missing her husband who had recently passed away and said she was ready to be with him in heaven. Resident #21 calmed down after she was able to express her feelings and the SSD offered emotional support. The SSD asked Resident #21 if she would like counseling, to which the resident replied what for? I'm not going to be here. Resident #21 denied having suicidal ideation or thoughts of harming herself, and said it was more of her having a feeling she would die soon.A quarterly social services progress note, dated 5/20/26 at 4:34 p.m., revealed Resident #21 had a difficult time adjusting to living in a nursing home. Resident #21 refused care, medications, and cursed and screamed at staff. Resident #21's mood ebbed and flowed, with her getting tearful then angry and repeating herself when talking about her family and life situation. Resident #21 became more agitated with redirection. Resident #21 was mourning the loss of her husband and was distressed because she did not know where her daughter or sister were. Resident #21 was offered counseling but declined it. Resident #21 scored a 17 on the PHQ-9 assessment, which was considered moderate to severe depression. Resident #21 said she had thoughts she would be better off dead but did not have any plans, and stated she would never hurt herself.III. Staff interviewsThe NHA was interviewed on 6/1/26 at 2:59 p.m. the NHA said Resident #21 had come to the facility from another city after attempting to drink bleach when her husband passed away. The NHA said Resident #21 was very resistant to care and medications.CNA #1 was interviewed on 6/3/26 at 10:56 a.m. CNA #1 said she tried to learn what Resident #21 liked and what would put her in a better mood. CNA #1 said she sometimes played Spanish music for Resident #21 since she enjoyed it. CNA #1 said Resident's moods varied but her mood was usually worse in the mornings. CNA #1 said sometimes Resident #21 felt like she was a burden to the facility staff, so they tried to encourage her. CNA #1 said when Resident #21 was in one of her moods they usually checked on her but otherwise let her be. CNA #1 said Resident #21 used to talk about her husband when she first admitted but recently started talking about her brother and his wife which made her upset, and talking about something to do with her house or her truck.Licensed practical nurse (LPN) #2 was interviewed on 6/3/26 at 1:04 p.m. LPN #2 said Resident #21 was usually grumpy, but her mood varied. LPN #2 said Resident #21 had a hard morning the other day during which she said she felt like a burden and was feeling sorry. LPN #2 said sometimes just staff walking into Resident #21's room would annoy her and she would yell at them to get out. LPN #2 said Resident #21 could be redirected with Boost nutritional shakes or just with conversation. LPN #2 said Resident #21 liked to talk about her husband passing away, or trying to find her brother, daughter and sister-in-law. LPN #2 said Resident #21 was constantly looking for her family members and asking for them. LPN #2 said Resident #21 had expressed she wanted to die and was waiting to die. LPN #2 said when Resident #21 gets into a mood where she begins expressing those thoughts, conversation seems to get her out of her mood momentarily before the mood returns and lasts for a while.CNA #2 was interviewed on 6/3/26 at 2:32 p.m. CNA #2 said Resident #21's mood was usually good when she was the one working with her, but said the resident could become hateful and begin refusing care if someone else was in the room with her. CNA #2 said if staff spoke Spanish with Resident #21 she would be their best friend. CNA #2 said Resident #21 liked bubble gum, and said she could get her to participate in care by saying she would give her bubble gum afterward. CNA #2 said she was not sure what interventions were in Resident #21's care plan or Kardex (a care reference tool), and said she just knew these interventions from working with her. CNA #2 said Resident #21 talked about her husband and her truck constantly. The SSD was interviewed on 6/3/26 at 3:20 p.m. The SSD said when residents were admitted with mental health issues, she would offer counseling, one-on-one visits, and ask them about their activity interests. The SSD said she conducted a trauma screening on admission, and the information from the screening would be put into the resident's care plan. The SSD said a resident's trauma care plan generally included their triggers and what their goals might be. The SSD said Resident #21 was very anxious, and was on two antidepressants when she first admitted to the facility. The SSD said Resident #21 refused to take the antidepressant medications so they were discontinued. The SSD said Resident #21 had a psychiatric evaluation scheduled but had refused to attend the appointment. The SSD said Resident #21 did not want any interventions and only wanted to go see her brother. The SSD said sometimes Resident #21 could be very calm, and generally stayed in her room and watched television. The SSD said Resident #21 became agitated depending on the staff's approach with her. The SSD said she did not know if Resident #21 had any other triggers besides her husband passing away in January 2026. The SSD said adult protective services had been involved with Resident #21's case because in her home city a friend may have taken advantage of her and her husband. The SSD said conversation with Resident #21 usually worked to calm her down and was helpful for her, and said that intervention was on her care plan and Kardex (staff directive tool).The SSD said Resident #21 had suicidal ideation when she first admitted to the facility and said she would be better off dead. -However, the facility failed to implement a person centered care plan related to the resident's history and ongoing statements of suicidal ideations. The SSD said Resident #21 never had a plan to actually commit suicide and said it was against her religion to do anything to herself. The SSD said she thought she had made a suicidal ideation care plan for Resident #21. The SSD said a care plan for suicidal ideation would include interventions such as observing the resident's mood and behaviors, asking if they wanted to call their family, asking if they had a plan and assessing their lethality risk. The SSD said she thought she may have conducted a lethality assessment for Resident #21 when she first admitted but was not sure since she said she did not have a plan. The SSD said she performed a lethality assessment when a resident expressed suicidal ideation w to see if the resident's risk for a suicide attempt was high or low.The SSD was interviewed a second time on 6/3/26 at 3:50 p.m. The SSD said she had mixed Resident #21 up with someone else, and said Resident #21 had not expressed suicidal ideation until the month prior (May 2026). -However, review of the hospital discharge paperwork, the 1/28/26 social trauma assessment and progress notes revealed the resident had suicidal ideations prior to May 2026 (see record review above).The SSD said she had not put in a suicidal ideation care plan for Resident #21. The SSD said she had not performed a lethality assessment on Resident #21 after she expressed suicidal ideation.The director of nursing (DON) was interviewed on 6/4/26 at 12:03 p.m. The DON said Resident #21 had on and off days. The DON said some days Resident #21 would come out of her room and joke around, other days she was mourning her husband, saying no one did anything for her, and screaming and throwing things at staff if they tried to sit and talk with her. The DON said Resident #21 had a history of trauma including her husband dying while she was in the hospital and her not getting to say goodbye, moving to the facility from her home city, and people coming into her house and taking advantage of her. The DON said Resident #21 had mentioned she wanted to die to be with her husband. The DON said Resident #21 did not have a plan and did not want to kill herself, but just wanted to be with her husband. The DON said the facility tried to have Resident #21 evaluated by a psychiatrist but the resident refused and said the doctors were trying to kill her. The DON said Resident #21's triggers included loud noises and how staff approached her. The DON said Resident #21 did not like being told what to do but did better when staff gradually coaxed her and kept their care on her terms. The DON said Resident #21 could be redirected with country and Spanish music, snacks including gum and soda, or sitting and talking with her about her husband and letting her express her feelings. The DON said these triggers and interventions were mostly communicated face-to-face with the nursing staff and were added to the resident's care plan if they were used successfully several times.

Based on observations, record review and interviews, the facility failed to ensure one (#7) of four residents reviewed, out of 23 sample residents received timely dental services.Specifically, the facility failed to ensure Resident #7 received replacement of missing dentures in a timely manner.Findings include:I. Facility policy and procedureThe Lost or Damaged Dentures policy, revised 3/12/18, was provided by the nursing home administrator (NHA) on 6/4/26 at 4:15 p.m. It read in pertinent part, To ensure that residents obtain needed dental services; to ensure the facility provides the assistance needed or requested to obtain these services; to ensure the resident is not inappropriately charged for these services; documentation of the facility is to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. Identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility. When staff discards dentures placed on a meal tray. When staff throws wrapped up dentures in trash. When staff do not adhere to standard nursing guidelines when performing cleaning procedures and drop and break the dentures. When staff does not check the pockets of clothing and sends the dentures to laundry. If it is the responsibility of the facility, when there is loss or damage to a resident's dentures due to carelessness, the facility is then liable. The facility must promptly refer residents with lost or damaged dentures for dental services.II. Resident #7 A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders, diagnoses included type 1 diabetes mellitus with hyperglycemia (high blood sugar), age related physical debility, and need for assistance with personal care. The 4/1/26 minimum data set (MDS) assessment indicated Resident #7 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set up assistance with personal hygiene and he had no natural teeth. B. Resident interviewResident #7 was interviewed on 6/1/26 at 11:07 a.m. He said his dentures went missing at least six months ago and he had not gotten a resolution yet. He said he had placed the dentures in a cup before he went to bed one evening and when he got up the next morning they were gone. He said no one had followed up with him on the status of denture replacement and the facility said they would pay for the dentures, but that had not happened. He said he had not been able to eat everything he would like because of the missing dentures. He said his diet order included ground meats, but now his gums were sore and there had been no change on his diet order to make things easier to chew. He said he thought he had lost some weight. Resident #7 was interviewed again on 6/3/26 at 8:50 a.m. He said he needed his dentures because his gums were getting sore. He said his diet was not changed from ground meats after the dentures went missing in December 2025. He said he wished they had changed his diet order so that meats would have been easier to chew. C. Record reviewResident #7's dental care plan, initiated 3/6/26 documented the resident had oral and dental health problems due to all teeth having been extracted on 3/11/25. The care plan documented he received new dentures on 3/19/25. The care plan documented his dentures got lost in December 2025 and he was in the process of getting new dentures. The care plan documented his health insurance denied coverage on 12/2/25 and 2/25/26. The care plan documented the social services director (SSD) was to process the claim for payment of new dentures through the post eligibility treatment of income (PETI) medical necessity certification form program. The care plan documented the resident complained of gum irritation on 2/27/26 at which time the dentist ordered an antibiotic. Pertinent interventions included coordinating arrangements for dental care and transportation as needed, providing the diet as ordered, consulting with a dietitian and changing diet order if chewing or swallowing problems are noted and monitoring, documenting, and reporting any signs or symptoms of oral pain.The nutrition at risk care plan initiated 5/22/24 and revised on 8/21/2,5 included interventions that the resident was to be offered a sandwich at meals for increased intake and to provide and serve diet as ordered (diabetic, ground meats, regular liquids).The 7/9/25 SSD progress note indicated the resident's dentures had been cutting his mouth, so a dental appointment was desired.The 1/8/26 SSD progress note indicated the resident was edentulous because his dentures got lost. The facility was looking into replacing them and he was seen by the dentist.The 1/9/26 SSD progress note indicated a call was made to the dentist for an update on the dental authorization. The note documented no determination had yet been made. The 1/21/26 SSD progress note indicated the resident had received the final decision that the denial for denture replacement was upheld because of benefit limitations. The dental company said the resident could qualify for a grant and was supposed to send the application and invoice for processing of the grant. Otherwise, the facility could see if PETI would cover the cost of replacing the dentures.The 3/6/26 SSD progress note documented a PETI form for dentures that was sent to the dental company. -The form was not sent for 10 weeks after the denial in January 2026.The 4/2/26 SSD note indicated the resident was edentulous and was in the process of getting new dentures. The note documented the facility was waiting on PETI approval)The 6/2/26 (during the survey) SSD progress note documented the facility central business office would resubmit the dental PETI request\The 6/3/26 (during the survey) SSD progress note documented an email had been sent to the dental company to send a statement or invoice for resident's dentures as soon as possible in the morning for PETI. On 6/4/26 (during the survey) the SSD documented an attempt was again made to contact the dental company but she was unable to talk to anyone.On 12/9/25 an insurance denial letter was submitted to the facility indicating the replacement of the dentures would not be covered.The denture request form completed on 2/2/26, indicated the resident said his dentures went missing in December 2025. He said he had placed the dentures in a cup next to his bed and the next morning they were gone.On 2/25/25 an insurance denial letter for upper and lower denture replacement was submitted to the facility. The emergency dental checklist, completed on 2/27/26, indicated the resident was having pain rated at eight to nine out of 10 with pressure sensitivity and swelling of his gums. On 3/25/26 a final insurance denial letter was submitted to the facility indicating the replacement of the dentures would not be covered.III. Staff interviewsThe SSD was interviewed on 6/3/26 at 3:30 p.m. She said when a resident's dentures went missing, the staff looked for them. She said then her and the management team got together to decide what to do, whether to replace them or try to get them paid for through the PETI process. The facility's central business office processes the PETI forms. She said she should have followed up regularly on the status of Resident #7's denture replacement. She said the NHA was responsible for deciding to pay for the replacement of dentures.The NHA was interviewed on 6/3/26 at 4:30 p.m. She said when a resident's dentures were lost in the facility the process was started to see if they could get paid for through the PETI process and if the request got denied then the facility was responsible for paying for replacements. She said once the denial was received the SSD was supposed to request an invoice from the dental company for the cost of the replacement and once the central business office received the invoice then the replacement dentures would be purchased. She said the ball was dropped and she did not follow up with the SSD on the status of this resident's denture replacement.The registered dietitian (RD) was interviewed on 6/4/26 at 11:33 a.m. She said she was new to the facility and had not reviewed Resident #7. She said when a resident's dentures were missing she would visit with the resident and collaborate with speech therapy as well as the interdisciplinary team to determine what would be best for the resident as far as diet texture to best maintain weight and chewing ability. She said if a resident's diet order was for ground meats and the resident was still having trouble chewing and his gums were becoming sore the diet could have been changed to minced and moist to facilitate easier chewing. She said when she made her visit to the facility she would check in with the resident to see how he was doing and would make any diet changes necessary.

Based on observation, record review and staff interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure a backflow prevention device was installed on the hand held shower hose in the shower room on B hall, increasing the risk of contamination to the facility's main water supply; and, -Ensure necessary kitchen equipment was maintained in safe, sanitary and working condition. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Distribution System Water Quality Protecting Water Quality through Cross-Connection Control and Backflow Prevention, October 2021 retrieved online 2/27/24 from: https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection, which can result in a potentially serious public health hazard. A cross-connection control and backflow prevention program helps prevent contaminants from entering a drinking water distribution system. This fact sheet is part of EPA's (Environmental Protection Agency) Distribution System Toolbox developed to summarize best management practices that public water systems (PWSs), particularly small systems, can use to maintain distribution system water quality and protect public health. B. Observation Observations of the resident living environment conducted on 2/26/24 at 11:14 a.m. revealed: The hand held shower head on the B hall shower room did not have a backflow prevention valve on it. The hand held shower head was long enough to sit on the side on the floor next to the drain. C. Staff interview The maintenance director (MTD) was interviewed on 2/26/24 at 1:15 p.m. He said he was familiar with backflow prevention devices. He said there was no backflow valve device in the shower room on the B hall. He had been to the hardware store earlier and purchased the part. He would be installing a backflow valve to the hand held shower head. He said without backflow prevention, the water could become contaminated. II. Kitchen equipment A. Observations Kitchen observations on 2/21/24 at 9:32 a.m. revealed: -The wall behind the garbage disposal was spongy to the touch indicating possible water damage. -The stove burners were coated with a black, hard crust. -The flat top grill grease trap drawer opening was sealed by a black, hard crust. -The grease trap drawer would not open. Kitchen observations on 2/22/24 at 9:45 a.m. revealed: -The wall behind the garbage disposal was spongy to the touch indicating possible water damage. -The stove burners were coated with a black, hard crust. -The flat top grill grease trap drawer opening was sealed by a black, hard crust. -The grease trap drawer would not open. Kitchen observations on 2/26/24 at 9:40 a.m. revealed: -The blue water sprayer garbage disposal valve was leaking water onto the floor. -The electrical wire protector sleeve going to the garbage disposal was detached and the wires were exposed. -The flat top grill grease trap drawer opening was sealed by a black, hard crust. -The grease trap drawer would not open. B. Staff interviews The dietary manager (DM) was interviewed on 2/21/24 at 9:40 a.m. He said the stove burners should be included in kitchen deep cleanings but had not been. The grease trap drawer would not come out unless the kitchen staff contacted the MTD for assistance. The drawer had become warped and when the flat top grill heated up, the drawer would not open. The kitchen equipment should be deep cleaned weekly. There had been a broken pipe in the area where the dishwasher and garbage disposal were located which caused a flood. The DM could not recall when the flood occurred but said it had been several months ago. Dietary aide (DA) #1 was interviewed on 2/22/24 at 9:50 a.m. He said he conducted a deep cleaning of the kitchen on a weekly basis but this did not include equipment. The corporate resource (CRS) and MTD were interviewed on 2/22/24 at 10:00 a.m. After observing the water damage to the wall under the garbage disposal, the MTD said he had not been made aware of the problem. The MTD said the flood in the dish pit had occurred prior to his start at the facility in August 2023. The CRS said the facility would order a mold test kit to test the wall. The facility would cut out the soft part of the wall and replace it. The nursing home administrator (NHA) was interviewed on 2/26/24 at 9:45 a.m. She said the mold test kit had come back negative and she would forward proof of the results. The MTD was interviewed again on 2/26/24 at 1:15 p.m. He said the plumbing and pipes in the facility were not good. He was aware of a flood on 2/13/24 but not one prior to that. After observing the equipment under the garbage disposal, he said he had not been aware of the leaks or exposed wires. He said he had cleaned the grease trap and upon inspection, the drawer opened. The MTD said the last time he had received a work order regarding the grease trap drawer was when he started in August 2023. He said the grease trap had been encrusted with dried grease and the hole going into the top of the drawer was clogged with dried grease. The NHA, MTD and DM were interviewed again on 2/27/24 at 10:31 a.m. For items in the kitchen to be repaired or cleaned by the MTD, a work order would need to be completed. The binder for work orders was kept in the front of the facility. Once a work order had been filled out, the MTD would take a copy and the NHA would take a copy. When the work order had been addressed, the MTD would sign off on the log included in the binder. The DM said he had not completed a work order for the grease trap because the prior maintenance director had a different system of addressing needs. -However, the DM said he did not notify the MTD of the problem and failed to complete a work order. He said he had not completed a work order for the equipment problems in the dish pit because he was not aware. A kitchen cleaning schedule was requested from the NHA on 2/27/24 at 11:38 a.m. III. Facility follow up On 2/27/24 at 9:38 a.m. the NHA provided proof of the mold test kit results ruling out mold. On 2/28/24 at 11:28 a.m. the NHA provided the weekly kitchen cleaning schedules via email. The schedules showed the days of the week included in the weekly schedule for the dietary aides The schedule revealed cleaning duties included cleaning the grill, the stove top and the burners. -The cleaning schedule failed to reveal for which month.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for four of four CNAs reviewed. Specifically, the facility: -Failed to ensure CNAs #2, #3, #4, and #5 received annual dementia management training; and, -Failed to ensure CNAs #2, #3, and #4 received annual abuse training. Findings include: I. CNA training records review Four CNAs were reviewed for the annual required abuse and dementia management training. -Training records revealed four of the four CNAs did not have dementia training and three of the four CNAs did not have abuse training. CNA #2 was hired on 5/2/14. He had not had annual abuse or dementia management training in the past 12 months. CNA #3 was hired on 1/15/22. She had not had annual abuse or dementia management training in the past 12 months. CNA #4 was hired on 4/16/21. She had not had annual abuse or dementia management training in the past 12 months. CNA #5 was hired on 1/31/23. She had not had annual dementia management training in the past 12 months. II. Interview The director of nursing (DON) was interviewed 2/26/24 at 11:20 a.m. The DON said she could not find documentation that the facility had provided annual abuse and/or dementia management training to the CNA #2, #3, #4 and #5 in the past 12 months. She said all CNAs providing care should be trained on abuse and dementia management in order to provide appropriate care for the facility's residents.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four certified nurse aides (CNAs) reviewed. Specifically, the facility failed to: -Provide inservice education plans based on the outcome of the performance reviews for CNA #2, #3, #4, and #5; and, -Ensure CNAs received 12 hours of training annually for CNA #2, #3 and #4. Findings include: I. Record review CNA #2 (hired 5/2/14) had a performance review on 7/11/23 with eight hours of training. CNA #3 (hired 1/5/22) had a performance review on 3/5/23 with 11 hours of training. CNA #4 (hired 4/16/21) had a performance review on 4/12/23 with 8.5 hours of training. CNA #5 (hired 1/31/23) had a performance review on 4/12/23. -None of theThe CNAs weredid not provided withhave an inservice education plans based on the outcome of their performance reviews. II. Interview The director of nursing (DON) was interviewed on 2/26/24 at 11:20 a.m. She said the facility had completed the annual employee performance evaluation reviews, but she was not aware the facility needed to also develop regular inservice education plans based on the outcome of the performance reviews. She said she was not aware CNA #2, #3 and #4the identified staff had not completed the 12 required hours of annual training. She said the facility would develop a plan to thoroughly complete the performance review process going forward and ensure the CNAs received the required 12 hours of training annually.

Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#25) of three residents reviewed for PASRR out of 17 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #25. Findings include: I. Resident status Resident #25, age 81, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included major depressive disorder, dementia and anxiety. The 10/27/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment revealed the resident had been identified as having a level II PASRR. II. PASRR level II notice of determination for MI (mental illness) evaluation and facility failures The PASRR level II, provided to the facility on [DATE], included the evaluation which revealed the resident had been evaluated for mental illness (MI) due to a qualifying diagnosis of major depressive disorder. Specialized services were recommended included psychiatric case consultation (psychiatry), individual therapy and a neurocognitive (a form of psychology focussed on how injuries or illnesses of the brain affect cognitive and behavioral functions) evaluation. III. Record review The comprehensive care plan, revised 1/29/24, revealed the resident had a level II PASRR due to a diagnosis of major depressive disorder. The recommendations included psychiatric case consultation, individual therapy and a neurocognitive evaluation. Interventions dated 10/25/23 included to encourage the resident to participate in mental health services. The February 2024 CPO revealed the following physician orders: -Quetiapine (Seroquel) 25 MG (milligrams)-give one tablet by mouth one time a day for dementia with anxiety-ordered on 10/13/23. -Fluoxetine (Prozac) 40 MG (milligrams)-give one tablet by mouth one time a day for depression ordered on 10/13/23. -Neurocognitive evaluation to be scheduled-ordered on 2/26/24 (during the survey). -No orders for individual therapy or psychiatric case consultation were located. -A review of progress notes dated 10/23/23 to 2/25/24 failed to reveal any PASRR progress notes. -No social services notes were located regarding PASRR or recommendations. No PASRR progress notes showing communication with the State Mental Health Agency regarding a delay or inability to follow the recommendations were located. IV. Staff interviews The social services director (SSD) was interviewed on 2/26/24 at 11:53 a.m. If a resident had a level II PASRR with recommendations, a PASRR progress note should be made if there was a delay in the resident obtaining the recommended services. She notified the State Mental Health Agency if recommendations could not be met. The SSD did not recall the PASRR recommendations for Resident #25. She said the resident had been seen by the mental health provider the facility used two weeks ago despite the recommendations being made in October 2023. The SSD had been trying to schedule a neurocognitive evaluation but the family wanted to be involved and this had delayed the process. The facility's mental health provider provided medication management with a psychiatrist but the SSD had not set this up for the resident. The SSD had not notified the State Mental Health Agency the recommendations made for Resident #25 were not provided, had not made a PASRR progress note or updated the care plan. The SSD had no documentation of the efforts to schedule a neurocognitive evaluation. The NHA was interviewed on 2/27/24 at 11:00 a.m. The SSD's responsibility included completing PASRRs and following through on PASRR recommendations. She was not aware the SSD had not been scheduling the recommended services for Resident #25.

Based on observation, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for one (#23) of 12 residents reviewed for activities of daily living (ADL) out of 17 sample residents. Specifically, the facility failed to revise Resident #23's person-centered, resident-specific care plan to addressed the resident's refusal of a physician ordered one-on-one for meal supervision. Findings include: I. Resident #23 Resident #23, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included hemiplegia following a cerebral infarction (stroke), contracture of right hand and aphasia (communication deficit). The 1/8/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment identified the resident needed supervision or touching assistance with meals. II. Observations Resident #23 was in the dining area on 2/21/24 at 1:13 p.m. He was sitting at a table alone, facing a wall. There was a wall directly in front of him and a wall to the right side of him. His fluids were delivered in two cups with lids and handles. The meal was delivered in three separate small bowls. Resident #23 picked up each bowl separately and drank down the contents. There was no one-on-one staff supervision during the meal (as indicated in the care plan, see below). After he finished his fluids and lunch, he left the dining room. Resident #23 was in the dining room on 2/26/24 at 12:10 p.m. He was sitting at the same table as he was on 2/21/24. He received his fluids in the same type of containers he did during the previous meal. The meal was delivered in three separate small bowls. He drank from his bowls quickly and left after approximately three minutes. There was no one-on-one supervision during his meal. III. Record review The care plan, initiated on 9/18/2020 and reviewed on 6/14/23, identified a self care performance deficit related to a history of a cerebral vascular incident with right sided hemiplegia (paralysis on one side of the body) and a right hand contracture. Interventions included the resident was on a regular diet with pureed texture and nectar thick liquids, one-on-one supervision for all oral intake, no hard straws, to load a small spoon or half a regular spoon with food, to have each item of food served in a separate bowl, encourage two to three swallows per bite using a supraglottic swallow and to stop feeding if the food started to fall from his mouth. The 6/30/23 physician order revealed regular diet, puree texture, nectar consistency, for one-to-one supervision for all oral intake. IV. Staff interviews Nurse aide (NA) #1 was interviewed on 2/26/24 at 12:40 p.m. She said the resident did not need any assistance with his meal. She said he was independent. Licensed practical nurse (LPN) #1 was interviewed on 2/26/24 at 12:45 p.m. She said Resident #23 was able to feed himself. She said he was able to make his needs known. She said he would get upset if staff hovered around him. She said staff would monitor from a distance. She said he would get mad at the assigned one-to-one and would throw food at them or refuse to eat. The director of nursing (DON) was interviewed on 2/26/24 at 2:30 p.m. She said Resident #23 required nearby supervision. She said when the one-on-one was tried he became upset and started throwing food at the staff. She said it escalated to him refusing to go to the dining room for meals. She said the provider did sign off on the orders monthly, however, the resident did not cooperate with the one-to-one and the facility needed to update the care plan and contact the provider.

Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#38) of two residents receiving hospice services. Specifically, the facility failed to orient hospice aides to the facility, including the policies and procedures. Findings include: I. Facility policy The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/26/24. It read in pertinent part, Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. II. Resident status Resident #38, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included congestive heart failure and hypertension. The 12/12/23 minimum data set (MDS) assessment revealed the resident had moderate cognition with a brief interview for mental status (BIMS) score of 12 out of 15. He had no behaviors or rejections of care. The assessment documented the resident was receiving hospice services. II Record review The care plan, initiated on 12/20/23 and revised on 1/3/24, identified the resident had a terminal prognosis and was receiving hospice services. Interventions included: -Work cooperatively with the hospice team to ensure Resident #38's spiritual, emotional, intellectual, physical, and social needs are met; and, -Work with nursing staff to provide maximum comfort for Resident #38. III. Interviews Registered nurse (RN) #1, who worked for the hospice agency, was interviewed on 2/21/24 at 10:50 a.m. RN #1 said Resident #38 received hospice nursing services one time a week. She said she had started working in the facility on 12/5/23. She said she had not received an orientation to the facility to include policies and procedures. Certified nurse aide (CNA) #1, who worked for the hospice agency, was interviewed on 2/21/24 at 10:50 a.m. CNA #1 said Resident #38 received hospice CNA services twice a week. She said she provided showers. She said she had been working in the facility off and on for the past two years. She said she had not received an orientation to the facility to include the policies and procedures. The director of nursing (DON) was interviewed on 2/26/24 at 2:50 p.m. The DON said the facility would complete a walk through of the facility with hospice staff but did not have a system to orient the hospice staff on the policies and procedures of the facility. She said the hospice staff provided Resident #38 two showers a week. She said it would be important for the hospice staff to know the policies and procedures of the facility to ensure the expectations of the facility for quality care and resident safety.

Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for two (#25 and #30) of five residents reviewed for unnecessary medication of out 17 sample residents. Specifically, the facility failed to ensure consents were obtained for the usage of psychotropic medications for Resident #25 and Resident #30. Findings include: I. Facility policy and procedure The Psychotropic Medication policy and procedure, which was undated, was provided by the nursing home administrator (NHA) on 2/26/24 at 11:09 a.m. It revealed in pertinent part, Residents, families, and/or representatives are involved in the medication management process. Psychotropic medication management includes: indications for use, dose, duration, and adequate monitoring for efficacy and adverse. II. Resident #25 A. Resident status Resident #25, age 81, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included major depressive disorder, dementia, and anxiety. The 10/27/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. B. Record review The comprehensive care plan, initiated on 11/21/23, revealed the resident took psychotropic medications related to dementia and depression. The interventions included administering medications per physician orders, educating the resident/family/caregiver about risks, benefits, and side effects, and monitoring effectiveness of the medications. The February 2024 CPO revealed the following physician orders: Quetiapine (Seroquel) (an antipsychotic medication) 25 mg (milligrams), give one tablet by mouth one time a day for dementia with anxiety. Ordered on 10/13/23. Fluoxetine (Prozac) (an antidepressant medication) 40 mg, give one tablet by mouth one time a day for depression. Ordered on 10/13/23. -A review of Resident #25's medical record failed to reveal consent had been obtained from the resident or the resident's representative for the administration of the Seroquel or Prozac. III. Resident #30 A. Resident status Resident #30, age 79, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included vascular dementia and depression. The 11/29/23 MDS revealed the resident had a moderately severe cognitive impairment with a BIMS score of ten out of 15. B. Record review The comprehensive care plan, revised on 1/5/24, revealed the resident took psychotropic medications related to dementia and depression. The interventions included administering medications per physician orders, educating the resident/family/caregiver about risks, benefits, and side effects, and monitoring effectiveness of the medications. The February 2024 CPO revealed the following physician orders: Risperidone (an antipsychotic medication) 0.5 mg, give one tablet by mouth one time a day for dementia.Ordered on 11/15/23. Zoloft (an antidepressant medication) 50 mg, give one tablet by mouth one time a day for depression. Ordered on 11/16/23. Haloperidol (Haldol) (an antipsychotic medication) 1 mg, give one tablet by mouth one time a day for dementia. Ordered on 11/27/23. Lorazepam (Ativan) (an antianxiety medication) 0.25 mg, give one tablet by mouth one time a day for anxiety. Ordered on 2/12/24. -A review of Resident #30's medical record failed to reveal consent had been obtained from the resident or the resident's representative for the administration of the Risperidone, Zoloft, Haloperidol or Lorazepam. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 2/26/24 at 10:40 a.m. She said psychotropic drug consents were obtained by the social services director (SSD) prior to the administration of the medications. Licensed practical nurse (LPN #1) was interviewed on 2/26/24 at 11:00 a.m. She said psychotropic drug consents were obtained by the SSD prior to the administration of the medications. The SSD was interviewed on 2/26/24 at 11:14 a.m. She said she contacted the resident's representative or talked to the resident about obtaining consent for psychotropic medications prior to the administration of the medications. She audited psychotropic medication consents at admission and monthly during the facilities psychopharmacological meeting. The SSD said she knew consents needed to be obtained even for medications the resident's admitted to the facility with. The SSD said she was unaware consents had not been obtained for Resident #25's or Resident #30's psychotropic medications. The director of nursing (DON) was interviewed on 2/26/24 at 11:25 a.m. She said the SSD audited the charts for the psychotropic consent forms and obtained consents. The SSD was notified in the morning management meeting of any new medication orders requiring consent. The DON was not aware consents had not been obtained for Resident #25's and Resident #30's psychotropic medications. The NHA was interviewed on 2/27/24 at 11:00 a.m. The NHA said it was the SSD's responsibility to obtain consents for psychotropic medications. The NHA was not aware consents had not been obtained for Resident #25's and Resident #30's psychotropic medications. V. Facility follow up On 2/27/24 at 11:18 a.m., the NHA forwarded an email with signed psychotropic drug consents for Resident #25 for Seroquel and Fluoxetine dated 2/27/24 (during survey). On 2/27/24 at 4:14 p.m. the NHA forwarded an email with signed psychotropic drug consents for Resident #30 for Lorazepam, Haloperidol, and Zoloft dated 2/27/24 (during survey). -No consent form for Resident #30's Risperidone was provided.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for three rooms out of 26 occupied rooms. Specifically the facility failed to ensure power strips were not plugged into another powerstrip/surge protector. Findings include: I. Facility policy The Electrical Safety for Residents policy, revised January 2011, was provided by the nursing home administrator (NHA) on 4/13/23 at 12:02 p.m. included, Power strips shall not be used as a substitute for adequate electrical outlets in the facility. Power strips may be used for a computer, monitor, and printer. II. Observations The room [ROOM NUMBER]A at 10:05 a.m. on 4/13/23 had a dark gray power strip plugged into the wall outlet next to the bedside with two cords plugged into it. One of the cords led to another light gray power strip attached to the bed frame. The light gray power strip had three items plugged into it. The room [ROOM NUMBER]B at 10:15 a.m. had a six plug outlet cover plugged into the wall next to the bedside. The six plug outlet had four outlets being used to include a gray power strip with two outlets being used. The room [ROOM NUMBER]C had a power strip plugged into the wall next to the bedside. The power strip had one outlet being used by another power strip. The second power strip did not have any outlets being used. III. Interviews The maintenance director (MTCE) was interviewed on 4/13/23 at 11:05 a.m. He said he was new to the position and was in the process of scheduling safety inspections. He said it was not safe to plug one power strip into another power strip power surge protector. He said he was not aware of the identified rooms and would do an audit immediately to fix and ensure there were no others. The NHA was interviewed on 4/13/23 at 12:20 p.m. She said the facility had just completed an audit and took out the power strips. She said it was not safe to have power strips plugged into each other. She said going forward the power strip use would be audited and included in safety inspections.

