Every finding on record at Devonshire Care Center

Based on observations, record review and interviews, the facility failed to ensure one (#11) of four residents out of 36 sample residents remained free from accidents.Resident #11 was admitted to the facility on [DATE] with diagnoses including parkinsonism, dementia, muscle weakness, a history of falls, and dysphagia (difficulty swallowing). On 1/28/26, Resident #11 sustained an unwitnessed fall from her electronic reclining chair. The facility recommended unplugging the resident's chair to prevent her from using the remote control due to cognitive impairments. The director of nursing (DON) said on 3/26/26, at some time before the fall on 2/14/26, the resident's electric chair was plugged back in (see interview below). On 2/14/26, the resident used the remote to the electronic reclining chair and sustained an additional unwitnessed fall. The resident was transferred to the hospital where she received staples to the laceration on her head and sustained a small hematoma (brain bleed).Specifically, the facility failed to ensure Resident #11's fall interventions were consistently implemented to prevent a fall with major injury. Findings include:I. Facility policy and procedureThe Fall Management policy, dated 3/1/26, was provided by the nursing home administrator (NHA) on 3/26/26 at 6:10 p.m. The policy revealed in pertinent part, Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Complete a thorough analysis of fall - time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall. Educate and communicate implemented interventions to direct care staff via verbal report.II. Resident #11A. Resident statusResident #11, age [AGE], was admitted to the facility on [DATE]. According to the March 2026 computerized physician orders, diagnoses included a history of falls, diagnosis of Parkinson's disease and dementia. The 2/21/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident used a manual wheelchair. The resident required substantial assistance with personal hygiene, toileting, transferring and walking. The MDS assessment documented Resident #11 had sustained two falls since admission to the facility with injuries. B. Record reviewThe activities of daily living (ADL) care plan, initiated 12/21/25, revealed Resident #11 had an ADL self-care performance deficit related to Parkinson's disease and dementia. Pertinent interventions included providing assistance with mobility in a wheelchair, providing one-person maximum assistance with transfers and encouraging the resident to use the call light for assistance. The fall care plan, dated 1/6/26, documented Resident #11 was at risk for falls related to a previous fall with fracture and dementia. Pertinent interventions included anticipating and meeting the resident's needs (initiated 12/21/25), assessing the resident's needs for adaptive devices (initiated 12/21/25), ensuring the resident's call light was in place (initiated 12/21/25), encouraging the resident to use her call light (initiated 12/21/25), ensuring there was adequate lighting in place (initiated 12/21/25), ensuring the resident was wearing appropriate footwear when ambulating (initiated 12/21/25), placing a fall mat next to the resident's bed when in bed (initiated 2/6/26), providing therapy as needed (initiated 12/21/25), placing the electric recliner with a manual recliner for safety (initiated 2/16/26) and reviewing past falls (initiated 12/21/25). -However, the facility failed to ensure the staff were educated regarding the unplugging of the electric reclining chair to ensure it remained unplugged to prevent an additional fall. The facility investigation, dated 1/28/26 was provided by the NHA on 3/26/26 at approximately 2:00 p.m. The investigation documented Resident #11 sustained an unwitnessed fall in front of her electric reclining chair on 1/28/26. Resident #11 was assessed by the nurse and no injuries were reported, however the physician ordered the facility to send the resident to the hospital for an evaluation. The resident was transported to the hospital at 6:20 p.m. According to the emergency room physician progress notes, Resident #11 was monitored in the emergency department and received one liter of normal saline fluid intravenously for dehydration. The physician reported Resident #11 appeared more awake, alert and discharged back to the facility at 8:10 p.m. The resident's representative was notified and stayed with the resident at the emergency department until discharge. The facility investigation, dated 2/14/26, was provided by the NHA on 3/26/26 at approximately 2:00 p.m. The investigation documented Resident #11 sustained an unwitnessed fall on 2/14/26 at 11:20 a.m. The resident was found lying on the floor on her right side with her head partially under the bedside table next to her with the legs of the table slightly under her right side. The residents' recliner was elevated in the fully upright position. The resident had blood coming from the right side of her head. The investigation documented the licensed practical nurse (LPN) reported it appeared the recliner button was inadvertently pushed by the resident, and the recliner raised her up and she fell out of the chair and hit her head on the bedside table. Resident #11 stated she did not know exactly what happened and how she fell out of her chair. The investigation documented emergency medical services (EMS) were called, and the resident was transported to the emergency room. Resident #11 was assessed by a physician who reported the resident sustained a mechanical fall from her recliner and sustained a laceration to the right side of her head that required staples. A computed tomography (CT - imaging test) scan was completed. The emergency department physician reported the CT scan showed a mixed subdural chronic hematoma (a brain bleed from a previous event) and an acute (portion that was two millimeters without any effacement - a new brain bleed). The resident was monitored in the emergency room with her daughter present for another five hours and 35 minutes. The investigation documented the resident was determined to be neurologically stable and discharged back to the facility.III. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 3/25/26 at 12:33 p.m. CNA #4 said Resident #11 required two-person assistance with transfers from the bed to the reclining chair. CNA #4 said she reported any concerns regarding care of Resident #11 to the nurse.The director of nursing (DON) was interviewed on 3/26/26 at 3:44 p.m. The DON said Resident #11 had sustained two falls since admission. The DON said Resident #11 had an unwitnessed fall on 1/28/26, where she was found in front of her electric reclining chair. The DON said the resident was assessed by a nurse, EMS was notified, and the resident was transported to the emergency department. The DON said the resident returned to the facility after a few hours with no injury. The DON said the facility implemented an intervention of unplugging the resident's electric reclining chair.-However, the facility failed to ensure the electric reclining chair was unplugged and the resident sustained an additional fall from the chair on 2/14/26, related to the resident using the remote (see record review above). The conversation between the facility staff and the resident about unplugging the electric reclining chair was not documented in the resident's electronic medical record (EMR).The DON said Resident #11 sustained another fall on 2/14/26, where she was found on the floor by the chair with her head bleeding. The DON said the resident was transported to the hospital and assessed by the emergency physician. The DON said a CT scan was completed and sutures were placed on the right side of the Resident #11's head. The DON said the CT scan was reviewed by the medical director (MD) who determined the CT scan showed no long-lasting concerns. The DON said the resident's electric recliner was replaced on 2/15/26 with a manual recliner. The DON said the facility conducted a root cause analysis of the fall on 2/14/26. The DON said the facility determined Resident #11 used the electric reclining chair, which was plugged back in since 1/28/26. He said he thought the housekeeping staff might have plugged the chair in again when it should have remained unplugged after Resident #11 sustained the fall on 1/28/26. The DON said the electric reclining chair should have been removed from Resident #11's room after the residents' fall on 1/28/26 and replaced with the manual recliner. The MD was interviewed on 3/26/26 at 4:50 p.m. The MD said he had reviewed Resident #11's hospital records from 2/14/26. He said the CT scan finding was not enough to cause any long lasting problems.