Based on observation, record review and interviews, out of a total of 14 sampled residents, the facility failed to ensure the environment for two (#2 and #8) out of eight residents reviewed remained as free of accident hazards as possible and that each resident received adequate supervision. Resident #8, with known elopement risk and exit seeking behaviors, was found by a passer-by and reported to the police on 11/23/2020 at 9:00 p.m., face down outside on the street without a coat and the outside temperature was 45 to 48 degrees Fahrenheit. The facility was not able to determine the amount of time the resident was outside. The facility failed to ensure the wander guard alarm placed on the resident, was in place on the door in which Resident #8 exited. The facility failed to investigate the incident as an elopement attempt which resulted in the facility failing to initiate interventions to prevent a recurrence and to ensure the safety of residents with elopement risk. Due to the facility failures, Resident #8 sustained skin tears to his right forearm and elbow area, left knee swelling and pain, swelling and hematoma to the left side of his face and was subsequently diagnosed at the hospital with pneumonia, [MEDICAL CONDITION] and left knee contusion. Furthermore, the facility failed to provide the supervision necessary to prevent elopements and failed to implement interventions necessary to prevent unsafe wandering for Residents #2 and #8. These facility failures created a situation with harm for Resident #8 and the likelihood of serious harm if not immediately corrected for Resident #2. Resident #2, diagnosed with [REDACTED]. A physician-ordered wander guard was in place as of 3/2/2020. Per progress notes, the resident verbally expressed a desire to leave the facility on several occasions, with an attempt to elope on 11/25/2020 that resulted in the use of chemical and physical restraints. Cross reference to F604 (physical restraint), F605 (chemical restraint) and F744 (dementia care). Findings include: I. Immediate jeopardy A. Situation of immediate jeopardy The facility was aware of one resident leaving the facility and going into unsafe areas around the facility and into the road. Resident #8, with known elopement risk and exit seeking behaviors, successfully left the building on 11/23/2020 without notice. He was found lying on the ground by two passer-bys with minor injuries, bump on head and skin tears to the left knee and elbow. The sheriff notified the facility that the resident was found outside (it was unknown how long the resident had been missing from the facility). The resident displayed exit seeking behaviors frequently and on 3/18/2020 was placed on hourly checks from 6:00 p.m. to 6:00 a.m. The resident wore a wander guard at the time of this incident but the facility failed to ensure all facility exit doors were equipped with alarms. Resident #2, with dementia, verbalized her desire to exit the facility frequently, however had not attempted an elopement until 11/25/2020. On 12/2/2020 at 12:45 p.m. the therapy gym door had a keypad on it which was observed to be open. The south door was unlocked and not alarmed. The facility failed to provide supervision to residents with known exit-seeking behaviors and poor safety awareness. The facility's failure to implement appropriate interventions to keep residents safe created the likelihood of serious harm if the facility's response was not immediately corrected. B. Imposition of immediate jeopardy On 12/2/2020 at 3:05 p.m., the nursing home administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to provide supervision to residents with known elopement risk and exit seeking behavior including poor safety awareness, creating the potential for serious harm to Resident #2 and #8. C. Facility response to immediate jeopardy On 12/2/2020 at 6:24 p.m., the facility submitted a plan to abate the immediate jeopardy via email. The abatement plan read: 1. Systemic changes The south door of the facility's gym, the door Resident #8 eloped from, was an egress door and could not be locked. On 12/3/2020 the facility installed an automatic door closer on the door leading into the fitness center which accessed the south door. 2. Corrective action Education would be completed with each staff member ensuring the door leading to the fitness center remained locked at all times and ensured the south door of the gym was closed tightly. Education for all staff would be completed by the NHA or designee by 12/4/2020. Education would be completed with each staff member on the facility's elopement policy. Education for all staff would be completed by the NHA or designee by 12/4/2020. 3. Monitoring A charge nurse was to monitor the door six times a day for one week and twice a day thereafter. Thirty minute checks would be done on residents and if residents were determined by the staff to be missing, the charge nurse would be notified immediately. D. Removal of the immediate jeopardy The above plan was accepted on 12/2/2020 at 6:24 p.m. via email; however, observations, record review and interviews revealed deficient practice remained at G level, actual harm that was isolated. II. Facility policy and procedure The Elopement policy and procedure, revised 12/2/2020, was provided by the social services director (SSD) on 12/2/2020 at 3:34 p.m. via email. The policy read in pertinent part, The director of nursing or designee will assess resident for further elopement risk, implement intervention, update care plan and provide training/inservice to staff III. Residents known to elope and/or to exhibit unsafe behaviors A. Resident #8 1. Resident status Resident #8, age 84, was admitted on [DATE]. According to the December 2020 computerized physician orders [REDACTED]. The 9/8/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. Staff assessment revealed that the residents cognitive skills for daily decisions making was modified independence. The resident required only set-up assistance for his activities of daily living (ADLs), including walking, dressing, personal hygiene and eating. The resident did not have behavioral disturbances and did not exhibit wandering behavior. 2. Record review Record review revealed a history of exit seeking behaviors and one elopement that resulted in a hospital transfer on 11/23/2020. The facility failed to investigate the incident as an elopement and to take steps to prevent a recurrence. A. Wandering/exit seeking behaviors A physician order [REDACTED]. The care plan initiated on 3/3/2020 revealed the resident had a history of [REDACTED]. Pertinent interventions included placing a wander guard (3/18/2020), distract the resident by offering structured activities, food, conversation, television, exercise in the fitness room, walks outside with staff when weather was nice (3/3/2020), monitor resident hourly (3/18/2020) and ensure all exits were secured. The 7/13/2020 at 8:82 a.m behavior note (late entry) revealed the resident had been wandering the halls asking for his wife. The note read that the resident believed his wife was in his car outside and attempted to leave the facility via the front door located in the lobby. The note revealed that the alarm on the door sounded and the resident went to the activity room and attempted to exit the facility via that door. The note revealed he attempted to leave the facility via a third door before being redirected. The 8/3/2020 at 10:40 a.m. behavior note revealed that the resident continued to wander through the facility day and night. The note revealed that the resident demanded to be let outside so he could get to his car. The 8/27/2020 at 10:13 a.m. behavior note revealed that the resident continued to wander throughout the facility and had been attempting to exit the facility through the door subsequently setting off alarms. The 8/29/2020 at 6:07 p.m. behavior note revealed the resident was trying to exit the facility stating he was going to Oklahoma. The 9/2/2020 wandering risk assessment revealed a score of 13, putting the resident at a high risk of wandering. It indicated the resident had a history of [REDACTED]. The assessment also revealed the resident was confused and delusional. The 9/7/2020 at 8:09 a.m. activity participation note revealed the resident remained a fall risk and was able to ambulate around the facility without assistance. The note revealed the resident wandered around the facility at times. The 9/20/2020 at 11:51 p.m. health status note revealed the resident continued to walk around the facility slightly confused. The 10/13/2020 at 4:03 p.m. behavior note revealed the resident was observed following a nurse stating he thought the nurse was going outside and the resident was going to follow the nurse outside. B. Elopement on 11/23/2020 The 11/23/2020 at 9:52 p.m. incident note revealed the resident was found outside, across the street on the south side of the facility at 9:20 p.m. The resident was found by two men passing by the facility. The facility was made aware the resident was outside by the sheriff via telephone. The resident's care plan was not updated with information on the incident and no new interventions were put in place to assist the resident with his wandering behavior. There was no evidence the 11/23/2020 incident was investigated to determine the reason/cause the resident left the facility. The 12 hour check logs for Resident #8 were provided by the SSD on 12/2/2020 at 3:34 p.m. The logs revealed missing documentation on 11/23/2020, the day of the incident. C. Facility witness statements of the event Three witness statements were provided by the DON on 12/2/2020 at 4:28 p.m. via email. The witness statements read: The witness statement from certified nurse aide (CNA) # 3 dated 11/23/2020 at 10:27 p.m. revealed resident was last seen at 7:30 p.m. lying in his room. The witness statement from CNA #4 dated 11/23/2020 revealed that at 8:47 p.m. the resident was found outside of the facility lying face down on the street. The statement read that she went into the facility to get the charge nurse to assess the resident. The charge nurse assessed the resident and the resident was transferred to the hospital. The witness statement from CNA #5 dated 11/23/2020 revealed the resident was last seen at 7:45 p.m. The statement read that the charge nurse asked her to go outside and look at the south side of the facility for a resident. It read that she observed a resident in a blanket lying on the pavement of the street, next to the curb with two men standing over him. The statement read the resident was lying face down and that she immediately called the charge nurse. The statement read that the two men stated emergency medical services (EMS) had been contacted and were on the way. It read that she asked the resident what happened and the resident stated he was not sure but thought he fell . It read that the sheriff arrived on scene and asked the resident what was going on. The resident stated he was uncomfortable. The statement read that the sheriff, one of the men and herself assisted the resident in turning over onto his back The statement read that the resident had blood on his arm and a hematoma on his head. It read that CNA #4 was walking down the sidewalk near the facility, was made aware of the situation and went into the facility to get the charge nurse. The statement read that the charge nurse arrived on scene, completed an assessment and the resident was transferred to the hospital. D. Hospital records The 11/23/2020 emergency department progress notes read in pertinent part, patient found lying in the road in front of the nursing home after he had wandered out the front door. Patient has some skin tears to his right forearm and elbow area, left knee swelling and pain, swelling and hematoma left side of his face It read that the resident received an x-ray to the right and left knee, and pelvis, a computerized tomography (CT) scan of the cervical spine and head. The results revealed the resident was diagnosed with [REDACTED]. B. Resident #2 1. Resident status Resident #2, above the age of 85, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 11/6/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. No wandering, behaviors, or refusal of care were exhibited during the review period. She was independent and required no assistance from staff for bed mobility, transfers, walking in her room and on/off unit, dressing, toileting, or personal hygiene. She utilized a four-wheeled walker for mobility. 2. Record review The 11/2/2020 care plan identified Resident #2 was an elopement risk/wanderer and had occasional episodes of wanting to leave the facility related to her dementia diagnosis. Pertinent interventions included: -Resident #2's triggers for wandering/eloping were becoming tearful, feeling like she was in prison, and her family not visiting for a long time. Resident #2's behaviors were deescalated by distraction - will forget quickly. -Provide structured activities: walking inside and outside, reorientation strategies including signs, pictures and memory boxes, and crafts such as coloring or quilting. -Wander guard placed on Resident #2's four-wheeled walker - check daily for proper functioning. The 11/2/2020 wandering risk scale assessment revealed a score of ten, which put the resident at risk to wander. Review of Resident #2's progress notes from August to November 2020 revealed: -The 8/11/2020 plan of care note documented the resident got tearful about having to stay at the facility and wanted to go home. -The 8/13/2020 social service note documented the resident enjoyed arts and crafts and was generally a happy, cooperative lady. It also read that the resident got confused at times thinking that someone was stealing her home. -The 11/10/2020 plan of care note documented that the resident kept herself busy with crafts but she would become forgetful thinking that she had a package she was waiting for from the mail or would get fixated on going home or taking care of her house. -The 11/25/2020 at 9:09 p.m. behavior note revealed that Resident #2 was upset that she was moved to the COVID-19 designated unit. The resident said to the staff that she wanted to leave and would call her son to pick her up. The resident walked up to the nurse with her fist raised and started walking toward the door (main door leading into the COVID-19 unit). The nurse was able to redirect the resident back to bed and reassure the resident that she was safe. The resident was able to calm down and return to bed. C. Staff interviews The DON was interviewed on 12/2/2020 at 12:28 p.m. She said that her understanding of the incident on 11/23/2020 with Resident #8 was he exited through the south door located in the gym. She stated the south door located in the gym was the only door in the facility that was not alarmed and she was not aware why the door was not alarmed. She stated at the time of the incident, the resident resided down the hall where the gym was located and that the door to the gym was likely left open. She stated the two men driving outside of the facility saw the resident lying on the side of the street on the south side of the facility around 9:00 p.m. The two men contacted the sheriff's office and upon arriving at the scene the sheriff had contacted emergency medical services (EMS) and the facility about the resident being found outside. The sheriff spoke with the charge nurse and the nurse then located the resident outside, assessed the resident for injury and provided EMS with discharge paperwork for the resident to be transferred to the hospital. She stated that she completed a report for a missing person and reported to the State Agency but did not treat the incident as an elopement. She stated that the resident had been placed on hourly checks for the hours between 6:00 a.m. and 6:00 p.m. on 3/18/202, prior to this incident and that staff completed a log with residents status, location and activity. The maintenance services director (MSD) and licensed practical nurse (LPN) #2 was interviewed and observed the therapy door propped open and the south door not locked on 12/2/2020 at 12:55 p.m. The MSD said that the south door was egress and was not locked. He said he felt the reason the therapy gym door was not alarmed was because staff were to keep it locked, however he acknowledged that staff used this exit to go outside to smoke and prop the door open so they did not get locked out of the facility. He said the only time the space was used since the outbreak of COVID-19 on 11/25/2020 was for storage of personal protective equipment (PPE). He said if a resident went through the therapy gym door then there would be no way for the staff to know the door was breached since it was not alarmed. LPN #2 said that the reason she had the gym door was propped open was because she was doing some charting. She said she kept the door open to hear the residents since she was the nurse on the unit and since COVID-19 outbreak the unit was closed off from the rest of the facility, as the clean unit. She said there were four residents on the unit at the moment and they did not have exit seeking behaviors. She said there were two residents with exit seeking behaviors, Residents #2 and #8. She said she was not working the night Resident #8 left the building and was found outside. She said usually the door was kept closed except when the staff were charting. A call light alarm sounded and she left the room and the door propped open to attend to the resident's needs. She did not ensure it was closed behind her. Physical therapist assistant (PTA) #1, was interviewed on 12/2/2020 at 1:15 p.m. PTA #1 was also the son of Resident #8. He stated the door to the therapy gym was not consistently kept closed because staff used the room for charting. He stated after Resident #8 had fallen outside, the facility had placed signs on the door stating to keep it closed. He stated he thought staff were using the south door to exit and enter the building during their smoke break. He stated the resident used to walk five miles every day and was very active in the years prior to admitting to the facility. He stated the facility was aware of the residents active history and he was more active in the night time. The DON was interviewed again on 12/2/2020 at 4:19 p.m. She stated she was aware of the missing logs for Resident #8 on 11/23/2020 and she was unable to locate them. She said based on the witness statements, the last time he was seen in the facility was at 7:45 p.m. The nurse was notified approximately 9:00 p.m. of Resident #8 being outside, she felt the resident was outside for no longer than one hour and fifteen minutes. Registered nurse (RN) #2 was interviewed on 12/3/2020 at 8:08 a.m. via telephone. He stated the resident had a history of [REDACTED]. He stated that one of the CNAs working that shift made him aware that the resident was lying down in his room as part of the frequent checks they completed on the resident. He said he was working with another resident at the time. He stated that he received a phone call from the sheriff who stated a resident had been located outside of the facility. He stated there was confusion as to where the resident had been located resulting in a delay in him reaching the resident. He stated that when he arrived at the scene, the resident was wrapped in a blanket, with EMS personnel, the sheriff, the two men who located the resident originally and a CNA from the facility (who had not entered the facility yet) were there. He stated that EMS had assessed the resident and provided treatment to the skin abrasion on the residents arm and leg. He stated that he had noted a goose egg on the residents temple and began assessing the resident himself. He stated that the resident was alert and talking with him and presented at his baseline cognition. He stated that he agreed with EMS that the resident should be transferred to the hospital for an additional evaluation. He stated he went back into the facility, provided transfer documentation to EMS and contacted the resident's family, DON and NHA. He stated that he believed the resident was outside for 45 minutes before he arrived on scene. He stated it was chilly outside the night of the incident. He stated he was not aware that the south door was not alarmed. The nursing home administrator (NHA) was interviewed on 12/3/2020 at 10:11 a.m. He provided instruction on the therapy gym door and how it was secured with the keypad and education to the staff to keep the door locked and secured at all times. He said as long as the therapy gym door was secured there was no access to the unsecured south door. He said it would take time to get an electrician in to the facility to alarm the therapy gym door but he would the process. He said and provided staff training about securing the therapy gym door at all times. He provided demonstration of how the automatic closing hinge worked on the door to prevent the staff from propping the door open. He said the staff were trained on doing 30 minute rounds on the residents and reporting any resident not in their rooms. He said this would continue until the alarm could be installed on the door. He said the staff were educated on the elopement policy. The charge nurses were going to monitor the door for remaining closed until the alarm could be put on the therapy door. He said Resident #8 was not exit seeking since he returned from the hospital and his illness worsened, he remained in his room and not walking. He said Resident #2 had not attempted to exit seek except on 11/25/2020 when she required physical and chemical restraints to keep her safe. The assistant director of nursing (ADON) was interviewed on 12/3/2020 at 10:26 a.m. She said a wander guard was placed on Resident #2's four-wheeled walker because the resident made comments about leaving the facility. She said Resident #2 had not made an attempt to exit through any facility doors, but the wander guard was put in place as a preventative measure. She said Resident #2 had not wandered aimlessly throughout the facility, but she verbalized wanting to leave. She said when Resident #2 was upset and made comments about leaving, she would stay in her room and staff would encourage her to engage in her crafts or talk with staff. She said staff had also contacted Resident #2's daughter in the past as the daughter was sometimes able to help calm Resident #2. She said that when Resident #2's exit-seeking behaviors escalated on the night of 11/25/2020 staff would normally have let her walk around or go back to her room, but staff were trying to keep the other residents safe due to Resident #2's positive COVID-19 status. She said if Resident #2 was to display similar exit-seeking and aggressive behaviors in the future, staff should move her to a different environment away from the other residents and bring her some of her crafts.