Based on observations, record review and interviews, the facility failed to ensure two (#30 and #11) of 11 residents out of 36 sample residents received the nutritional care and services necessary to maintain their highest practicable level of well-being.Resident #30 was admitted to the facility on [DATE] with a diagnosis of dementia. Upon admission, the resident weighed 141.5 pounds (lbs) and was not identified to have nutritional concerns. On 12/10/25, the resident weighed 134.5 lbs, indicating a 7 lbs weight loss. The facility failed to address the residents' weight loss. On 12/17/25, the resident weighed 131 lbs, which indicated the resident sustained a 7.4% (10.5 lbs) weight loss in 30 days, which was considered severe. Per interviews with the registered dietitian (RD), the facility failed to identify the resident's weight loss until 1/30/26. However, Resident #30 continued to lose weight. On 2/26/26, the resident weighed 121.5 lbs, which indicated a 14.13% (20 lbs) weight loss, which was considered severe. The facility failed to implement a nutritional intervention until 2/6/26, approximately two months after the resident began losing weight. Resident #11 was admitted on [DATE] with diagnoses of Parkinson's disease and dementia. Upon admission, Resident #11 weighed 119 lbs. On 12/30/25 the resident weighed 117 lbs. On 2/4/26, the resident weighed 107 lbs, indicating a 18.9% (22 lbs) weight loss from 12/21/25 to 2/23/26, a period of two months, which was considered severe. The facility failed to address and implement nutritional interventions until 2/20/26, approximately two weeks after the resident sustained weight loss. Specifically, the facility failed to timely implement person-centered nutritional interventions for Resident #30 and Resident #11, who experienced severe weight loss.Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation, on 3/23/26 to 3/26/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/13/26. I. Situation of harm Resident #30 sustained a 7.4% (10.5 lbs) weight loss from 11/16/25 to 12/17/25 and 14.13 % (20 lbs) from 11/16/25 to 2/26/26, which was considered severe. The facility failed to identify the resident's weight loss and implement person-centered nutritional interventions for approximately two months after the resident began losing weight. Resident #11 sustained a 18.9% (22 lbs) weight loss from 12/21/25 to 2/23/26, which was considered severe. The facility failed to identify the resident's weight loss and implement person-centered nutritional interventions for approximately two weeks. II. Facility plan of correction On 3/26/26 at 10:47 a.m. the director of nursing (DON) provided a corrective action plan the facility implemented in response to residents' weight loss. The corrective action plan documented the following: A. Identification of concern The facility identified there were concerns regarding weight loss on 3/1/26. B. Corrective action for affected residents included the following: -Reviewed weights for identified residents, reweights completed by 3/6/26 by certified nurse aide (CNA) leaders. -Notification of the provider and the RD regarding identified residents was completed on 3/6/26 by the assistant director of nursing (ADON). -Notified the corporate team of the concerning weights on 3/6/26 during the weekly weight meeting. -Checked the last calibration of the weight scale on 3/5/26 with the ADON and the maintenance assistant. Discussed community order weights to complete calibration, or a company coming into the community every three months. C. Identification of other residents having the potential to be affected: The facility identified all residents had the potential for deficient practice. D. Address measures or systemic changes to ensure the deficient practice will not recur: -Education was provided to the interdisciplinary team (IDT) on the weight management process completed by a registered nurse (RN) quality mentor on 3/6/26. -Education was provided to CNA staff on the weight management program by the CNA team lead. -Each resident would be weighed upon admission and weekly or per provider orders. The nursing management team would review triggered weight changes daily (Monday through Friday) in the clinical morning meeting. -Any concerning weights would be addressed with the RD. -Weekly IDT would complete a weight meeting and review any residents with weight concerns. Residents reviewed would be written on the weight log, and progress note entered into the EMR. The RD would review abnormal weights and review high-risk residents monthly and all residents quarterly. The team would implement interventions as needed, and the resident's care plan would reflect the resident's weight concerns and interventions. E. Plan to monitor for sustained compliance The DON/designee would audit abnormal weights weekly for 12 weeks, audits would be written on the weekly weight log. Any abnormal weights would be addressed with the RD. -The DON/designee would report findings from the audits to the QAPI (quality assurance and performance improvement) Committee monthly for 90 days. The QAPI committee would identify any trends and take corrective action as needed. The first weight meeting was on 3/6/26 with the IDT and the RD. The RN quality mentor joined and provided additional education. Supplement orders were entered in the residents' electronic medical records (EMR). Education was provided to the team by the RN quality mentor on 3/6/26. -The facility documented the date of compliance was 3/13/26. III. Facility policy and procedure The Weight Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 3/26/26 at 8:25 a.m. It read in pertinent part, Residents are monitored for weight change on a regular basis. Results are reviewed and analyzed by the facility for interventions as appropriate. Residents identified with weight change will be assessed by the interdisciplinary team (IDT), and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability. Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD evaluation, and assisted dining. The director of nursing or designee will analyze results for trends and patterns in residents identified with weight changes and report findings to the QAPI committee for review and recommendations. IV. Resident #30 A. Resident status Resident #30, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included left femur fracture, chronic kidney disease, atrophy of the thyroid, essential hypertension, need for assistance with personal care and unspecified dementia. The 1/9/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The MDS assessment documented Resident #30 had no issues swallowing and could eat independently, without any setup assistance or verbal cues. The resident was 70 inches tall and weighed 134 lbs. The MDS assessment documented Resident #30 had not experienced any significant weight loss. B. Observations and representative interview Resident #30's representative was interviewed on 3/24/26 at 9:11 a.m. The representative said she noticed Resident #30 had been losing weight, but did not know why. The representative said when she visited the facility, she encouraged Resident #30 to eat, and Resident #30 would eat the majority of her meals. The representative was observed asking Resident #30 if she had eaten yet, but Resident #30 did not answer. The representative said some days Resident #30 did not talk much. The representative said Resident #30 appeared sleepy. On 3/24/26, from 12:12 p.m. to 12:36 p.m., Resident #30 was continuously observed. Resident #30 was in the dining room for lunch. An unidentified staff member set a plate of spaghetti in front of Resident #30 and asked her if she wanted her food cut up. Resident #30 did not respond and the staff member walked away. Resident #30 sat in front of the plate for a few minutes without eating. Resident #30's representative then assisted Resident #30 and cut up the spaghetti into smaller bites. Resident #30 ate around 25% of her meal and left the dining room. C. Record review The nutrition care plan, initiated 11/24/25, identified Resident #30 was at risk for nutrition problems as a result of leaving more than 25% of her meals uneaten. The interventions included monitoring weights as ordered, offering food alternatives, providing the diet as ordered, monitoring food intakes and the RD was to evaluate as needed. The weight loss care plan, initiated 2/23/26, revealed Resident #30 had unplanned weight loss as a result of having poor oral intake. Pertinent interventions included alerting the RD if intake was poor for greater than 48 hours, providing supplements, monitoring oral intake and monitoring weekly weights. Resident #30's weights were documented in the EMR as follows: -On 11/16/25, the resident weighed 141.5 lbs; -On 12/10/25, the resident weighed 134.5 lbs; -On 12/17/25, the resident weighed 131 lbs; -On 1/9/26, the resident weighed 134 lbs; -On 2/11/26, the resident weighed 127 lbs; -On 2/26/26, the resident weighed 121.5 lbs; -On 3/8/26, the resident weighed 123 lbs; and, -On 3/11/26, the resident weighed 118.5 lbs. -The resident sustained a 7.4% (10.5 lbs) weight loss, which was considered severe, from 11/16/25 to 12/17/25, in one month. -The resident sustained a 14.13% (20 lbs) weight loss, which was considered severe, from 11/16/25 to 2/26/26, in three months. -The facility failed to obtain an admission weight for four days after the resident was admitted to the facility. Resident #30's March 2026 CPO revealed the following physician's orders: Regular diet with regular consistency and thin liquids, ordered 11/12/25 and discontinued on 2/6/26. Regular diet with mechanical soft texture, thin liquids and fortified meals, ordered 2/6/26. Mighty shakes two times a day, ordered 2/20/26. -The facility failed to implement a nutritional intervention until 2/6/26, which was approximately two months after the resident first sustained severe weight loss. The 11/12/25 mini nutritional assessment documented Resident #30 had a normal nutritional status. On 11/13/25, Resident #30's cognition was moderately impaired with a BIMS score of nine out of 15. The 1/5/26 mini-nutritional assessment documented Resident #30 was at malnourished nutritional status based on a measurement taken of her calf. On 1/5/26, Resident #30's cognition was severely impaired with a BIMs score of four out of 15. -However, despite the facility identifying the resident was malnourished, the facility failed to implement any person-centered nutritional interventions. D. Staff interviews The RD was interviewed on 3/26/26 at 9:04 a.m. The RD said Resident #30 had multiple risk factors for nutritional concerns, such as diagnoses of dementia, a recent bone fracture and a low body mass index. The RD said Resident #30's decline in weight was a result of poor oral intake due to dementia and difficulty staying engaged during meals. The RD said the direct care staff assisted in keeping the resident engaged during meals. The RD said she became involved in Resident #30's care on 1/30/26, when the significant weight loss had been identified. -However, Resident #30 sustained a 7.4% (10.4 lbs) weight loss from 11/16/25 to 12/17/25, which was considered significant. The RD said no interventions were in place prior to the significant weight loss that she identified on 1/30/26, although the weights had been trending down since admission. The RD said she added the resident to the fortified food program on 2/6/26 and added supplements at the end of February 2026. The DON was interviewed on 3/26/26 at 10:47 a.m. The DON said he did not think the facility had implemented enough interventions to prevent weight loss for all residents in the facility, which was why he enacted a PIP (performance improvement plan) on 3/1/26. The DON said since enacting the action plan, many residents had stopped losing weight, and some had gained weight. The medical director (MD) was interviewed on 3/26/26 at 12:20 p.m. The MD said Resident #30's weight change within her first month of admission was very significant and should have warranted intervention. The MD said the facility had not been doing a good job of managing residents' weights. The MD said the facility recently identified systemic weight loss in the facility and was taking action to correct the issue with a QAPI and IDT approach. The MD said the facility had made progress in the management of residents' weights, but was still developing successful systems. The activities director (AD) was interviewed on 3/26/26 at 4:14 p.m. The AD said she would sometimes help out as a CNA in the facility and was familiar with Resident #30. The AD said Resident #30's eating habits varied, based on her cognition level at the time. The AD said some days, Resident #30 was more distracted at mealtimes and needed frequent redirection from staff to eat. CNA #5 was interviewed on 3/26/26 at 4:15 p.m. CNA #5 said in recent weeks, Resident #30 needed increased cuing and encouragement to eat her food because she became distracted. CNA #5 said she often checked Resident #30's meal tickets and had observed only 25% of the meal had been eaten. V. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included Parkinson's disease, dementia, muscle weakness and dysphagia (difficulty swallowing). The 2/26/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. Resident #11 required substantial assistance with personal hygiene, toileting, bed mobility, wheelchair assistance, transfers and eating. The MDS assessment revealed Resident #11 was 65 inches tall and weighed 98 lbs., was on a mechanically altered diet and had difficulty or pain with swallowing. B. Record review The activities of daily living (ADL) care plan, initiated 12/21/25, documented Resident #11 had deficits related to Parkinsonism and dementia and Resident #11 required partial to moderate assistance with eating. The nutrition care plan, revised 3/10/26, documented Resident #11 had a swallowing problem related to coughing or choking during meals or swallowing medication. Pertinent interventions included providing assistance with meals using the hand over hand technique as needed. The poor oral intake care plan, initiated 1/6/26, revealed Resident #11 was at risk for poor fluid intake related to Parkinson's disease and dementia. Pertinent interventions included encouraging fluid as tolerated. The unplanned/unexpected weight loss care plan, initiated 3/14/26, revealed Resident #11 had recent weight loss related to an acute illness and poor food intake. Pertinent interventions included alerting the RD if the resident's intake was low for over 48 hours, providing supplements as ordered, alerting the RD if the resident was not consuming supplements as ordered, notifying the RD and the physician for weight loss, monitoring meal intake and monitoring weekly weights. The nutrition care plan, initiated 3/14/26, documented Resident #11 was malnourished related to her declining health status and leaving greater than 25% of her meals. Pertinent interventions included monitoring for symptoms of swallowing difficulties and providing Mighty Shake twice and a day and Boost Breeze twice a day. Resident #11's weights were documented in the EMR as follows: -On 12/21/25, the resident weighed 119 lbs; -On 12/24/25, the resident weighed 117.2 lbs; -On 12/30/25, the resident weighed 117 lbs; -On 1/5/26, the resident weighed 116 lbs; -On 1/15/26 the resident weighed 114 lbs; -On 2/4/26 the resident weighed 107.5 lbs; -On 2/9/26, the resident weighed 106.5 lbs; -On 2/16/26, the resident weighed 101.5 lbs; -On 2/23/26, the resident weighed 97 lbs; -On 2/26/26, the resident weighed 97.5 lbs; -On 3/2/26, the resident weighed 98.5 lbs; -On 3/5/26 the resident weighed 97.8 lbs; -On 3/9/26 the resident weighed 97.5 lbs; and, -On 3/16/26 the resident weighed 96.5 lbs. -The resident had a 18.9% (22 lbs) weight loss from 12/21/25 to 2/23/26, a period of two months, which was considered severe. A review of Resident #11's March 2026 CPO revealed the following physician's orders: -Magic cup (frozen nutritional supplement), offer two times per day with lunch and dinner, ordered on 2/20/26. -Regular diet, pureed texture, regular/thin, fortified meals, ordered on 2/18/26. -Boost Breeze supplement (oral nutritional supplement), offer two times each day, ordered on 3/7/26. A nutrition progress note, dated 2/23/26, documented Resident #11 had lost 5% in 30 days. The note documented the resident's body mass index was 16.7 (indicating the resident was underweight). The note documented Resident #11's meal intake was between 0% to 25%, Resident #11 received Mighty Shake supplement three times each day, Magic cup supplement two times each day and fortified meals had recently been added. The note documented Resident #11 was being followed by the IDT. -However, review of Resident #11's EMR revealed the facility did not implement a nutritional intervention until 2/18/26, which was approximately two weeks after the resident sustained significant weight loss. A nursing progress note, dated 2/24/26, documented the resident weighed 97 lbs. The note documented Resident #11's diet texture changed and the resident was eating at a table in the dining room with meal assistance provided. The note documented the physician and the pharmacist had been notified of Resident #11's weight loss. The nursing progress note, dated 2/27/26, documented Resident #11 weighed 97.5 lbs pounds The IDT progress note, dated 3/6/26 at 3:33 p.m., documented a nutrition review meeting was held to review Resident #11's weights, skin, nutrition plan and interventions. The note documented interventions including fortified meals and Magic Cup supplements twice daily. The note documented a new intervention to add an eight ounces Boost Breeze supplement two times each day.D. Staff interviews CNA #4 was interviewed on 3/25/26 at 12:33 p.m. CNA #4 said Resident #11 needed help with eating her pureed meal and the resident liked the magic cup supplement.CNA #4 said Resident #11 was offered Boost and Mighty Shake supplements between meals, but sometimes did not drink the supplements when offered. CNA #4 said she reported Resident #11's meal intake to the nurse. The RD was interviewed on 3/26/25 at 9:20 a.m. The RD said the facility had implemented a plan to address weight loss in the last two months. She said there had been further improvement in weight loss after initiating meetings to review weekly weights. The RD said she began participating in virtual phone meetings weekly to review weight and skin concerns with the dietary manager and a nurse. The RD said the facility began weighing all residents weekly and she began reviewing residents for any changes, including weight loss of 5% or more and she documented the information in the residents' care plans. The RD said Resident #11 was at high risk as her weight had been under 100 lbs since February 2026. The DON was interviewed on 3/26/26 at 10:59 a.m. the DON said Resident #11's weight loss was related to her diagnosis of Parkinson's disease, dementia, weakness and poor oral intake. The DON said there were recent improvements with the facility's nutritional practices related to assessment for residents' weight loss, including the initiation of facility audits, weekly weight monitoring for all residents and specific multidisciplinary review of residents with any documented weight loss. The DON said adjustments had been made to individualized care plans, including for Resident #11. The DON said interventions for Resident #11 included fortified foods, Mighty Shake supplements twice a day and chocolate milk at meals.