Based on interviews and record review, the facility failed to ensure one (#2) of two residents reviewed remained free from chemical restraints out of 14 sampled residents. Specifically, the facility failed to implement effective person-centered behavior management interventions to prevent exit-seeking behaviors which resulted in Resident #2 experiencing a catastrophic reaction as evidenced by anger which caused aggression that led to Resident #2 injuring self and staff by self-directed responses of hitting, shoving, biting, and scratching the staff. Resident #2 was verbally aggressive by threatening to leave and wanting to call son, screaming, and cursing at staff. Resident #2 became verbally and physically aggressive towards staff after being provoked, at which time Resident #2 was given a chemical restraint, of an intramuscular (IM) injection of [MEDICATION NAME] ([MEDICAL CONDITION]) due to her reaction to being physically restrained by staff which provoked Resident #2's aggression. Resident #2 was placed on the COVID-19 unit which had an unsecured door, cross-reference F689 for failing to provide the supervision necessary to prevent elopements and failing to implement interventions necessary to prevent unsafe wandering. The facility failed Resident #2 by not ensuring a chemical restraint was not used for discipline or convenience. Cross-reference to F604 (Physical Restraint), F689 (Accident Hazards) and F744 (Dementia Care) Findings include: I. Facility policy and procedure The nursing home administrator (NHA) provided the abuse policy, last revised on 3/2/18, via email on 12/2/2020. It read in pertinent part, - The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. -We should never use medication as a way to 'deal' with anybody. We should always do our best to use (the) least restrictive measures first. If we have to administer any type of medication and hold the resident to do this, this now becomes a restraint. We cannot hold them down. If you ever feel the need to hold a resident to provide medication: try all interventions first - listen to them! But never hold them - you should call the sheriff's office to do this and this is also not encouraged, but a safer practice for you. II. [MEDICATION NAME], antipsychotic medication, manufacturer recommendations The Janssen pharmaceutical company of Johnson and Johnson, [MEDICATION NAME] Full Prescribing Information Including Boxed Warning, revised February 2020, accessed on 12/10/2020, http://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/[MEDICATION NAME]-pi.pdf. It read in pertinent part, Increased Mortality in Elderly Patients with Dementia-Related [MEDICAL CONDITION]; Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] injection is not approved for the treatment of [REDACTED]. III. Resident status Resident #2, above the age of 85, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 11/6/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She was independent and required no assistance from staff for bed mobility, transfers, walking in her room and on/off unit, dressing, toileting, or personal hygiene. She utilized a four wheeled walker for mobility. A. Record review The 11/25/2020 at 9:09 p.m. behavior note revealed that Resident #2 was upset that she was moved to the COVID-19 designated unit. The resident said to the staff that she wanted to leave and would call her son to pick her up. The resident walked up to the nurse with her fist raised and started walking toward the door (main door leading into the COVID-19 unit). The nurse was able to redirect the resident back to bed and reassure the resident that she was safe. The resident was able to calm down and return to bed. The 11/26/2020 at 1:58 a.m. behavior note revealed that Resident #2 became upset at approximately 10:45 p.m. on 11/25/2020 when a light was turned on by staff for medication pass in the COVID-19 unit. The resident got up from her bed and stated she was going back to her room and would call her son to come get her. The licensed practical nurse (LPN) #3 informed the resident that she could not leave the unit to go back to her room due to her positive COVID-19 status. The resident walked to the main COVID-19 unit door to leave the COVID-19 unit and told LPN #3 to move out of her way or she would knock her out. LPN #3 called for assistance from the certified nurse aides (CNA) #2 as the resident had begun kicking, swinging her fists, and using foul language. LPN #3 and CNA #2 tried to explain to the resident why she could not leave the COVID-19 unit but the resident continued attempting to leave. The resident then walked to a different door (door that led outside the facility) within the isolation unit, stopped using her walker, pushed staff and furniture out of the way, and was able to unlock the door and attempted to exit the facility. LPN #3 and CNA #2 held the resident's hands to prevent her from going outside. The resident started hitting LPN #3 and CNA #2 and attempted to bite their hands. LPN #3 and CNA #2 assisted the resident to sit in a chair as she continued biting, hitting, stomping on staff' feet, and verbally threatening the staff. LPN #3 and CNA #2 continued to hold the resident's hands to prevent her from harming herself or others. LPN #3 called for help from registered nurse (RN) #1 and asked her to call the director of nursing (DON) for assistance. RN #1 returned with an order from the medical director for 2.5 milligram (mg) [MEDICATION NAME] (antipsychotic) intramuscular (IM) injection which could be repeated again after 30 minutes if necessary. RN #1 explained to the resident the purpose of the medication and how it would be administered to which the resident responded that she did not care. The resident calmed down quickly after the injection and staff convinced her to walk over to her bed using her walker and lie down. The resident fell asleep within ten minutes of lying down. Staff monitored the resident for an additional thirty minutes. B. Resident interview and observation Resident #2 was interviewed on 12/2/2020 at 4:15 p.m. She said that she recalled attempting to leave the building last week and that a nurse attempted to get her back to bed. She stated that she wanted to leave and was banging on a door trying to leave so that she could get to a restaurant to call her son and have him pick her up. She stated that she remembered the nurse holding her hand and telling her that she could not leave. She stated that she was not afraid but she would fire the nurse if she could. She was unable to recall any other details about the event. On 12/1/2020 at 10:53 a.m. Resident #2 was observed leaving her room and walking with her walker to the nursing station. The nursing home administrator (NHA) immediately walked over to the resident and verbally reminded her that there was [MEDICAL CONDITION] in the building and that no one could come out of their room right now for safety. Resident #2 stated she was unaware of [MEDICAL CONDITION] and would go back to her room. The NHA walked with the resident and ensured she made it back to her room and reminded her again that no residents should come out of their room while [MEDICAL CONDITION] was in the building and to ask staff if she needed something. Resident #2 willingly went back to her room. C. Staff interviews The director of nursing (DON) was interviewed on 12/1/2020 at 2:56 p.m. She said that she was not present during the event with Resident #2. She said that she received a phone call from RN #1 asking what could be done to calm Resident #2 due to her behaviors and she directed RN #1 to call the medical director. She said Resident #2 had no history of these types of behaviors since her admission. She said if a resident displayed negative behaviors or if the behaviors were escalating, staff should try non-pharmacological interventions first. She said staff should have attempted to identify what was causing the resident's behaviors, used distraction techniques, and moved the resident to an area that was more safe, comfortable, and quiet so that the external or internal stimuli could be decreased. She said staff should have known what interventions had been identified in the care plan such as going for a walk with the resident, validating her feelings, using distractions, or getting her to a more comfortable environment. She said it was her responsibility to work with the staff involved in the incident and provide education and training for how to handle that type of situation but she had not had time to do that yet. CNA #2 was interviewed on 12/1/2020 at 4:17 p.m. via telephone. She said that she was present during the event with Resident #2. She said that Resident #2 became upset when the lights were turned on during nursing rounds the evening of 11/25/2020. She said LPN #3 tried to talk to Resident #2 when she became upset but the resident stood up from her bed and tried to hit LPN #3. She said she kept her distance and watched at first, but when LPN #3 backed up and the resident followed her attempting to fight LPN #3, she got involved. She said the resident bit her, knocked off her glasses, hit her, and was cursing at her. She said she and LPN #3 tried to block the door so the resident could not leave. She said that eventually they got the resident to sit down in a chair. She said she held Resident #2's left hand between her and the resident so that she would not try to hit RN #1 as she was administering the injectable medication. She said she had not seen that behavior from Resident #2 before. She said if staff had given Resident #2 more control of the situation or dimmed the lights more this may have helped calm the resident but she was not sure. LPN #3 was interviewed on 12/1/2020 at 5:05 p.m. via telephone. She said Resident #2 was lying down in bed as she passed out medications. She said there were four residents in the COVID-19 unit, which was normally utilized as the chapel for the facility. She said there was one light switch for the room and it happened that one of the lights was positioned over Resident #2's bed. She said she put the light on as dim as possible, but the resident was upset. She said she reassured the resident that everything was alright and she was passing medications out to other residents in the room and would turn off the light once that was completed. She said the resident got out of her bed and began trying to leave the COVID-19 unit. She said she tried to distract Resident #2 from attempting to exit the COVID-19 unit by talking to her about her children, Christmas, holidays, things she did when she was young, crafting, and quilting, but her behaviors escalated to the point that staff could not control them. She said she attempted to explain to the resident the need for COVID-19 isolation, but the resident continued attempting to exit the unit and hitting staff. She said she called for assistance from RN #1 due to the resident's violent behaviors and disrupting the three other residents in the COVID-19 unit. She said the resident's behaviors occurred for approximately 45 minutes prior to the physician order [REDACTED]. She said Resident #2 apologized for her behaviors the next day. She said she reassured Resident #2 that it was alright. She said that it must have been hard for the resident to be in such a small confined area when she was used to walking the halls and being in her own room. No documentation was found indicating that the above mentioned interventions were attempted during the event on 11/25/2020 which resulted in physical and chemical restraints for Resident #2. RN #1 was interviewed on 12/1/2020 at 5:33 p.m. via telephone. She said she was not working the COVID-19 unit at the time of the incident. She said CNA #2 called her on to the COVID-19 unit due to an emergency and because she had good rapport with Resident #2. She said she observed Resident #2 trying to bite the staff and trying to get through the back door leading outside but LPN #3 was blocking the doorway so the resident could not leave. She said she was surprised to see Resident #2 hitting, scratching, and threatening the staff. She said she spoke calmly to Resident #2 to get her to sit down and told her she would be receiving some medication. She said Resident #2 was looking at her when she delivered the IM injection of [MEDICATION NAME] and that LPN #3 and CNA #2 held the resident's hands. She said the resident was wringing her hands while the staff were holding them trying to get her hands free. The medical director was interviewed 12/2/2020 at 11:04 a.m. via telephone. He said he was not the doctor for Resident #2 and that he was usually only involved if the on-call doctor did not answer the phone. He did not recall the incident that required the IM injection of [MEDICATION NAME]. He stated that the standard practice was to attempt non-pharmacological interventions prior to administering a medication. The on-call doctor at the time of the event was interviewed on 12/2/2020 at 3:46 p.m. via telephone. She stated that she recalled the event with Resident #2 that resulted in the IM [MEDICATION NAME] injection. She said that Resident #2 was very mobile, active within the community, and wandering were the resident's baseline behaviors. She said Resident #2 tested positive for COVID-19 earlier that day and was therefore placed on isolation protocols. She said the nurse contacted her explaining that Resident #2 had become very agitated on the COVID-19 unit and staff felt she would hurt herself or staff. She stated that she directed other interventions be used including supportive measures and to have familiar staff engage with the resident. She stated that a one-time dose of [MEDICATION NAME] was prescribed as that was the only medication available in the emergency kit at the time and other interventions had not been effective.

Based on interviews and record review, the facility failed to ensure one (#2) of two of 14 sample residents reviewed for restraints were free from physical restraints not required to treat the residents medical symptoms. Specifically, the facility failed to implement appropriate person-centered behavior management interventions to prevent exit-seeking behaviors for Resident #2 who had a [DIAGNOSES REDACTED]. Resident #2 was physically restrained by staff when trying to leave the unit, which increased known behaviors of wandering, exit seeking and agitation. Resident #2 became verbally and physically aggressive towards staff after being provoked, at which time Resident #2 was given a chemical restraint, cross-reference F605, in conjunction with the physical restraint by staff. Resident #2 was given an intramuscular (IM) injection of [MEDICATION NAME] due to her reaction to being physically restrained by staff which provoked Resident #2's aggression. Resident #2 was placed on the COVID-19 unit which had an unsecured door, cross-reference F689 for failing to provide the supervision necessary to prevent elopements and failing to implement interventions necessary to prevent unsafe wandering. Findings include: I. Facility policy and procedure The nursing home administrator (NHA) provided the abuse policy, last revised on 3/2/18, via email on 12/2/2020. It read in pertinent part, - The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. -We should never use medication as a way to ' deal ' with anybody. We should always do our best to use (the) least restrictive measures first. If we have to administer any type of medication and hold the resident to do this, this now becomes a restraint. We cannot hold them down. If you ever feel the need to hold a resident to provide medication: try all interventions first - listen to them! But never hold them - you should call the sheriff's office to do this and this is also not encouraged, but a safer practice for you. II. Resident #2's status Resident #2, above the age of 85, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 11/6/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She was independent and required no assistance from staff for bed mobility, transfers, walking in her room and on/off unit, dressing, toileting, or personal hygiene. She utilized a four wheeled walker for mobility. A. Record review The 11/25/2020 at 9:09 p.m. behavior note revealed that Resident #2 was upset that she was moved to the COVID-19 designated unit. The resident said to the staff that she wanted to leave and would call her son to pick her up. The resident walked up to the nurse with her fist raised and started walking toward the door (main door leading into the COVID-19 unit). The nurse was able to redirect the resident back to bed and reassure the resident that she was safe. The resident was able to calm down and return to bed. The 11/26/2020 at 1:58 a.m. behavior note revealed that Resident #2 became upset at approximately 10:45 p.m. on 11/25/2020 when a light was turned on by staff for medication pass in the COVID-19 unit. The resident got up from her bed and stated she was going back to her room and would call her son to come get her. The licensed practical nurse (LPN) #3 informed the resident that she could not leave the unit to go back to her room due to her positive COVID-19 status. The resident walked to the main COVID-19 unit door to leave the COVID-19 unit and told LPN #3 to move out of her way or she would knock her out. LPN #3 called for assistance from the certified nurse aides (CNA) #2 as the resident had begun kicking, swinging her fists, and using foul language. LPN #3 and CNA #2 tried to explain to the resident why she could not leave the COVID-19 unit but the resident continued attempting to leave. The resident then walked to a different door (door that led outside the facility) within the isolation unit, stopped using her walker, pushed staff and furniture out of the way, and was able to unlock the door and attempted to exit the facility. LPN #3 and CNA #2 held the resident's hands to prevent her from going outside. The resident started hitting LPN #3 and CNA #2 and attempted to bite their hands. LPN #3 and CNA #2 assisted the resident to sit in a chair as she continued biting, hitting, stomping on staff' feet, and verbally threatening the staff. LPN #3 and CNA #2 continued to hold the resident's hands to prevent her from harming herself or others. LPN #3 called for help from registered nurse (RN) #1 and asked her to call the director of nursing (DON) for assistance. RN #1 returned with an order from the medical director for 2.5 milligram (mg) [MEDICATION NAME] (antipsychotic) intramuscular (IM) injection which could be repeated again after 30 minutes if necessary. RN #1 explained to the resident the purpose of the medication and how it would be administered to which the resident responded that she did not care. The resident calmed down quickly after the injection and staff convinced her to walk over to her bed using her walker and lay down. The resident fell asleep within ten minutes of lying down. Staff monitored the resident for an additional thirty minutes. B. Resident interview and observation Resident #2 was interviewed on 12/2/2020 at 4:15 p.m. She said that she recalled attempting to leave the building last week and that a nurse attempted to get her back to bed. She stated that she wanted to leave and was banging on a door trying to leave so that she could get to a restaurant to call her son and have him pick her up. She stated that she remembered the nurse holding her hand and telling her that she could not leave. She stated that she was not afraid but she would fire the nurse if she could. She was unable to recall any other details about the event. On 12/1/2020 at 10:53 a.m. Resident #2 was observed leaving her room and walking with her walker to the nursing station. The nursing home administrator (NHA) immediately walked over to the resident and verbally reminded her that there was [MEDICAL CONDITION] in the building and that no one could come out of their room right now for safety. Resident #2 stated she was unaware of [MEDICAL CONDITION] and would go back to her room. The NHA walked with the resident and ensured she made it back to her room and reminded her again that no residents should come out of their room while [MEDICAL CONDITION] was in the building and to ask staff if she needed something. Resident #2 willingly went back to her room. C. Staff interviews CNA #2 was interviewed on 12/1/2020 at 4:17 p.m. via telephone. She said that she was present during the event with Resident #2. She said that Resident #2 became upset when the lights were turned on during nursing rounds the evening of 11/25/2020. She said LPN #3 tried to talk to Resident #2 when she became upset but the resident stood up from her bed and tried to hit LPN #3. She said she kept her distance and watched at first, but when LPN #3 backed up and the resident followed her attempting to fight LPN #3, she got involved. She said the resident bit her, knocked off her glasses, hit her, and was cursing at her. She said she and LPN #3 tried to block the door so the resident could not leave. She said that eventually they got the resident to sit down in a chair. She said she held Resident #2's left hand between her and the resident so that she would not try to hit RN #1 as she was administering the injectable medication. LPN #3 was interviewed on 12/1/2020 at 5:05 p.m. via telephone. She said Resident #2 was lying down in bed as she passed out medications. She said there were four residents in the COVID-19 unit, which was normally utilized as the chapel for the facility. She said there was one light switch for the room and it happened that one of the lights was positioned over Resident #2's bed. She said she put the light on as dim as possible, but the resident was upset. She said she reassured the resident that everything was alright and she was passing medications out to other residents in the room and would turn off the light once that was completed. She said the resident got out of her bed and began trying to leave the COVID-19 unit. She said she tried to distract Resident #2 from attempting to exit the COVID-19 unit by talking to her about her children, Christmas, holidays, things she did when she was young, crafting, and quilting, but her behaviors escalated to the point that staff could not control them. She said she attempted to explain to the resident the need for COVID-19 isolation, but the resident continued attempting to exit the unit and hitting staff. She said she called for assistance from RN #1 due to the resident's violent behaviors and disrupting the three other residents in the COVID-19 unit. She said the resident's behaviors occurred for approximately 45 minutes prior to the physician order [REDACTED]. RN #1 was interviewed on 12/1/2020 at 5:33 p.m. via telephone. She said LPN #3 and CNA #2 held the resident's hands while she administered the IM injection of [MEDICATION NAME]. She said the resident was wringing her hands while the staff were holding them trying to get her hands free.