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen.Specifically, the facility failed to ensure: -Food was held at the correct temperature;-Hand hygiene was conducted during meal service and dishwashing; -The kitchen was clean and sanitary; and, -Food was labeled and stored correctly in the walk-in refrigerator, freezer, reach-in refrigerator, and dry storage area. Findings include:I. Failure to hold food at the correct temperatureA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/31/26. It revealed in pertinent part, Time/Temperature control for safety food, hot and cold holding at 135 degrees F (Fahrenheit) or higher and 41 degrees F and lower. (Chapter 3)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the nursing home administrator (NHA) on 3/26/26 at 8:25 a.m. It read in pertinent part, Cold foods are kept between 34 to 41 degrees F prior to serving and frozen foods are kept at 0 degrees F or below.C. ObservationsDuring a continuous observation on 3/24/26, beginning at 5:00 p.m. and ending at 6:01 p.m., the following was observed during the meal service in the main kitchen:At 5:00 p.m. the kitchen staff began serving room trays. A tray of small souffle cups with sour cream in them was sitting on a metal cart next to the service line. The tray of souffle cups were not sitting on ice. At 5:22 p.m. the tray of sour cream remained sitting on the cart and the souffle cups have been put on trays and sent out to the residents. At 5:54 p.m. the assistant dietary manager prepared the test tray for the five surveyors and used one of the souffle cups of sour cream. At 6:01 p.m. the five surveyors evaluated the test tray and the temperature of the sour cream was 74 degrees F. D. Staff interviews The assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the souffle cups of sour cream should have been on ice. She said any dairy products should be on ice during meal service. II. Failure to perform hand hygiene appropriately during meal service and dishwashingA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/31/26. It revealed in pertinent part, The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the NHA on 3/26/26 at 8:25 a.m. It read in pertinent part, Food is handled properly with frequent handwashing and proper sanitation guidelines.Handwashing signs are posted above handwashing sinks and employees have handwashing techniques reviewed regularly and at orientation.C. ObservationsOn 3/23/26 at 11:50 a.m. an unidentified dietary staff member entered the kitchen, did not wash or sanitize her hands, prepared a plate, and then wiped her nose with the back of her hand. She then immediately came out of the kitchen and served the plate to a resident.On 3/23/26 at 11:59 a.m. the same unidentified dietary staff member entered and exited the kitchen using the door handle to enter and pushing the door to exit the kitchen. The dietary staff member did not sanitize or wash their hands before continuing to serve the residents' meals.During a continuous observation on 3/24/26, beginning at 5:00 p.m. and ending at 6:01 p.m., the following was observed during the meal service in the main kitchen:At 5:00 p.m. cook (CK) #3 began preparing room trays.At 5:10 p.m. CK #3 s moved the room tray cart around the kitchen while wearing gloves. Without changing gloves or performing hang hygiene, CK #3 continued to prepare the room trays. At 5:15 p.m. CK #3 walked away from the service line to talk to another dietary staff member. During this time, CK #3 touched multiple different surfaces (preparation tables, meal trays and the reach-in refrigerator) without changing her gloves. At approximately 5:22 p.m. the kitchen staff began to serve the residents who were in the dining room. CK #3 was still wearing the same gloves that she was wearing when she touched multiple items in the kitchen. At 5:31 p.m. an unidentified dietary staff member came into the kitchen and grabbed silverware and a napkin, she did not wash her hands. At 5:41 p.m. CK #3 touched three premade cheeseburgers with her gloved hand (the same pair of gloves as before).At 5:44 p.m. DA #1, who was washing dishes at the three-compartment sink went from dirty dishes to clean dishes without washing his hands. D. Staff interviewsDA #1 was interviewed on 3/25/26 at 2:40 p.m. He said he was unsure if he needed to wash his hands when going from dirty dishes to clean dishes. He said he was recently hired. The assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the staff should be changing their gloves any time they change tasks or touch other surfaces. She said staff should wash their hands when they change their gloves. She said the staff should wash their hands when they go from dirty dishes to clean dishes. She said that CK #3 should not have touched the cheeseburgers. III. Failure to ensure the kitchen was clean and sanitaryA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/31/26. It revealed in pertinent part, Physical facilities shall be cleaned as often as necessary to keep them clean. Plumbing fixtures such as handwashing sinks, toilets, and urinals shall be cleaned as often as necessary to keep them clean. Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Refuse, recyclables, and returnables shall be removed from the premises at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (Chapter 4, 5 and 6)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the NHA on 3/26/26 at 8:25 a.m. It read in pertinent part, Kitchen and serving areas are clean at all times. A cleaning schedule is followed and initialed when tasks are done. Rags are stored in clean areas and when in use, in proper sanitation and soap solutions. Foods are stored under cleanable conditions.C. ObservationsOn 3/23/26 at 8:44 a.m. an environmental tour of the kitchen and dishroom was conducted, the following was observed:-Two wet towels were on the preparation tables, one of the towels was next to a staff member who was cutting cake. -The floor leading from the dish room to the door that went outside had a large strip where the tiles were pulled up. The threshold of the door that went outside of the building was crumbling leaving enough space underneath the door to see directly outside. -The cove base was missing in the dishroom.-The large trash can in the food preparation area did not have a lid on it. -The large mixer was not covered, not in use and had sleeves of styrofoam bowls sitting on top of the mixer. On 3/24/26 at 5:00 p.m. the following was observed:-DA #1 was wiping the counter and wiping the debris off the counter onto the plate dolly, which was full of clean plates being used for meal service. The plate dolly was not covered and was open to air. -The plate dolly had large amounts of food debris on it, on all sides. -The large trash can was overflowing with trash and did not have a lid on it-The floor underneath the three-compartment sink was warped and the tile was coming up.There were small holes in the grout where the tiles were coming up around the drain on the floor. Where the floor meets the wall, the wall was crumbling and peeling. -The large mixer was not covered and had the sleeves of styrofoam bowls on top of it. D. Staff interviewsCK #3 was interviewed on 3/25/26 at 2:38 p.m. She said that the plate dolly got cleaned during the evening shift. She said that the day shift used it and the evening shift cleans it. The assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the plate dolly was cleaned two times a day and whenever it needed to be. She said sanitizer towels should be kept in the sanitizer buckets when they were not being used. She said that the large mixer never had a cover on it due to daily use. She said that they did not have a current cleaning checklist but they were working on making one. IV. Failure to ensure foods were labeled and stored appropriately in the walk-in freezer, walk-in refrigerator, reach-in refrigerator and dry storage area. A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), was retrieved on 3/31/26. It revealed in pertinent part, Food packaged in a food establishment shall be labeled, label information shall include: the common name of the food, or absent a common name, an adequately descriptive identity statement. Food shall be protected from contamination by storing the food in a clean, dry location, where it is not exposed to splash, dust, or other contamination and at least six inches above the floor. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. (Chapter 3)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the NHA on 3/26/26 at 8:25 a.m. It read in pertinent part, Foods not in original containers are labeled and dated with opening and suggested to have a use by date. Foods are stored under cleanable conditions.C. ObservationsOn 3/23/26 at 8:44 a.m. the following was observed in the main kitchen:In the dry storage area a box of hot dog buns was sitting directly on the floor. In the reach-in refrigerator:-A bowl of chopped hard-boiled eggs was not dated.-A small container of pre-poured sauces in souffle cups were not labeled or dated. In the walk-in refrigerator:-A shallow pan of pre-poured sauces in souffle cups were not labeled or dated. -Two personal lunch boxes that were not labeledIn the walk-in freezer:-Approximately four boxes of frozen vegetables were sitting directly on the floorIn the second dry storage area there were two cans of stewed tomatoes with fist-sized dents and one can of jellied cranberry sauce with a dent on the side right by the top of the can, they were sitting with all of the other canned goods. On 3/25/26 at approximately 2:30 p.m. the following was observed in the main kitchen:In the reach-in refrigerator, a small container of pre-poured souffle cups were labeled as tarter sauce however, when the container was pulled down there was a couple of souffle cups that did not have dates on them and were sour cream. D. Staff interviewsThe assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the souffle cups were normally dated on the lids and the containers the staff put them in normally would have the description of what was in the souffle cups and dated. She said boxes of food should never be stored on the floor. She said staff normally would inspect the canned goods and would put the dented cans in the dietary manager's office so they could be reimbursed for them.

Based on observations, record review and interviews, the facility failed to ensure residents' personal funds accounts were managed adequately for the facility and accessible to the residents for three (#7, #27 and #44) of three residents out of 36 sample residents. Specifically, the facility failed to ensure residents were educated on how to access their money on the weekends. Findings include: I. Resident interviewsResident #7 was interviewed on 3/23/26 at 2:40 p.m. He said the person who handled the money was not always at the facility. He said he was not aware of any times on the weekends when he could pull out his money. Resident #7 was interviewed a second time on 3/25/26 at 1:04 p.m. He said he normally went to the business office manager or the front desk to pull out his money. He said he could not get money out on the weekends.Resident #27 was interviewed on 3/25/26 at 1:07 p.m. She said she was not able to pull money out of her account on the weekends. Resident #44 was interviewed on 3/25/26 at 1:11 p.m. He said he had to pull money out before the weekend if he had any plans to go anywhere on the weekend. II. ObservationsDuring the survey process, a sign listing banking hours was not observed in the facility. III. Staff interviewsThe wound care nurse was interviewed on 3/26/26 at 11:12 a.m. She said she did work on weekends. She said when she did work on the weekends, the issue of pulling money out had not come up. She said during the week the residents would go to the front office. She said she was unsure of what the process was for the weekends. Licensed practical nurse (LPN) #2 was interviewed on 3/26/26 at 11:15 a.m. She said she did work on the weekends and during the week the residents usually went to the business office manager to pull out their money. She said she was unsure of the process of how residents accessed their money on the weekends. The business office manager was interviewed on 3/26/26 at 1:05 p.m. He said he was unsure if the residents had ever been educated on how to access their money on the weekends. He said he thought the residents were told when they first admitted to the facility. He said the facility did not have their banking hours posted anywhere. He said the residents were able to access their money on the weekend by going to the receptionist at the front desk. He said the facility had a receptionist seven days a week. He said the receptionist had access to the petty cash box. He said he was unsure if all of the staff knew the weekend process of how residents access their money. He said residents should be aware of how to access their funds on the weekends. The nursing home administrator (NHA) was interviewed on 3/26/26 at 1:22 p.m. She said the residents should be able to access their funds on the weekends. She said the facility would post their banking hours and would educate residents during resident council meetings. She said that all of the staff should know the process of how residents access their funds on the weekends because a resident can ask any staff member.