Based on observations, interviews and record review, the facility failed to develop, implement, monitor and reevaluate its quality assurance performance improvement (QAPI) program to ensure the unique care and services the facility provided were maintained at acceptable levels of performance and continuously improved. Specifically, the facility's QAPI program failed to systematically self-identify, investigate, analyze and correct problems relating to resident safety and resident rights. This failure contributed to serious adverse outcomes and the likelihood of further serious adverse outcome. Cross-reference F604 for physical restraints, F605 for chemical restraints,F689 for accident/hazards and F744 for treatment and services for dementia care. Findings include: I. Facility policy The 2020 QAPI Plan, undated, was provided via email by the nursing home administrator (NHA) on 12/9/2020. It read in pertinent part, (Facility name) uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. (Facility name) applies a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. (Facility name) approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement. (Facility name) also has developed policies and procedures regarding expectations of the use of root cause analysis when problems are identified. This element includes a focus on continual learning and continuous improvement. II. The infection control survey (12/1/2020 to 12/3/2020) revealed multiple areas in which the facility failed to deliver care and services to its complex and unique resident population at an acceptable level of performance. A. Cross-reference F689 for failure to ensure resident safety from accidents, cited at J level, immediate jeopardy for serious harm. Survey findings revealed Resident #8, severely cognitively impaired with behavioral disturbances that placed him at risk for harm, including daily exit seeking behaviors. Staff left the door to the therapy gym ajar so Resident #8 was able to exit the building undetected. The facility failed to identify and address Resident #8's known daily exit seeking behaviors and failed to anticipate and plan for the possibility of Resident #8 ' s elopement from the building, whose dementia and/or behaviors placed them at risk of elopement. The facility failed to identify the door that was left open by staff as a potential elopement risk for residents with exit seeking behaviors and/or wandering tendencies. B. Cross reference to F604 (physical restraints), F605 (chemical restraints) and F744 (dementia care) for failure to implement person-centered interventions to prevent physical and chemical restraints used during agitation, cited at G level, actual harm, isolated. Survey findings revealed Resident #2, severely cognitively impaired with behavioral disturbances that placed her at risk for harm, including daily wandering in the building with all exits of the facility not being secured. Staff placed the resident on a unit that did not have security on the doors leaving the COVID-19 unit to the exterior of the building which resulted in the staff having to physically restrain the resident and eventually chemically restrain the resident to protect the resident from injury. The facility failed to implement effective person-centered behavior management interventions to prevent exit-seeking behaviors which resulted in Resident #2 experiencing a catastrophic reaction from the use of physical restraint by the staff, while preventing the resident from leaving the building and getting injured. This ultimately resulted in the use of a chemical restraint, [MEDICATION NAME] intramuscular (IM) injection, to ensure the resident ' s safety. Resident #2 was physically and verbally aggressive towards staff with the high likelihood of causing herself injuries. III. Leadership interviews The medical director was interviewed 12/2/2020 at 11:04 a.m. via telephone. He said he was not the doctor for Resident #2 and he was usually only involved if the on-call doctor did not answer the phone. He did not recall the incident that required the IM injection of [MEDICATION NAME] administered to Resident #2. He stated standard practice was to attempt non-pharmacological interventions prior to administering a medication. He said at next QAPI meeting he would be involved in the review of the event that took place with Resident #2. He said during the meeting the appropriate use of the medication [MEDICATION NAME] would be discussed to identify interventions to prevent the use of it in the future. The nursing home administrator (NHA) was interviewed on 12/3/2020 at 3:56 p.m. He said they have a QAPI committee which consisted of himself, the director of nursing, dietary manager, therapy manager, assistant director of nursing, maintenance director, housekeeping director, activity director and they meet monthly. The medical director and pharmacy participate in the QAPI meetings quarterly. He said the usual concerns reviewed in the meetings consisted of safety, grievances, family surveys, past citations, staffing and other current identified needs. He said staff brought concerns to the daily morning meetings with the committee team members except the medical director and pharmacist. He said that once the identified issues were identified they were assigned to the relevant department for establishing interventions to correct the issue and to train the staff accordingly. He said the committee reviewed the interventions for effectiveness monthly. He said if other issues were identified during the process then the plan would be adjusted accordingly to resolve the concern. The NHA confirmed that the facility had reviewed residents with elopement risk, identified all the doors leading to the exterior of the building and ensured locks and/or alarms were in place. He said the committee could not foresee the staff leaving the physical therapy door open for Resident #8 to elope from the building. He said the staff have been trained and reminded about the importance of ensuring the door to the therapy gym was closed and secured. The staff were educated on using the keypad lock system on the door of the therapy gym. The NHA said concerns from staff were generally brought up in morning meetings, and there was a concern form staff could fill out.

Based on observation, record review and interviews, the facility failed to provide dementia treatment and services to maintain the highest practicable physical, mental, and psychosocial well-being for two (#2 and #8) of two residents reviewed out of 14 sample residents. The facility was aware Resident #2 who had a [DIAGNOSES REDACTED]. During an exit seeking event on 11/25/2020 by Resident #2, the facility failed to implement interventions on the current care plan, such as distraction-will forget quickly, provide structured activities-reorientation strategies(see care plan). Instead of following the care plan and implementing effective person-centered behavior management, Resident #2 was physically restrained by staff, when trying to leave the unit, which increased known behaviors of wandering, exit seeking and agitation. Resident #2 became verbally and physically aggressive towards staff after being provoked, at which time Resident #2 was given a chemical restraint ([MEDICATION NAME], intramuscular injection-used for the treatment of [REDACTED]. Additionally, the facility failed to implement the person-centered approaches for Resident #8's [DIAGNOSES REDACTED]. These approaches included providing diversional activities, providing adequate staff supervision which included monitoring the resident hourly, and ensuring the exits were secured. Due to the lack of person-centered approaches, the resident was exit seeking and eventually eloped on 11/23/2020 (cross-reference F689 accident/hazards). Cross-reference to F604 (Physical Restraint), F605 (Chemical Restraint), and F689 (Accident Hazards) Findings include: I. Professional reference The Alzheimer's Association (last updated 3/30/2020) : Tips for Dementia Caregivers in Long-Term or Community-Based Settings, retrieved on 12/10/2020 from: https://www.alz.org/professionals/professional-providers/coronavirus-covid-19-tips-for-dementia-caregivers?_ga=2XXX 437XXX XXX - XXX &_gac=1XXX 9244XXX .eaiaiqobchmiqfd6qvlr6wivqdbach2thgoceaayasaaegl_8pd_bwe. It read in pertinent part, Nonverbal dementia-related behaviors may be an option or response for a person living with dementia to communicate a feeling, unmet need or intention. These behaviors are triggered by the interaction between the individual and his or her social and physical environment. A response may include striking out, screaming, or becoming very agitated or emotional. The dementia care provider's role is to observe and attempt to understand what the person living with dementia is trying to communicate. Root causes of dementia-related behaviors may include: Pain; hunger; fear, depression, frustration; loneliness, helplessness, boredom; hallucinations and/or overstimulation; changes in environment or routine; difficulty understanding or misinterpreting the environment; difficulty expressing thoughts or feelings; and, unfamiliarity with personal protective equipment or clothing, such as gowns or masks. Strategies to observe and respond to dementia-related behaviors include: Rule out pain, thirst, hunger or the need to use the bathroom as a source of agitation; Speak in a calm low-pitched voice; Try to reduce excess stimulation; Ask others what works for them; Validate the individual's emotions. Focus on the feelings, not necessarily the content of what the person is saying. Sometimes the emotions are more important than what is said; Understand that the individual may be expressing thoughts and feelings from their own reality, which may differ from generally acknowledged reality. Offer reassurance and understanding, without challenging their words, can be effective; Through behavioral observation and attempted interventions, try to determine what helps meet the person's needs and include the information in the individualized plan of care; Be aware of past traumas (veterans, abuse survivors, survivors of large-scale disasters); and, Never physically force the person to do something. Proactive strategies for addressing dementia-related behaviors: It can be difficult to anticipate and respond to dementia-related behaviors in a changing environment - especially in emergency situations. However, applying some of the following strategies may help: Provide a consistent routine; Use person-centered care approaches for all individuals living with dementia during activities of daily living - every interaction or task is an opportunity for engagement; Promote sharing of person-centered information across the care team; Encourage all staff to treat individuals living with dementia with dignity and respect; and, Put the person before the task. II. Facility policy and procedures The nursing home administrator (NHA) provided the abuse policy, last revised on 3/2/18, via email on 12/2/2020. It read in pertinent part, When we have a resident that presents with abnormal behaviors/negative behaviors, we understand and acknowledge that they could be a danger to themselves and or others. This is when we need to use distraction techniques and provide non-pharmacologic interventions. -Move to an environment that is safe, allowing the resident to calm down. -Decrease external stimuli: turn down the lights, go to a quiet area, sit in a relaxing chair, walk with the resident to a different location in the building, let them rest in a different room, offer food and fluid. III. Census and conditions The Census and Conditions form was provided via email by the nursing home administrator (NHA) on 12/1/2020. It read in pertinent part that the resident census was 29 and the residents with a dementia [DIAGNOSES REDACTED]. IV. Resident status Resident #2, above the age of 85, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 11/6/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. No wandering, behaviors, or refusal of care were exhibited during the review period. She was independent and required no assistance from staff for bed mobility, transfers, walking in her room and on/off unit, dressing, toileting, or personal hygiene. She utilized a four wheeled walker for mobility. A. Resident exit-seeking event resulting in physical and chemical restraints The 11/25/2020 at 9:09 p.m. behavior note revealed that Resident #2 was upset that she was moved to the COVID-19 designated unit. The resident said to the staff that she wanted to leave and would call her son to pick her up. The resident walked up to the nurse with her fist raised and started walking toward the door (main door leading into the COVID-19 unit). The nurse was able to redirect the resident back to bed and reassure the resident that she was safe. The resident was able to calm down and return to bed. The resident was redirectable with the above exit-seeking event. However, was not redirectable on the following event, see note below. The 11/26/2020 at 1:58 a.m. behavior note revealed that Resident #2 became upset at approximately 10:45 p.m. on 11/25/2020 when a light was turned on by staff for medication pass in the COVID-19 unit. The resident got up from her bed and stated she was going back to her room and would call her son to come get her. The licensed practical nurse (LPN) #3 informed the resident that she could not leave the unit to go back to her room due to her positive COVID-19 status. The resident walked to the main COVID-19 unit door to leave the COVID-19 unit and told LPN #3 to move out of her way or she would knock her out. LPN #3 called for assistance from the certified nurse aides (CNA) #2 as the resident had begun kicking, swinging her fists, and using foul language. LPN #3 and CNA #2 tried to explain to the resident why she could not leave the COVID-19 unit but the resident continued attempting to leave. The resident then walked to a different door (door that led outside the facility) within the isolation unit, stopped using her walker, pushed staff and furniture out of the way, and was able to unlock the door and attempted to exit the facility. LPN #3 and CNA #2 held the resident's hands to prevent her from going outside. The resident started hitting LPN #3 and CNA #2 and attempted to bite their hands. LPN #3 and CNA #2 assisted the resident to sit in a chair as she continued biting, hitting, stomping on staff' feet, and verbally threatening the staff. LPN #3 and CNA #2 continued to hold the resident's hands to prevent her from harming herself or others. LPN #3 called for help from registered nurse (RN) #1 and asked her to call the director of nursing (DON) for assistance. RN #1 returned with an order from the medical director for 2.5 milligram (mg) [MEDICATION NAME] (antipsychotic) intermuscular (IM) injection which could be repeated again after 30 minutes if necessary. RN #1 explained to the resident the purpose of the medication and how it would be administered to which the resident responded that she did not care. The resident calmed down quickly after the injection and staff convinced her to walk over to her bed using her walker and lie down. The resident fell asleep within ten minutes of lying down. Staff monitored the resident for an additional thirty minutes. B. Resident interview and observation Resident #2 was interviewed on 12/2/2020 at 4:15 p.m. She said that she recalled attempting to leave the building last week and that a nurse attempted to get her back to bed. She stated that she wanted to leave and was banging on a door trying to leave so that she could get to a restaurant to call her son and have him pick her up. She stated that she remembered the nurse holding her hand and telling her that she could not leave. She stated that she was not afraid but she would fire the nurse if she could. She was unable to recall any other details about the event. On 12/1/2020 at 10:53 a.m. Resident #2 was observed leaving her room and walking with her walker to the nursing station. The nursing home administrator (NHA) immediately walked over to the resident and verbally reminded her that there was [MEDICAL CONDITION] in the building and that no one could come out of their room right now for safety. Resident #2 stated she was unaware of [MEDICAL CONDITION] and would go back to her room. The NHA walked with the resident and ensured she made it back to her room and reminded her again that no residents should come out of their room while [MEDICAL CONDITION] was in the building and to ask staff if she needed something. Resident #2 willingly went back to her room. C. Record review The 11/2/2020 care plan identified Resident #2 was an elopement risk/wanderer and had occasional episodes of wanting to leave the facility related to her dementia diagnosis. Pertinent interventions included: -Resident #2's triggers for wandering/eloping were becoming tearful, feeling like she was in prison, and her family not visiting for a long time. Resident #2's behaviors were deescalated by distraction - will forget quickly. -Provide structured activities: walking inside and outside, reorientation strategies including signs, pictures and memory boxes, and crafts such as coloring or quilting. -Wander guard placed on Resident #2's four-wheeled walker - check daily for proper functioning. No new elopement risk interventions were implemented or documented on the care plan after Resident #2's incident on 11/25/2020 which resulted in the use of physical and chemical restraints. The 11/2/2020 wandering risk scale assessment revealed a score of ten, which put the resident at risk to wander. The 11/2/2020 care plan identified Resident #2 as at risk for a change in psychosocial well-being related to restriction on visits by family and friends due to COVID-19. Interventions listed in the care plan included: -Encourage alternative communication with family and friends. -Monitor for psychosocial changes. -Observe and report any changes in mental status caused by situational stressors. -Outdoor visits (as allowed based on county and facility COVID-19 status) -Provide opportunities for expression of feelings related to situational stressor. The facility failed to identify person-centered psychosocial well-being interventions prior to the resident's catastrophic reaction to being on the COVID-19 unit on 11/25/2020 that resulted in physical and chemical restraints. Review of the progress notes from August to November 2020 revealed: -The 8/11/2020 plan of care note documented the resident got tearful about having to stay at the facility and wanted to go home. -The 8/13/2020 social service note documented the resident enjoyed arts and crafts and was generally a happy, cooperative lady. It also read that the resident got confused at times thinking that someone was stealing her home. -The 11/10/2020 plan of care note documented that the resident kept herself busy with crafts but she would become forgetful thinking that she had a package she was waiting for from the mail or would get fixated on going home or taking care of her house. D. Staff interviews The social services director (SSD) was interviewed on 12/1/2020 at 3:49 p.m. and again on 12/2/2020 at 11:01 a.m. She said prior to the COVID-19 outbreak in the facility, Resident #2 was out of her room several times a day to socialize and keep active. She said Resident #2 regularly walked the hallways with another resident, looked out windows, sat at the front of the facility and quilted with another resident, and would often walk to the business office to inquire about items she believed she had ordered. She said Resident #2 needed frequent reminders and redirection due to her confusion. She said Resident #2 would remark that she needed to go home several times a week but SSD did not recall Resident #2 attempting to actively exit the facility. She said Resident #2 was on the COVID-19 unit when her aggressive behaviors occurred resulting in the use of physical and chemical restraints. She said the COVID-19 unit, which was the facility chapel, was a new environment with different staff than Resident #2 was accustomed to. She said when the residents who tested positive for COVID-19 were moved to the COVID-19 unit, staff did not take any of the residents' belongings with them. She said she believed that staff should have brought some of Resident #2's belongings with her to the COVID-19 unit since she liked to keep busy with her crafts and that may have helped when her behaviors escalated. She said that staff knew she was always on-call as a resource for non-pharmacological intervention ideas. She said when the facility received additional test results for residents who were positive for COVID-19, they realized they did not have enough beds for everyone on the COVID-19 unit so the facility created a COVID-19 negative unit and moved all residents who had tested positive back to their original rooms. She said she believed having residents who tested positive for COVID-19 back in their normal environment would help them while they were not feeling well. She also believed Resident #2 would have benefited from staying in her own familiar environment and having her favorite activities and supplies available to her. Licensed practical nurse (LPN) #3 was interviewed on 12/1/2020 at 5:05 p.m. via telephone. She said she was present during the event with Resident #2 that resulted in the use of physical and chemical restraints. She said Resident #2 was lying down in bed as she passed out medications that night. She said there were four residents in the COVID-19 unit, which was normally utilized as the chapel for the facility. She said there was one light switch for the room and it happened that one of the lights was positioned over Resident #2's bed. She said she put the light on as dim as possible, but the resident was upset. She said she reassured the resident that everything was alright and she was passing medications out to other residents in the room and would turn off the light once that was completed. She said the resident got out of her bed and began trying to leave the COVID-19 unit. She said she tried to distract Resident #2 from attempting to exit the COVID-19 unit by talking to her about her children, Christmas, holidays, things she did when she was young, crafting, and quilting, but her behaviors escalated to the point that staff could not control them. No documentation was found indicating that the above mentioned interventions were attempted during the event on 11/25/2020 which resulted in physical and chemical restraints for Resident #2. She said she attempted to explain to the resident the need for COVID-19 isolation, but the resident continued attempting to exit the unit and hitting staff. She said she called for assistance from RN #1 due to the resident's violent behaviors and disrupting the three other residents in the COVID-19 unit. She said the resident's behaviors occurred for approximately 45 minutes prior to the physician order [REDACTED]. The medical director was interviewed 12/2/2020 at 11:04 a.m. via telephone. He said he was not the doctor for Resident #2 and that he was usually only involved if the on-call doctor did not answer the phone. He did not recall the incident that required the IM injection of [MEDICATION NAME]. He stated that the standard practice was to attempt non-pharmacological interventions prior to administering a medication. The director of nursing (DON) was interviewed on 12/2/2020 at 3:27 p.m. She said for future COVID-19 outbreaks, she did not believe she would utilize the chapel as a COVID-19 unit again. She said she would not put Resident #2 or any other resident with exit-seeking behaviors back in that area of the facility. She said she would try to secure a different hallway with secured doors where staff would not be entering or exiting the building through the hallway. The assistant director of nursing (ADON) was interviewed on 12/3/2020 at 10:26 a.m. She said a wander guard was placed on Resident #2's four-wheeled walker because the resident made comments about leaving the facility. She said Resident #2 had not made an attempt to exit through any facility doors, but the wander guard was put in place as a preventative measure. She said Resident #2 had not wandered aimlessly throughout the facility, but she verbalized wanting to leave. She said when Resident #2 was upset and made comments about leaving, she would stay in her room and staff would encourage her to engage in her crafts or talk with staff. She said staff had also contacted Resident #2's daughter in the past as the daughter was sometimes able to help calm Resident #2. She said that when Resident #2's behaviors escalated on the night of 11/25/2020 staff would normally have let her walk around or go back to her room, but staff were trying to keep the other residents safe due to Resident #2's positive COVID-19 status. She said if Resident #2 was to display similar aggressive behaviors in the future, staff should move her to a different environment away from the other residents and bring her some of her crafts. She said she provided education to staff upon hire and quarterly about dementia care. It included abuse with dementia care, use distraction techniques and provide non-pharmacologic interventions, move to an environment that was safe, allowing the resident to calm down. Decrease external stimuli: turn down the lights, go to a quiet area, sit in a relaxing chair, walk with the resident to a different location in the building, let them rest in a different room, offer food and fluids. V. Resident #8 A. Resident status Resident #8, age 84, was admitted on [DATE]. According to the December 2020 computerized physician orders [REDACTED]. The 9/8/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required only set-up assistance for his activities of daily living (ADLs), including walking, dressing, personal hygiene and eating. The resident did not have behavioral disturbances and did not exhibit wandering behavior. B. Record review A physician order [REDACTED]. The care plan initiated on 3/3/2020 revealed the resident had a history of [REDACTED]. Pertinent interventions included placing a wander guard (3/18/2020), distract the resident by offering structured activities, food, conversation, television, exercise in the fitness room, walks outside with staff when weather was nice (3/3/2020), monitor resident hourly (3/18/2020) and ensure all exits were secured. The care plan initiated on 3/3/2020 revealed the resident had impaired cognitive function due to a [DIAGNOSES REDACTED]. The 7/13/2020 at 8:82 a.m behavior note (late entry) revealed the resident had been wandering the halls asking for his wife. The note read that the resident believed his wife was in his car outside and attempted to leave the facility via the front door located in the lobby. The note revealed that the alarm on the door sounded and the resident went to the activity room and attempted to exit the facility via that door. The note revealed he attempted to leave the facility via a third door before being redirected. The 8/3/2020 at 10:40 a.m. behavior note revealed that the resident continued to wander through the facility day and night. The note revealed that the resident demanded to be let outside so he could get to his car. The 8/27/2020 at 10:13 a.m. behavior note revealed that the resident continued to wander throughout the facility and had been attempting to exit the facility through the door subsequently setting off alarms. The 8/29/2020 at 6:07 p.m. behavior note revealed the resident was trying to exit the facility stating he was going to Oklahoma. The 9/2/2020 wandering risk assessment revealed a score of 13, putting the resident at a high risk of wandering. It indicated the resident had a history of [REDACTED]. The assessment also revealed the resident was confused and delusional. The 9/7/2020 at 8:09 a.m. activity participation note revealed the resident remained a fall risk and was able to ambulate around the facility without assistance. The note revealed the resident wandered around the facility at times. The 9/20/2020 at 11:51 p.m. health status note revealed the resident continued to walk around the facility slightly confused. The 10/13/2020 at 4:03 p.m. behavior note revealed the resident was observed following a nurse stating he thought the nurse was going outside and the resident was going to follow the nurse outside. C. Elopement on 11/23/2020 The 11/23/2020 at 9:52 p.m. incident note revealed the resident was found outside, across the street on the south side of the facility at 9:20 p.m. The resident was found by two men passing by the facility. The facility was made aware the resident was outside by the sheriff via telephone. The resident's care plan was not updated with information on the incident and no new interventions were put in place to assist the resident with his wandering behavior. There was no evidence the 11/23/2020 incident was investigated to determine the reason/cause the resident left the facility. The 12 hour check logs for Resident #8 were provided by the social service director (SSD) on 12/2/2020 at 3:34 p.m. The logs revealed missing documentation on 11/23/2020, the day of the incident. The facility failed to implement the person-centered approaches for his dementia with his behaviors of wandering aimlessly throughout the facility. These approaches included providing diversional activities, providing adequate staff supervision which included monitoring the resident hourly, and ensuring the exits were secured. Due to the lack of person-centered approaches, the resident was exit seeking and eventually eloped on 11/23/2020 (cross-reference F689 accident/hazards). D. Staff interviews The director of nursing (DON) was interviewed on 12/2/2020 at 12:28 p.m. She said that her understanding of the incident on 11/23/2020 with Resident #8 was he exited through the south door located in the gym. She stated the south door located in the gym was the only door in the facility that was not alarmed and she was not aware why the door was not alarmed. She stated at the time of the incident, the resident resided down the hall where the gym was located and that the door to the gym was likely left open by the staff. She stated that she completed a report for a missing person but did not treat the incident as an elopement. She stated that the resident had been placed on hourly checks for the hours between 6:00 a.m. and 6:00 p.m. on 3/18/2020, prior to this incident and that staff completed a log with residents status, location and activity. Physical therapist assistant (PTA) #1, was interviewed on 12/2/2020 at 1:15 p.m. PTA #1 was also the son of Resident #8. He stated the resident used to walk five miles every day and was very active in the years prior to admitting to the facility. He stated the facility was aware of the residents active history and he was more active in the night time. Registered nurse (RN) #2 was interviewed on 12/3/2020 at 8:08 a.m. via telephone. He stated the resident had a history of [REDACTED]. He stated he was not aware that the south door was not alarmed.

Based on observations, record review, and interviews, the facility failed to establish and maintain and infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the developlment and transmission of communicable disease and infections such as COVID-19 in three of four neighborhoods for seven of seven sample residents. Specifically, the facility failed to: -Follow proper housekeeping protocols to prevent cross-contamination; -Maintain proper cleaning standards and procedures; -Ensure residents had face covering while out of their rooms; and, -Ensure social distancing was followed during meals. Findings include: I. Improper housekeeping protocols A. Facility policies and procedures The Infection Control Policies and Procedures policy, revised 10/2012, was provided on 4/28/2020 at 10:14 p.m. by the director of nursing (DON). The goals of the infection control program are to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. B. Observations of improper housekeeping protocols On 4/29/2020 at 11:30 a.m., Housekeeper (HSK) #1 was observed cleaning room #C-8. Housekeeper HSK#1 put on gloves, and grabbed a rag, cleaner, and toilet brush and walked directly into the residents' bathroom. HSK #1 removed the commode chair from the toilet. HSK #1 was observed to use her gloved hands, and pour in a disinfectant into the toilet. She sprayed the toilet bowl and cleaned the toilet bowl. She exited the resident's room and placed the bowl brush back into her cart. She proceeded to wet the mop head and rang it out in the bucket and reentered the resident restroom. She mopped the bathroom floor and exited the resident's room after mopping. She placed the mop back in the mop bucket. She grabbed a clean rag and immersed the rag in the bucket filled with a disinfectant. She reentered the resident's room. She wiped the toilet lid, seat and base with the rag. She wiped the commode chair with the same rage she cleaned the toilet bowl and base with. She replaced the commode chair over the toilet. She then walked outside of the room and placed the dirty rag into the plastic bag on her cart, and retrieved another rag and submersed the rag into the disinfectant and rang it out. She wiped the sink and counter lifting wash cloths and other personal items which were on the counter. She wiped the towel dispenser with the same rag. She walked over to the window and wiped the window seal and wiped the window seal. She then wiped the bedside table. She then walked outside of the room and placed the used rag in a plastic bag. She grabbed the second mop, and proceeded to ring the mop out. She reentered the resident room and mopped the resident's room working her way out the door. She completed cleaning the residents' room and then removed her gloves. She washed her hands in the residents sink. C. Staff interviews HSK#1 was interviewed on 4/28/2020 at 10:39 a.m. She said the process to clean a resident's room was to start in the bathroom and then go to the rest of the room. She said, the dwell time for the disinfectant was approximately 45 seconds. She said as long as the rag was wet it was okay. The laundry housekeeping manager (LHSKM) was interviewed 4/29/2020 at 11:59 a.m. The LHSKM was informed of the observation above. She said the housekeepers are supposed to go from clean to dirty, which was starting from the window working out towards the door with the restroom being the last task. She said it was her expectations that the housekeeper would have followed facility procedure when cleaning the residents' rooms. She said the disinfectant used to be in a spray bottle but it had been changed to the bucket and using the rags. She said she thought the dwell time for the Eco lab disinfectant. She said a negative outcome for not following cleaning procedure and lack of dwell time would be cross contamination. She said she would reach out to the ECO lab provider to clarify the dwell time on the disinfectant. The Eco lab tech was interviewed on 4/30/2020 at 8:47 a.m. He said the disinfectant could be used with a rag immersion and a towel. He said it could also be utilized in a spray bottle. He said the dwell time for either procedure would be five minutes in order to be an effective disinfectant. He said the spray bottle method would be the best method to accomplish the dwell time it required. He said he would reach out to the facility to educate the facility of proper application. II. Failed to ensure residents had face covering while out of their rooms Findings include: I. CDC recommended guidelines The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (4/28/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (Update April 13, 2020) Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. A. Observations of improper housekeeping protocols On 4/28/2020 at 10:09 a.m. Four residents were sitting in various places in the common area watching television. All four did not have on any face mask. On 4/28/2020 at 10:23 a.m. Two male residents were sitting in their recliners on the memory lane. They both did not have on any face mask. On 4/28/2020 at 11:48 a.m. a male resident was walking by the nurse station and was not wearing a mask. On 4/29/2020 at 9:08 a.m.-12:00 p.m. continuous observation of the facility revealed seven resident sitting in their wheelchairs on C hall. All seven residents did not not have on any face masks. On 4/29/2020 at 9:18 a.m., four residents were sitting in their wheelchairs on B hall. All residents' did not have on any face masks On 4/29/2020 at 9:32 a.m., one female resident was sitting in her wheelchair on D hall. She was not wearing a face mask. On 4/29/2020 at 10:03 a.m. a female resident was sitting in the common area watching television. She did not have a mask on. During the observations above no staff encouraged residents to wear mask when not in their personal rooms. B. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/29/2020 at 10:26 a.m. She said, No we do not have face masks for the residents'. Certified nurse aide (CNA) #3 was interviewed on 4/29/2020 at 10:35 a.m. She said one resident prefers to wear a mask but all other residents do not wear masks when they are out of their rooms. CNA #1 was interviewed on 4/29/2020 at 10:45 a.m. She said, No the residents do not wear masks. CNA #2 was interviewed on 4/29/2020 at 10:50 a.m. She said staff are the only ones who are required to have face masks. The nursing home administrator (NHA) was interviewed on 4/29/2020 at 11:59 a.m. He said he was not aware the resident required face mask on when they were out of their rooms. He said he would immediately get that corrected. The director of nursing (DON) was interviewed on 4/29/2020 at 12:06 p.m. She said she was not aware that the residents' were required to wear masks outside of their rooms. The DON said they would get a mask for residents' immediately. III. Ensure social distancing was followed during meals. A. Meal observations On 4/29/2020 at 11:45 a.m. the residents were being seated in the main dining room. There were approximately 23 residents' seated at various tables in the dining room. There were five tables with three residents seated at each table. The resident's seated at the five tables were the residents' who required assistance during meals. The distance between the residents seated in the dining room was approximately three feet to four and a half feet. The assisted tables also had one staff member seated with the three residents which resulted in the distancing being less than three feet of distancing between them all. The residents who were seated at the double tables were seated approximately four and a half feet of distancing between them. B. Staff interview The dietary manager was interviewed on 4/29/2020 at 11:48 a.m. She said they have had to adjust things when it comes to resident dining. She said we have 11 residents who required assistance during meals. She said the facility had moved the independent residents in the back activity area, which has allowed independent residents to social among themselves while keeping the social distancing. She said the facility had tried to keep the social distance of six feet which was difficult because the alternative would be for all the residents to eat in their rooms. The nursing home administration (NHA) was interviewed on 4/29/2020 at 12:16 p.m. The NHA was asked to observe the residents during their meal. He said the distance between the residents in the dining room was not exactly six feet. He said the only alternative would be to make all the residents eat in their rooms which would not go well with the residents'.