Based on record review and interviews, the facility failed to ensure three (#45, #58 and #27) of five residents were kept free from abuse out of 36 sample residents. Specifically, the facility failed to:-Protect Resident #45 and Resident #58 from physical by Resident #80; and,-Protect Resident #27 from physical abuse by Resident #21. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/23/26 at 11:21 a.m. It read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. Each facility assesses each potential resident prior to admission. This assessment includes a behavior history. Persons with a significant history or high risk of violent behavior are carefully screened and assessed for appropriateness of admission. If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization, can then be implemented. II. Incident of physical abuse by Resident #80 towards Resident #45 on 11/2/25 A. Facility investigation The facility's investigation, dated 11/2/25, was provided by the NHA on 3/25/26 at 10:00 a.m. The investigation documented the following: On 11/2/25 certified nurse aide (CNA) #7 witnessed Resident #80 strike Resident #45 on the back with her hand. CNA #7 separated the residents and then notified the NHA. The nurse assessed both residents for injury and none were noted. Resident #80 was placed on a one-to-one observation initially and then 15-minute checks. Resident #45 and Resident #80's care plans were updated and their physicians were notified of the incident. Resident #45 was checked frequently and the residents were immediately separated from each other. The investigation documented Resident #45 was interviewed by the social services director (SSD). It was documented due to the resident's cognitive impairment she stated she had never been hit before and she had never hit anyone. Resident #45 did not recall any one yelling or talking to her that day or prior. Resident #45 self-propelled herself throughout the halls of the facility in her wheelchair. The investigation documented Resident #80 was interviewed by the SSD. It documented the resident had no recollection of the incident and stated she did not hit anyone. Resident #80 struggled to focus on the conversation and talked about birds in the hall. It documented the SSD attempted a second interview with Resident #80 to obtain further information. The resident did not remember the incident. The investigation documented CNA #7 was interviewed by the SSD. CNA #7 said she was walking onto the 100 hallway near the tubroom. CNA #7 said she observed Resident #80 sitting in her wheelchair behind Resident #45, who was also sitting in her wheelchair. CNA #7 said Resident #80 yelled that she needed to go to the doctor. The investigation documented Resident #45 ignored Resident #80 and then Resident #80 leaned forward and hit Resident #45 with a closed fist in the back. The investigation documented CNA #7 removed Resident #80 from the situation and took the resident to the dining room. It documented Resident #80 continued to yell out that she needed to go to the doctor. CNA #7 continued to redirect the resident by reminding her it was Sunday multiple times. CNA #7 said Resident #45 did not say anything about the incident during or after Resident #80 hitting her. The investigation revealed Resident #80 had episodes of yelling out and had entered other residents' rooms while yelling. The investigation documented the facility substantiated the abuse. B. Resident #45 (victim) 1. Resident status Resident #45, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included dementia with agitation, encephalopathy (disease, damage, or malfunction to the brain), depression, hyperthyroidism and hypertension (high blood pressure) . The 2/22/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. She required maximal assistance with all activities of daily living (ADL). 2. Resident #45's representative interview Resident #45's representative was interviewed on 3/25/26 at 10:36 a.m The representative said he did recall the incident between Resident #45 and Resident #80. The representative said the residents were never roommates. He said they had rooms near each other. The representative said Resident #80 moved rooms to be farther away from Resident #45 as part of the intervention. The representative said Resident #45 did not recall the event due to her cognitive impairment and did not seem upset because she did not remember the incident. 3. Record review The elopement care plan, revised 6/17/25, revealed Resident #45 wandered related to impaired safety awareness. The care plan documented Resident #45 wandered but did not exit-seek. Pertinent interventions included distracting the resident by offering her pleasant diversions, structured activities, food, conversation, television or a book. The care plan documented Resident #45 preferred conversations with staff and other residents. The dementia care plan, revised 6/17/25, revealed Resident #45 had impaired cognitive function as evidenced by her BIMS score related to dementia. Pertinent interventions included cueing, reorienting the resident, task segmentation, offering the resident simple choices and providing supervision as needed. The social services progress note, dated 11/3/25 at 11:23 a.m., documented the SSD interviewed Resident #45. It documented Resident #45 had no recollection of the incident with Resident #80. It documented the resident was in a pleasant mood, smiling and wanting to hold hands with the SSD. It documented Resident #45 was at her baseline with confusion. The risk management review note, dated 11/4/25 at 7:57 a.m., documented the root cause for the incident between Resident #45 and Resident #80 was due to dementia and Resident #45 was blocking the hallway with her wheelchair. It documented treatment was required. It documented interventions included assessment and observation of Resident #45 for possible injury and/or psychosocial upset. It documented referrals were made to social services and the physician recommended monitoring Resident #45. A nursing progress note on 11/4/25 at 8:03 a.m. documented Resident #45 was involved in a resident-to-resident contact incident on 11/2/25. It documented there was no delayed injury or psychosocial effects noted. A social services progress note, dated 11/4/25 at 2:07 p.m., documented the SSD interviewed Resident #45. It documented the resident reported feeling safe in the community, and she was having a good day. It documented the resident remained at her baseline with confusion. C. Resident #80 (assailant) A. Resident status Resident #80, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included dementia with other behavioral disturbance, type two diabetes and excoriation disorder. The 9/9/25 MDS assessment revealed Resident #80 had severe cognitive impairments with a BIMS score of zero out of 15. The assessment revealed Resident #80 needed partial to moderate assistance with most of her ADLs. The assessment further revealed that Resident #80 had both physical and verbal symptoms directed towards others. B. Record review The trauma-informed care plan, initiated 9/6/25, revealed Resident #80 had significant family trauma. The care plan documented the trauma she experienced may have contributed to her problematic behaviors, such as trust in others. Pertinent interventions included assessing the resident's need for additional therapeutic services, reinforcing participation in structured activities, and allowing time for Resident #80 to share feelings. The behavior care plan, initiated 9/5/25, revealed Resident #80 had behaviors of yelling at staff and other residents, and physical aggression, and attention-seeking behaviors possibly due to pain, confusion and other residents being in her way. Pertinent interventions included intervening as necessary to protect the rights and safety of others, diverting attention with tasks or activities, monitoring behaviors to identify underlying causes and one-on-one as needed while awake and line-of-sight while in bed. A nursing progress note dated 9/4/25 at 7:14 p.m. documented