Based on observation, record review and interviews, the facility failed to take timely and sufficient steps to implement interventions to prevent the development of pressure injuries, affecting one (#29) out of one resident reviewed for pressure injuries out of 29 sample residents. Resident #29 admitted to the facility with a stage 2 pressure ulcer to her left buttock and was identified as being at risk for pressure ulcer development related to multiple comorbidities including post-polio syndrome, adult failure to thrive, spinal stenosis, and [MEDICAL CONDITION]. Record review revealed Resident #29's pressure ulcer to her left buttock healed over three times. The facility failed to have a system in place to identify and review residents at risk for pressure ulcer development and pressure ulcer re-development. As a result, the facility failed to put appropriate interventions in place timely for Resident #29, which contributed to the development of a pressure ulcer. She developed a pressure ulcer to her coccyx which worsened to a stage 4 pressure ulcer. Although the wound to the left buttock healed, Resident #29 developed a wound to her left coccyx, documented on 6/20/19 as a deep tissue pressure injury (DTPI), which never healed and worsened to a stage 4 pressure ulcer. Record review and staff interviews revealed the facility failed to implement appropriate interventions timely. As Resident #29 continued to decline and spent more time in bed, staff did not recognize a need for increased nutritional support when Resident #29's meal intake decreased as well. The pressure reducing overlay mattress which was provided to Resident #29 was ineffective, and likely contributed to the pressure ulcer development. The staff did not implement an alternating air mattress until the wound had worsened on 8/22/19 (over a two month period since the development of the wound), which created an immediate jeopardy situation with the likelihood of causing serious harm to additional residents if not immediately corrected. Findings include: I. Immediate jeopardy [NAME] Findings of immediate jeopardy Resident #29 admitted to the facility with a stage 2 pressure ulcer to her left buttock. She had multiple comorbidities including post-polio syndrome, failure to thrive, [MEDICAL CONDITION], and spinal stenosis which placed her at a higher risk for pressure ulcer development and redevelopment. Nursing staff did not consistently review residents at risk for pressure ulcers for effective interventions, such as residents who had changes in condition including poor intake and spending more time in bed, as evidenced by record review, staff interviews and the resident's skin assessments, which did not always accurately describe the condition of the resident's skin. The wound assessments completed by the wound nurse did not include all the information needed to comprehensively assess the overall status and health of the resident's wounds. Finally, nursing staff did not review as an interdisciplinary team (IDT) systemic conditions affecting wound healing, such as nutritional and fluid support, or refusal of care including refusing to eat and to be repositioned in bed, implement preventative measures timely; and update care plans to reflect the current status of Resident #29's wound, which contributed to wound redevelopment which advanced to a stage 4 pressure ulcer. Observation, record review, and interviews with staff and health professionals revealed the facility failed to have an effective system in place to implement and monitor preventative measures for residents who were assessed to be at risk for pressure ulcers, which created a situation of immediate jeopardy with the likelihood of causing serious harm to additional residents if not immediately corrected. On 10/10/19 at 3:25 p.m., the nursing home administrator (NHA) was notified of the findings above, which created a situation of immediate jeopardy for serious harm. B. Plan to correct the immediate jeopardy situation On 10/10/19 at 7:50 p.m. the NHA submitted a final plan to remove immediate the jeopardy situation. It read as follows: Resident specific: In regard to (Resident #29) the resident is receiving daily wound care. Peri care is provided every 2 hours. Weekly wound measurement and skin assessment done. This resident is on a low air loss alternating pressure mattress. Hospice as well as the facility wound consultants have evaluated this resident and provided their recommendation which the facility has followed. Repositioned every 1-2 hours. This resident is asked prior to each meal what her preference of food and drink are. On (MONTH) 9, 2019 RD (registered dietitian) did a nutritional assessment. The Assistant DON (director of nursing) has spoken with this resident as well as her family regarding her wound treatment and poor nutritional intake. Hospice has also spoken and discussed her wound issues with the resident and daughter. All residents will have a skin assessment, nutritional assessment and Braden (tool used to determine risk for pressure ulcer development) scale assessment completed by 2:00 p.m. on (MONTH) 11, 2019. Any resident that is identified as a high risk for pressure ulcer development will have an individualized intervention established by 4:00 p.m. on (MONTH) 11, 2019. All staff will be in serviced on pressure ulcer prevention interventions and review interventions for all residents receiving wound care will be started 10/10/19 and all staff will be educated and in serviced prior to the start of their shift. C. Removal of immediate jeopardy On 10/10/19 at 8:30 p.m., the nursing home administrator (NHA) was notified the immediate jeopardy had been removed based on the plan to complete skin, Braden, and nutritional assessments on each resident, with appropriate interventions for those identified. However, based on observation, interviews, and record review, deficient practice remained at a G (harm) level. Although the facility had interventions in place during the survey, the following did not occur until after the coccyx wound worsened and then developed to a stage 4 pressure ulcer: -The care plan documented to turn the resident every 2 hours and provide peri-care every 1-2 hours. However, the facility did not implement any new interventions when Resident #29 declined to be turned and was spending more time in bed (see wound notes and progress notes). -The hospice wound specialist did not assess Resident #29's wound until it worsened (see health status note 8/23/19). -The registered dietitian or facility staff did not identify and assess Resident #29's decreased meal intake until she had severe weight loss of 13.4% (see meal intake record for (MONTH) and (MONTH) 2019 and nutrition/dietary note 6/13/19). -Finally, the facility did not place Resident #29 on an alternating low air loss mattress until after the wound had worsened on 8/22/19 (see health status note 8/23/19). II. Facility policy and procedure The Wound Management policy, revised on 2/20/18, was provided by the director of nursing (DON) on 10/9/19 at 5:30 p.m. It read in pertinent part, the facility's wound management program identified staff participation and accountability to include: -A qualified RN (registered nurse) is responsible for weekly wound measurements. -All caregivers are involved in prevention and identification of skin integrity issues. -All caregivers are to observe resident skin integrity during the daily provision of the residents' personal care. -Comprehensive assessment of any wound will include: -Location of Wound; -Length, width, and depth measurements recorded in millimeters; -Direction and Length of tunneling and undermining; -Appearance of the wound base; -Type and percentage of tissue in wound; -Drainage amount and characteristics including color, consistency and odor; -Appearance of wound edges; and -Description of the peri-wound (area around the wound bed) condition or evaluation of the skin adjacent to the wound. -Wound Management principles provide the basis of effective wound care and should be considered in development of the plan of care. -Wound Management principles include, and are not limited to: -Control or elimination of causative factors such as: -Pressure; -Shear; -Friction; -Moisture; and -Circulatory impairment. -Provision of systemic support to reduce existing and potential co-factors such as: -Nutritional and fluid support per assessed need; -Control of systemic conditions affecting wound healing per medical plan of care; -Documentation and Care Planning; -Goals of the wound care plan are collaboratively determined with the resident, family and interdisciplinary team; and -Currently, it is the facilities protocol to have the MDS (minimum data set) coordinator created the initial care plan and subsequent updates. -Risk factors and interventions are documented within the care plan including, but not limited to: -Impaired mobility; -Need for pressure relief such as support surfaces, repositioning, and pressure relieving devices; and -Nutritional status. -Preventative measures and interventions shall include, but not limited to: Use air mattress to relieve pressure, especially to those who are bed bound or spend extended periods of time in bed. III. Professional References The National Pressure Ulcer Advisory Panel (2017) NPUAP Pressure Injury Stages, retrieved from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ revealed the following pertinent information: Pressure injuries can be numerically staged (i.e. Stage 1, 2, 3, or 4), if the type of tissue injured can be visualized or directly palpated (e.g., in case of Stage 4 when exposed bone is visible or directly palpated). The NPUAP also recognizes the very real clinical limitations of being able to visualize the types of tissue exposed by injury. Based on these limitations, the NPUAP staging system provides two additional options: (1) unstageable pressure injuries to address situations where the wound base is obscured by slough and/or eschar and (2) Deep Tissue Pressure Injury (DTPI) where the skin may still be intact, but is purple or maroon indicating deeper tissue damage has occurred. After DTPIs evolve, or unstageable pressure injuries are debrided, these injuries can be numerically staged. Due to the unique anatomy in mucosal membranes, pressure injuries in these tissues should be noted, but can never be staged. -In many situations, the level of tissue injury can be accurately assessed with [REDACTED].g., pain), temperature (e.g., warmer from inflammation, colder as tissues die), firmness (firmer or boggy with tissue destruction and [MEDICAL CONDITION]), color (signs of inflammation consistent with skin tone) and drainage expressed from surrounding tissues as they are palpated. This more thorough assessment of surrounding tissue may alert the clinician to more extensive damage than is readily visible. These additional findings should be described and documented. VI. Failure to prevent redevelopment and worsening of a pressure ulcer to a stage 4. [NAME] Resident #29 1. Resident status Resident #29, age 85, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/6/19 minimum data set (MDS) assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. She exhibited the behavior of poor appetite or overeating nearly every day. She exhibited delusions and hallucinations, but did not exhibit verbal or physical behavioral symptoms or resist care (contrary to record review and interview - see below). She was totally dependent on two staff for bed mobility, transfers, dressing, and toilet use. Her weight was 118 pounds (contrary to the health status note dated 8/23/19 - see below). She had one stage 1 or greater over a bony prominence. She had two stage 2 pressure ulcers and one unstageable pressure ulcer. She was always incontinent of bowel and bladder. 2. Observation and staff interview Cross-reference F880, failed to perform proper hand hygiene prior to, during and after wound care to prevent possible contamination of the resident's wound. On 10/9/19 at 10:08 a.m. licensed practical nurse (LPN) #4 was observed providing wound care to Resident #29's coccyx. She had cleansed the surface of an over bedside table, draped the table, and placed all supplies on the clean field. Upon entering the room, certified nurse aides (CNAs) #1 and #3 assisted the resident to her right side and assisted with pulling the resident's brief down, while LPN #4 performed hand hygiene. LPN #4 washed her hands for eight seconds, turned the sink off with her bare hands and grabbed paper towels and dried her hands. LPN #4 donned gloves and removed the dressing from Resident #29's sacrum (area between the lumbar and coccyx bone). There was a large gaping wound to Resident #29's sacrum with a large amount of serosanguineous (thin watery pink or red fluid that contains red blood cells) drainage. LPN #4 said Resident #29's wound was measured weekly by the assistant director of nursing (ADON). LPN #4 doffed her gloves, and donned clean gloves. She did not perform hand hygiene. Then she cleansed Resident #29's wound with normal saline and a 4 x 4 gauze pad. Resident #29's coccyx wound bed was pink and red. It had a small amount of adherent slough (dead tissue), yellow/black/brown slough located at 12 o'clock of the wound. LPN #4 doffed her gloves and donned new gloves. She did not perform hand hygiene. She used a 4x4 to apply and dab [MEDICATION NAME] (antibiotic powder) to the wound bed, then placed calcium alginate rope (highly absorbent dressing) to the undermining (a pocket beneath the skin at the wound edge) areas. There was undermining almost completely surrounding the wound. LPN #4 said there was a small portion to the top of the wound which did not have undermining, but it was worse towards 5-6 o'clock of the wound. After applying calcium alginate to the wound she placed a [MEDICATION NAME] coated absorbent dressing (calcium alginate impregnated with 100% Leptospermum or Manuka honey) to the wound and then covered with [MEDICATION NAME] border (absorbent foam dressing). After repositioning the resident, LPN #4 changed the dressing to the resident's left lower extremity, doffed her gloves, washed her hands for seven seconds, shut the water off with her bare hands and grabbed paper towels to dry her hands. LPN #4 said she needed to apply additional dressings to Resident #29's arms as they were weeping. 3. Record review a. Care plans The skin care plan, initiated 9/5/18 and last revised on 5/30/19, revealed the resident admitted with a stage 2 wound to her left buttock which healed 11/15/18. On 1/18/19 the left buttock wound reopened and resolved on 1/24/19. Then on 4/23/19 the resident had currently a suspected deep tissue injury to her left buttock. Interventions included: -Administer treatment as ordered; -Assess/record/monitor wound healing weekly; -Avoid positioning the resident on her left buttock if possible; -Educate family and resident as to causes of skin breakdown; -Instruct/assist the resident to shift weight in wheelchair at least every 15 minutes; -The resident needed assistance to turn/reposition at least every 2 hours; -Monitor nutritional status; -The resident required pressure relieving/reducing device on bed (air mattress); and -If the resident refused treatment, confer with the physician IDT and family to determine why and try alternative methods to gain compliance. There were no revisions made to this care plan to include the reopening of left buttock wound stage 2 which was documented in the wound-weekly observation tool on 4/5/19 and when it resolved, the current stage of the resident's pressure ulcer on the coccyx which was a stage 4 observed during survey; and there was no update to the care plan to include an alternating low air loss mattress which was not placed until after the residents wound to her coccyx worsened from a documented shearing (see weekly wound tool 6/20/19) to a stage 4 pressure ulcer. The nutritional care plan, initiated 9/6/18 and revised on 9/4/19 revealed the resident had a potential nutritional problem related to unhealed pressure ulcers. Interventions included to weigh the resident weekly for the first month and then monthly per facility protocol, registered dietitian (RD) to evaluate and make diet change recommendations as needed (PRN), and provide and serve diet as ordered. There were no revisions made to this care plan to include the resident's weight loss. The activities of daily living (ADL) care plan, initiated on 9/5/18 and revised on 9/4/19 revealed the resident required total assistance by two staff to turn and reposition in bed every 2 hours, with dressing, personal hygiene, transfers, and toileting which included to be checked and changed every 2 hours. The care plan also revealed the resident had an alternating low air loss mattress; however, it did not document when the mattress was initiated, and skin/wound notes revealed it was not added until the wound worsened (see below). b. Meal intake record April 2019 Review of the (MONTH) meal intake record 4/1/19-4/30/19 revealed the resident accepted 64 meals, she refused her meal 11 times, ate 0 (zero) - (to) 25% (percent) 45 times, ate 26-50% 12 times, ate 50-75% one time, ate 76-100% six times, and it was documented as not applicable 11 times; which meant the resident nutritional intake was less than 50% more than half of the time. May 2019 Review of the (MONTH) meal intake record 5/1/19-5/31/19 revealed the resident accepted 50 meals, she refused her meal 27 times, ate 0-25% 39 times, ate 26-50% five times, ate 50-75% five times, ate 76-100% one times, and it was documented as not applicable 11 times; which meant the resident nutritional intake was less than 50% more than three (3) fourths (4) of the time. c. Progress notes, skin/wound notes, and wound-weekly observation tool The restorative program note, dated 3/11/19 at 1:14 p.m., documented program and equipment needs for the month of (MONTH) 2019, the resident continued on a nursing level II program with the goal to prevent further loss of range of motion (ROM), exercises included active/passive ROM as the resident was unable to move extremities unassisted, she used a Hoyer lift for transfers, she was a total assist with meals, and she had a hi/low bed with an air mattress (air overlay mattress). The Wound-Weekly Observation Tool, dated 4/5/19 at 4:12 p.m., revealed the resident had a pressure ulcer stage 2 to the left buttock which was measured as a cluster with two open areas. The wound measured 1.6 cm (centimeters) x (by) 0.7 cm, peri-wound was within normal limits (WNL) and wound edges were irregular. The treatment was to apply [MEDICATION NAME] (medicated cream) until resolved. -The resident had refused to be repositioned off her buttocks. When attempted to reposition the resident only tolerated for a few minutes and requested to be back on her back/buttocks due to comfort. The resident's family was notified; however, there was no documentation of the resident or the family being provided education of the risks of the pressure ulcer worsening on the Wound-Weekly Observation Tool or alternate intervention implemented. The skin/wound note dated 4/9/19 at 12:00 p.m., revealed the resident's left buttock was resolved. The progress note, dated 4/23/19 at 10:55 a.m., revealed the resident had a wound to her left buttock which measured 3.2 cm x 2.0 cm; it was a deep purple raised discoloration to left buttock which was the same area which had previous openings. The treatment provided was [MEDICATION NAME] and border foam dressing. The Wound-Weekly Observation Tool dated 4/23/19 at 11:49 a.m. documented the left buttock wound was suspected deep tissue injury (SDTI) with 100% necrotic (brown, black, leather, scab-like) tissue present. The wound was dry with no drainage. The peri-wound had old scar tissue from a previous wound. -The resident had refused to be repositioned off her buttocks, when attempted to reposition the resident only tolerated for a few minutes and requested to be back on her back/buttocks due to comfort. The resident's family was notified; however, there was no documentation of the resident or family being provided education of risks of pressure ulcer worsening on the Wound-Weekly Observation Tool or the progress notes. The physician note dated 4/26/19 revealed the resident continued to decline and at previous visit she was referred to hospice but was declined. The skin/wound note dated 5/3/19 at 3:25 p.m., revealed the purple discoloration to the resident's left buttock was improving measured 0.5 cm x 0.5 cm. The restorative program note, dated 5/9/19 at 4:22 p.m., revealed the purple discoloration to the resident's left buttock measured 2.5 cm x 1.5 cm. The following two skin/wound notes dated 5/14/19 and 5/17/19 did not address the resident's left buttock. The skin/wound note, dated 5/23/19 at 4:44 p.m., revealed the purple discoloration to the resident's left buttock now had a small opening just medial to the purple discoloration and it looked as though the dressing peeled a piece of dry flaky skin from the wound. The Wound-Weekly Observation Tool, dated 5/23/19 at 4:47 p.m., revealed the resident's wound was improving and measured 1.5 cm x 0.6 cm. The wound continued to have 100% necrotic tissue. The plan of care note, dated 5/30/19 at 11:03 a.m., revealed the resident had only been staying up out of bed for a short time and staff reported the resident refused to turn and reposition in bed. She was on an air mattress and palliative care for pain. She was refusing to eat and drink and had a resolving suspected deep tissue injury. -There was no mention of an IDT review of the resident's poor nutritional intake, refusal to be turned, the resident becoming bed bound, education provided to the resident or family of the potential wound worsening, and no notification to the physician or family documented in the care plan note. The health status note, dated 6/1/19 at 5:43 a.m., revealed hospice was in on 5/31/19 to evaluate the resident (she was placed on hospice 6/5/19). The skin/wound note, dated 6/20/19 at 3:38 p.m., revealed the resident's left outer buttock had purple discoloration and was almost resolved. However, there was a new area of purple/red discoloration to the resident's left coccyx area, measuring 2.7 cm x 1.4 cm. The treatment orders were to cleanse the area with normal saline, pat dry, skin prep peri-wound, apply [MEDICATION NAME], and cover with border foam daily. The resident continued on an air mattress, repositioned every 2 hours and continued on hospice services. There was no documentation of any IDT review for further interventions. The skin/wound note, dated 7/1/19 at 10:53 a.m., revealed the resident had a new stage 2 wound to right inner buttock which measured 1.0 x 1.2 cm. She also had several cuts/abrasions to her inner groin from wearing Attends briefs, and the plan was to leave the briefs unfastened. The skin/wound note, dated 7/4/19 at 12:46 p.m., revealed skin to the resident's left coccyx was sloughing (shedding) off. The Wound-Weekly Observation Tool, dated 7/18/19 at 3:51 p.m., revealed the resident's left coccyx wound was pink and moist, surrounding tissue pink, and was documented as a shearing. [MEDICATION NAME] tissue present, with a scant amount of serous drainage, irregular with two open areas measured as a cluster with peeling skin between the two openings. The wound measured 2.0 cm x 4.0 cm. The Wound-Weekly Observation Tool, dated 8/9/19 at 12:53 p.m., revealed the resident's left coccyx wound had two distinct open areas with 10% necrosis, documented as shearing. It measured 2.5 cm x 1.5 cm x 0.1 cm. It was documented as worsening, hospice nurse to report findings to the hospice physician in their next IDT meeting. The skin/wound note, dated 8/18/19 at 15:10 p.m., revealed the resident's coccyx wound had eschar, and an area with tan/gray stringy tissue and what appeared to be an open cavity underneath. The resident was encouraged to lie on her side which she did not like to do because it caused pain in her neck. -Education was provided to the resident as her wound was getting worse, but there was no immediate action taken to provide any other pressure relief interventions such as treatment changes until 8/20/19. The Wound-Weekly Observation Tool, dated 8/20/19 at 11:31 a.m., revealed the resident's left coccyx wound was documented as SDTI and was worsening. The wound was documented as one wound it measured 2.0 cm x 2.5 cm x 1.0 cm. It had a tunnel measuring 1 cm at 7 o'clock. The wound bed had 75% slough. There was a small amount of serosanguineous and tan colored drainage. The peri-wound was pink and scarred. New treatment orders were obtained to cleanse the area with normal saline (NS), pat dry, apply [MEDICATION NAME] (paste or gel) to the wound bed, lightly pack tunneled area with gauze packing, and cover with bordered foam dressing daily. The skin/wound note, dated 8/21/19 at 12:06 p.m., revealed the resident's coccyx wound was worsening and staff discussed with the hospice nurse options to help relieve pressure and assist with wound healing/prevention. The resident had been on air overlay mattress, and could benefit from an alternating low air loss mattress (pressure relieving mattress). The hospice nurse agreed and ordered the mattress. -Although on 8/21/19 the alternating air mattress was discussed and then implemented on 8/22/19, it was not implemented until after the resident had acquired multiple pressure ulcers which healed over. One pressure ulcer (coccyx) developed into a stage 4 ulcer because the facility failed to implement the preventative mattress timely for Resident #29 as she had a known history to lie on her back (see above), had become bed bound (see above and hospice physician interview below), and had poor nutritional intake and multiple comorbidities, which placed her at greater risk for pressure development. The health status note, dated 8/23/19 at 9:10 a.m., revealed the resident and family agreed to have a wound care specialist observe the wound and provide recommendations. New treatment orders were obtained. The coccyx wound measured 2.0 cm x 3.0 cm x 1.0 cm. There was undermining from 6 o'clock to 1 o'clock that measured 1.4 cm. The resident weight was down to 106 pounds. The resident's mattress was changed to an alternating low air loss mattress on 8/22/19. -The coccyx wound was not staged in the 8/23/19 health status note. The resident's wound continued to worsen over the next couple of months as documented in the skin/wound notes (see below). The skin/wound note, dated 8/27/19 at 1:25 p.m., revealed the wound to Resident #29's coccyx had a strong foul odor and the wound bed was black and stringy. The skin/wound note, dated 8/30/19 at 4:34 p.m., revealed the wound to Resident #29's coccyx was worsening, had 100% necrotic tissue present and the wound measurements were increasing in size. New wound treatment orders were obtained. The skin/wound note, dated 9/12/19 at 12:24 p.m., revealed the wound to Resident #29's coccyx continued to worsen, and measurements of the wound continued to increase daily. The wound continued to have a large amount of brown drainage. Staff were changing the wound dressing more than daily. The wound had large pieces of tissue sloughing off, black/brown in color. The wound had odor even though they had started applying [MEDICATION NAME] (antibiotic powder) to the wound. The skin/wound note, dated 9/17/19 at 3:23 p.m., revealed the wound to Resident #29's coccyx continued to worsen as evidenced by the wound measurements increasing. The skin/wound note, dated 9/26/19 at 4:59 p.m., revealed the wound was showing improvements as it had less necrotic tissue 45% and 55% granular tissue; however, it continued to have a large area of undermining to most of the wound except at 6 o'clock. The skin/wound note, dated 10/3/19 at 2:01 p.m., revealed the wound to Resident #29's coccyx had improved; however, at this point the wound was a stage 4 pressure ulcer (see Wound-Weekly Observation Tool below). The Wound-Weekly Observation Tool (most current wound status during survey), dated 10/3/19 at 12:40 p.m., revealed Resident #29's coccyx wound was a stage 4 pressure ulcer. It measured 7.5 cm x 8.5 cm x 1.5 cm, it had undermining from 9-12 o'clock equal to 4.0 cm, 12-3 o'clock equal to 3.5 cm, 3-6 equal to 3.0 cm, 6-9 o'clock equal to 3.6 cm. The wound had granular tissue and slough present, the slough covered 35% of the wound, and it had a large amount of serosanguineous drainage. The peri-wound had induration (associated with inflammation, a hardened mass or formation) right border near right buttock, three purple discolorations with small opening measured 6.0 cm x 3.5 cm. d. Air overlay mattress According to Direct Supply (2018) Air Overlays vs. Mattresses, retrieved from https://www.directsupply.com/blog/air-overlays-vs-mattresses-which-is-best-for-my-resident: Most air overlays only measure three inches thick, and are not nearly large enough to prevent a typical resident bottoming out. When this happens, all benefits of immersion are lost as the body's peak points of pressure will rest on the surface underneath, providing the ideal condition for pressure ulcers. e. Nutrition/dietary note and weight loss The nutrition/dietary note, dated 9/17/18 at 2:24 p.m., revealed the resident needed increased nutrient needs related to the demands of wound healing as evidenced by multiple wounds, plan to trial mighty shakes twice a day and offer current diet as tolerated. The resident's weight was 138 pounds and her body mass index (BMI) was 24.4. The nutrition/dietary note, dated 3/8/19 at 4:12 p.m., revealed the resident was below the recommended amount for her fluids and the plan was to monitor for signs and symptoms of dehydration. The nutrition/dietary note, dated 6/13/19 at 3:24 p.m., revealed the resident had a severe weight loss of 19 pounds in one month (13.4%), the resident was not eating or drinking and her intake was less than 50% of most meals. The resident did not have wounds, continue current diet and honor preferences, the resident was on hospice. f. Braden scale The Braden scale dated 9/4/18 revealed the resident was at risk for pressure ulcer development with a score of 15 (15-18 at risk, 13-14 moderate risk, 10-12 high risk, and nine or below very high risk). The Braden scale dated 11/30/18 revealed the resident was a moderate risk for pressure ulcer development with a score of 13. The resident's Braden scale score continued to decrease as the resident became more at risk for developing pressure ulcers. On 9/4/19 she was high risk for developing pressure ulcers with a score of 10. g. Skin assessments The skin assessment, dated 6/24/19 at 10:37 a.m., documented the resident's left buttock sore was resolved and applying [MEDICATION NAME] as preventative; however, it did not address the new area to the left coccyx identified in progress notes and skin/wound documentation 6/20/19 (see above). The skin assessment, dated 7/1/19 at 10:46 a.m., documented the resident had an open sore, stage 2 to right inner buttock; however, did not address the resident's coccyx wound. The skin assessment, dated 8/19/19 at 10:57 a.m., documented the resident's stage 2 to the coccyx resolving and continued to be treated with [MEDICATION NAME]. h. Additional record review Review of Resident #29's CPO, medication

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to: -Identify systemic issues in its management for residents at risk for pressure ulcers to ensure they were consistently reviewed and appropriate interventions implemented to prevent the redevelopment of pressure ulcers; -Ensure residents were reviewed consistently as an interdisciplinary team (IDT) to prevent unintended weight loss and activities of daily living (ADL) decline; -Perform proper hand hygiene prior to, during, and after wound care treatment; -Ensure clinical signs and symptoms (s/s) of an infection were identified and culture and sensitivity (C&S) were obtained prior to the start of an antibiotic; and -Ensure the dietary department followed safe practices to prevent the potential of cross- contamination of food. Findings include: Cross-referenced citations Cross-reference F686 failure to prevent the redevelopment of pressure ulcers. Cross-reference F692 failure to review residents with unintended weight loss and ADL decline. Cross reference F812 failure to follow safe practices to prevent the contamination of food. Cross-reference F880 failure to perform proper hand hygiene during wound care treatment. Cross-reference F881 failure to identify s/s of an infection and obtain C&S prior to the start of antibiotics. Record review Review of received QAPI program for the last quarter with the nursing home administrator (NHA) revealed the facility had been trying to retain staff and reduce agency use by offering paid training and sign on bonus. However, the QAPI review failed to identify concerns for potential wound development, weight loss and ADL decline, infection control practices with wound care, antibiotic stewardship monitoring, and following safe practices to prevent the contamination of food. QAPI staff interviews The medical director was interviewed on 10/11/19 at 2:35 p.m. He said he was at the facility at least once a month, and he attended [MEDICAL CONDITION] review and QAPI quarterly. He said if the facility had any troubles he would give recommendation. He said if there was a problem for example with physician care he would step in and provide education to the physicians. He said no concerns related to care were brought to his attention last QAPI meeting, but they did discuss trying to get the residents vaccinated with influenza by the end of (MONTH) or beginning of November. He said he was unaware of the immediate jeopardy regarding the development of wounds until just then, but planned to work with the facility as he felt they typically did a good job. The NHA was interviewed on 10/11/19 at 3:00 p.m. He said the facility had quarterly QAPI reviewed and all department heads (nursing, social services, dietary, housekeeping, maintenance and activities), pharmacist and medical director attended. He said they would set goals, and review them to see if anything needed to be changed. He said the QAPI they reviewed staffing and they had trouble obtaining a night nurse. He said they even went on social media and they recently had turnover of three department heads; so for the last six months and last QAPI a couple of months ago, they had been focusing on staffing and recruiting for Certified nurse aides (CNAs), with paying for training, and offering sign on bonus. He said they were trying to reduce and or eliminate agency by (MONTH) 2020. -He said he believed resident care suffered when staffing was a problem, and they had asked staff what they wanted to try to get people to stay. He said he planned to help get the facility together to review and identify issues, and plan to improve communication and sharing amongst the staff. He said he was not too involved with the day to day clinical concerns because he did not have much input, but planned to work with the staff as they did not identify the concerns that were found during survey.

Based on record review and staff interview, the facility failed to ensure that two of 26 sample residents (#8 and #20) received adequate supervision and assistive devices to prevent accidents. Specifically: -Resident #8, who was admitted to the facility due to falls at home, fell five times in the facility. The resident's falls were not thoroughly investigated and resident-specific safety interventions were not developed to prevent repeat falls. On 1/22/13, her third fall in January, the resident was transferred out of facility. The resident was diagnosed with [REDACTED]. -Resident #20 fell several times in the bathroom. Safety interventions were not re-evaluated or monitored for effectiveness. The findings include: 1. Resident #8 (closed record) Resident #8, age 91, was admitted on [DATE]. The resident's January 2013 monthly Computerized Physician order [REDACTED]. The resident had five falls since admission in two months (11/20/12 to 1/22/13). The first fall occurred on 11/29/12. The second fall occurred on 12/16/12 and three falls occurred in January 2013. After the last fall on 1/22/13, the resident was sent to the emergency room and from there to another hospital. The resident was diagnosed with [REDACTED]. a. Known Fall Risk - Facility Response Record review revealed the resident was admitted with a history of having multiple falls at home prior to admission. The Minimum Data Set (MDS) New Admission Assessment summary completed on 11/23/12 documented the following: -The resident was alert and oriented x3, but her short-term memory was poor and she had memory problems with forgetfulness. -Vision in the resident's left eye was poor from glaucoma and macular degeneration. -Resident was having multiple falls at home 2-3 times weekly. The resident tended to go off without using her front wheeled walker and would lose her balance and fall. Fall Risk Assessments were completed at admission on 11/20/12 and after her first fall on 1/10/13. Both assessments showed a score of "20" with a "Total score of 10 or above represents HIGH RISK." A fall care plan was initiated on 11/23/12 with a goal that the resident would be free of injurious-type of falls. The care plan read: Resident was at high risk for falls related to poor vision, weakness, impaired mobility with use of front wheeled walker (FWW), forgetfulness to use FWW occasionally with history of falls, urgency of bladder etc. b. Falls after Admission - Facility Response The resident fell in the facility on 11/29/12. Her second fall occurred on 12/16/12 and three falls occurred in January 2013 (1/10/13, 1/16/13, and 1/22/13). (1) Handwritten entries on the fall care plan following the resident's falls read: -11/29/12-Resident was in her room in recliner and tried to stand up. FWW was in front of her. When she stood, knees gave out. Hollered for help. Had complaints of bilateral hip pain. (Nursing note of 11/29/12 at 8:40 p.m. stated the resident complained of left knee pain.) -12/18/12-Resident found sitting on floor next to recliner, bleeding from left forehead. Said she just "passed out". Sustained a hematoma (bruise) to left forehead. Cleaned, antibiotic ointment, dressed and ice applied to site. Reminded to ask for help with transfers and ambulation. -1/10/13-Resident reported to staff that she had a fall. Had spilled water and was leaning over to clean it up and lost balance and fell to buttocks. No injuries and didn't hit head. -1/16/13-Found on floor in room on buttocks near her oxygen concentrator. Was trying to walk without use of FWW and fell . Didn't hit head and no injuries were noted. Care planned approaches included: -Monitor environment for wet spots or items placed below field of vision on floor and keep pathways clear. -Assure light was adequate. -Monitor for side effects from medications and labs as cause for falls. -Make sure my call light is close and answered promptly. -Monitor me for steadiness and balance when ambulating with FWW. -Resident was to ambulate with walker at all times for safety and reassurance-remind the resident not to ambulate without it. -Encourage the resident to ask for help with transfers and toileting. Added/handwritten were: -Released by therapy to walk to dining room independently on 12/11/12. -Added TABS monitor/pressure alarm for FWW, bed, 1/18/13. (2) Accident/Incident Reports Fall on 1/10/13 at 8:10 a.m. The report documented the following: "Safety and mobility devices in use - FWW. No apparent injury. Describe what you observed or heard: the resident came to the CNA (Certified Nurse Aide) and told her she had fallen in her room. This nurse did a skin check, and checked her range of motion (ability to move the joints in her arms and legs) and her neurological checks were within the normal range. The resident was adamant that she had not hit her head. A second skin check and neurological check was done by the Director of Nursing. The resident was alert and able to make her needs known. No injuries were noted." Fall 1/16/13 at 6:45 p.m. The report documented the following: The resident was listed to have memory impairment and to have impaired vision and hearing. The resident was found sitting on the floor next to her oxygen concentrator, she did not have her walker and said she was not using it. Assessment revealed no apparent injuries and the resident denied hitting head. Neurological assessments were started as the fall was not witnessed. The recommended steps to prevent recurrence were listed as a TABS and pressure alarm-check frequently. The resident had already been moved to a room closer to the nurses' station. Fall on 1/22/13 at 6:45 p.m. The resident was listed to have impaired memory, physically impaired, visually impaired and to have general weakness. Under "Other pertinent health status information," the facility documented that the resident was non-verbal initially, but able to answer simple questions later. Her pupils were small-The resident moved her arms and legs. The resident was non-responsive. She did not follow commands well, giving inappropriate responses. The facility documented the type of injury as right occipital bleeding but no laceration. There was a bruise to her right shoulder and right hip. Staff documented that the CNA found the resident on the floor in her room, sitting against the recliner with her head to the right. There was a moderate amount of blood noted on the floor and the right side of her head. The resident did not have pants or Attends (adult incontinence product) on. The physician was notified and the resident was sent to the nearest emergency room . The resident was given a [DIAGNOSES REDACTED]. A nurses' note revealed that staff from the hospital notified them on 1/23/13 at 11:10 p.m. that the resident had passed away. (3) Post Fall Assessment Report These assessments were reviewed for the five falls that resident #8 had experienced while in the facility. All the post fall assessments were documented to have been completed on the day of the fall. This form consisted of a check sheet with vital signs, notification to the physician and family and an "Action Plan." The Action Plans for the falls were: a. 11/29/12-areas checked were: -Physical Therapy Screen; -Care Plan reviewed/updated; and -Isolated Incident. b. 12/18/12-areas checked were: -Physical Therapy Screen; -Educate/reorient resident to call light; and -Care Plan reviewed/updated. c. 1/10/13-areas checked were: -Physical Therapy Screen; -Care Plan reviewed/updated; and -Isolated Incident. d. 1/16/13-areas checked were: -Physical Therapy Screen; -Care Plan reviewed/updated; and e. 1/22/13-areas checked were: -Safety Devices Implemented-Type-continue alarms; -Other-to hospital. c. Facility Failures The facility failed to thoroughly investigate the resident's falls in order to develop resident specific interventions and in order to ensure the resident received adequate supervision. (1) The Facility Policy for Addressing Falls was reviewed. The Clinical Protocol that addressed specific circumstances of the fall was not implemented. Specifically: Falls were to be categorized as: a) Those that occur while trying to rise from a sitting or lying to an upright position; b) Those that occur while upright and attempting to ambulate; and c) Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. Possible causes were to be defined within 24 hours of the fall. After more than one fall, the physician should review the resident's gait, balance, and current medications, and especially combinations of medications in several of those categories (that) increase the risk of falling. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome of the management of falling and fall risk. -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Examples of such interventions may include: calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing or changing problematic medications. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reason for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. (2) Record review revealed no evidence that potential causes for the resident's falls had been identified. Interventions were not specific and not added to the care plan until after the fourth fall, even though, the facility's Post Fall Assessments listed that the care plan had been reviewed and updated. (3) The intervention after the fourth fall was not effective as the resident removed the alarm and carried it in her pocket, rendering it ineffective. A nurses' note on 1/19/13 at 10:00 p.m. documented the resident continued to ambulate independently without calling for or awaiting assistance and that one time that evening, the resident was observed ambulating in her room by her chair with the TABS alarm clipped to the shoulder of her blouse and the alarm in her pocket. The resident was reminded to await assistance and the resident stated she did not need any help to walk three feet from her walker to her chair. (4) The staff provided reminders to the resident to call for assistance, but the resident did not have sufficient short-term recall to retain the information. A nurses' note, documenting a therapy referral on 1/18/13 at 8:45 a.m. read: The resident was evaluated for Physical and Occupational therapy after the fall on 1/6/13. Because of the resident's cognition, therapy did not feel she would retain anything taught to her. They did recommend use of alarm for her. See above nurses' note on 1/19/13 at 10:00 p.m. There was no evidence that staff, documenting that planned interventions were ineffective as of 1/19/13, took steps to ensure the resident's safety. There was no evidence staff considered increasing supervision of the resident through means that were agreeable to the resident. d. Staff Interview The Director of Nursing (DON) was interviewed on 2/6/13 at 1:50 p.m. The DON was asked if the staff had considered keeping the resident in an area where she could be observed, instead of in her room. The DON stated the resident liked to sit in her own recliner. When asked if they had tried to place the resident's personal recliner in an area where it could be observed by staff, the DON confirmed that had not been tried. The surveyor asked the DON about the follow up monitoring. She stated that it should be documented in Nurses Notes. When asked who reviewed the success of the interventions and determined if the interventions needed to be adjusted, she stated that she did. The DON was asked if there was a fall committee that followed up and then re-evaluated as needed. She stated that the facility did not have a fall committee. On 2/7/13 at 11:38 a.m. the DON reported that the Fall Policy and Procedures (see above) were not appropriate or realistic with the physician's interaction throughout the process. She reported that the Fall Policy did not match what was being done at the facility. 2. Resident #20 Resident #20, an [AGE] year old female, was admitted to the facility on [DATE] with diagnoses, per face sheet, of delirium, legal blindness, depression, and chronic obstructive pulmonary disease (COPD). On 8/16/12 the Admission Minimum Data Set (MDS) documented the resident's Brief Interview for Mental Status score was 12, which indicated minimal cognitive impairment. -She required extensive assistance of one person with dressing and bathing. She required limited assistance of one person with personal hygiene, ambulation in the corridor, locomotion on and off the unit. She required supervision with setup assistance with ambulation in the room, eating, and toileting. She was independent with setup assistance with transfers. She was independent without any assistance with bed mobility. Her mobility device was a walker. -She had functional limitation in range of motion (ROM) with the upper extremities and not any impairment with the lower extremities. -She had one fall without injury during the assessment period. Record Review: On 11/5/12 the Accident/Incident Report form documented that the resident was found on the floor of her room, lying with her back against the bed and a slipper under head as a pillow. She sustained redness to the right hip, right shoulder, left lower jaw line, and a small scrape to the right jawline and a bump to the right lower lip of mouth. The family and physician were notified. No safety recommendations were documented. On 1/14/13 the Accident/Incident Report form documented that the resident was found on the floor of her room while attempting to go to the bathroom. She sustained left hip redness. The family and physician were notified. No safety recommendations were documented. On 1/14/13 the Post Fall Assessment Report form documented that the resident was found on the floor of the bathroom and had sustained a red area on the left hip. The family and physician had been notified. The form was completed on the same date as the fall. On 1/19/13 the Accident/Incident Report documented that the resident was found on the floor near the bed stand trying to go to the bathroom and had sustained a raised area on the proximal occipital area of her head. The family and physician were notified. The neurological checks were completed for 72 hours. The recommendation was to move the resident closer to the nurses' station but the resident refused, so a risk versus benefit statement outlined the risks for the resident. On 1/19/13 the Post Fall Assessment Report form documented that the resident was found on the floor next to the bedside table, trying to go to the bathroom and sustained a bump on the occipital region of the head. The form did not identify causes and/or prevention interventions. On 1/19/13 the Fall Risk Assessment form documented the resident's score was 20, which indicated that she was at high risk of falls. On 1/19/13 (last reviewed) the Fall Care Plan documented that the resident was at moderate risk for falls related to "vision/hearing problems, gait/balance problems." The interventions included the following: "- 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. - Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as; morning exercise group every morning with activities. - Ensure that the resident is wearing appropriate footwear when ambulating with front wheeled walker. - Follow facility fall protocol. - Resident did not want to move to closer room but did agree to tabs monitor/pressure alarm for fall risk/safety. - I have an enabler bar placed on the side of my bed to help with bed mobility and repositioning and to prevent rolling out of bed at night. - The resident needs a safe environment with: (even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light; the bed in low position at night; handrails on walls; personal items within reach)." Staff Interviews: On 2/5/13 at 8:41 a.m. the floor nurse reported that the resident had fallen on 1/19/13 and sustained a raised area on the occipital region of her head. On 2/7/13 at 11:38 a.m. the DON said the facility did not have a system in place to help identify causes so, the staff had not identified that the resident had fallen several times attempting to go to the bathroom. She stated that staff needed to adopt better fall interventions for the residents and set up a system to re-evaluate the effectiveness/in-effectiveness of fall interventions. She indicated this had not been done for this resident.