Resident #80 was in the lobby with other residents. The note documented she was yelling and screaming and using profanity at the other residents. The note documented she was not easily redirected. A nursing note, dated 11/4/25 at 8:07 a.m., documented that Resident #80 was the aggressor of a resident-to-resident contact on 11/2/25. The note documented that Resident #80 had been on one-to-one supervision while she was in her wheelchair. The note documented Resident #80 had not had any other aggressive behavior. D. Staff interviews CNA #2 was interviewed on 3/26/26 at 9:07 a.m. CNA #2 said Resident #45 frequently showed signs of wandering and went into other residents' rooms. CNA #2 said she redirected the resident when she was trying to go into other rooms. CNA #2 said Resident #45 also yelled out and made disruptive sounds. CNA #3 was interviewed on 3/26/26 at 9:10 a.m. CNA #3 said if she witnessed a resident-to-resident altercation, she would separate the residents to allow them time to calm down from the situation. CNA #3 said once she separated the residents and ensured their safety, she would notify the nurse on duty, the director of nursing (DON) and the NHA immediately. CNA #3 said she did not witness the incident between Resident #45 and Resident #80 on 11/2/25, but was working that day and heard about it. CNA #3 said Resident #80 had previously exhibited behaviors of yelling, hitting, and making accusations. CNA #3 said the resident had accused her of taking her food tray, but the tray was right in front of her on the table. CNA #3 said Resident #80 exhibited ticking behaviors, such as touching or fidgeting with other residents' wheelchairs and reaching out to tap a resident on their arm with her finger as a way to get their attention. The DON, the NHA and the SSD were interviewed together on 3/26/26 at 3:00 p.m. The NHA said she was notified for any reports of abuse. The NHA said the facility initiated an investigation immediately after notification of an allegation of abuse. The DON said staff were educated on abuse at the time of hire and annually. The NHA said all staff had received training on abuse in April 2025. The NHA said staff were to make sure the residents were safe if any resident exhibited behaviors of aggression. The NHA said sometimes it was necessary to walk away from the resident if de-escalation was not working. The NHA said sometimes the resident needed space to cool down. The NHA said if there was no injury found, the investigation should be completed within five days. The NHA said it was important to ensure the residents were safe after an incident. The SSD said Resident #45 had been pushed from behind by Resident #80, however later Resident #45 did not recall what happened. The SSD said Resident #45 was blocking the hallway for Resident #80 to pass and this was the reason Resident #80 pushed her. (However, the investigation indicated Resident #80 struck Resident #45 with a closed fist - see investigation above). The SSD said Resident #80 was in her wheelchair behind Residen #45 and pushed Residen #45 on the back in an attempt to get her out of the way. The SSD said Resident #80 was placed on a one-to-one supervision for 72 hours and then placed on 15-minute checks after that. The SSD said Resident #80 was very vocal in general and Resident #45 was not aware of her surroundings unless you were face-to-face with her. The SSD said Resident #80 may have been frustrated that day (11/2/25). The SSD said CNA #7 witnessed the event. The SSD said Resident #80 constantly repeated she needed to go to the doctor. The SSD said this behavior was common for Resident #80 because she had dementia. The SSD said Resident #80 could be fine one minute and then the next she was not. The SSD said Resident #80 struggled to communicate what was bothering her at times. The SSD said Resident #80 went to activities but would wheel herself back out of the activity. The SSD said Resident #45 did not say anything after she was struck by Resident #80. The SSD said CNA #7 was walking down a hallway and as she turned the corner to the 100 hallway she witnessed the incident. The SSD said the facility conducted huddles with staff when they made any changes to a resident's care plan regarding behavior interventions. The SSD said this was to ensure staff were aware of the changes. The SSD said after the incident between Resident #45 and Resident #80, there was a staff huddle and new interventions were discussed. The SSD said new interventions for Resident #80 included one-to-one supervision for 72 hours to monitor, and then 15-minute checks. The SSD said behavioral health services were not offered due to the resident's dementia and it was difficult for her to engage in therapy. The SSD said Resident #80 was hard of hearing and headphones had been attempted. The SSD said the resident did have a doll that was comforting to her. The DON said Resident #80 did not have a history of aggression, and this incident was unexpected. The DON said Resident #80 spoke loudly because she could not hear. The SSD said the facility substantiated the abuse because it was witnessed by CNA #7. III. Incident of physical abuse by Resident #80 towards Resident #58 on 11/15/25 A. Facility investigation The facility investigation, dated 11/15/25, documented that at approximately 8:35 p.m. Resident #80 was observed grabbing Resident #58 from behind his right ear and scratching the back of his neck on the right side. The staff separated the residents. A one-to-one caregiver was initiated for Resident #80 when she was not in bed and 15-minute checks were initiated when she was in bed. Resident #58 was assessed for further injuries. Both residents' representatives were informed of the incident, as well as the police. The facility investigation documented that Resident #80 was in a previous physical abuse allegation on 11/2/25 (see incident above). The facility investigation documented the SSD interviewed Resident #58 (alleged victim) on 11/17/25 at 10:50 a.m. about the incident with Resident #80. Resident #58 said he did not remember the incident and could not recall how he had gotten the scratch on the back of his neck. When the SSD asked if another resident had ever hurt him, Resident #58 told her no. When the SSD asked him if he was ever afraid or worried that something might happen to him or someone else he shook his head indicating no. The facility investigation documented Resident #80 was interviewed on 11/17/25 at 11:11 a.m. The investigation documented Resident #80 had a hard time maintaining focus and attention to the conversation due to her cognitive impairment. Resident #80 could not recall seeing Resident #58 in the lobby and she could not recall being upset with any other residents. The SSD interviewed the CNA that witnessed the incident between Resident #58 and Resident #80 on 11/21/25. The CNA said Resident #80 was speaking loudly to the other residents in the front lobby like she normally did. She said that both Resident #80 and Resident #58 were in the front lobby area. The CNA observed Resident #80 lean forward and grab Resident #58's ear. The CNA reported she thought that Resident #80 was trying to get Resident #58's attention. The CNA reported she separated the residents immediately. The CNA said that Resident #58 looked confused and wide-eyed but once he was away from Resident #80, he went back to his normal self. The CNA reported that Resident #58 did not verbalize being afraid. The CNA mentioned that Resident #80 was far from the nurses and CNAs that were taking care of her that day and felt that it would have been more efficient if Resident #80 stayed closer to the nurses' station down her hall. The facility substantiated the allegation of physical abuse. The occurrence was witnessed by staff, Resident #58 had an injury to the back of his neck which was consistent with the CNAs account. B. Resident #58 (victim) 1. Resident status Resident #58, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included Alzheimer's disease, dementia and sensorineural hearing loss bilateral (gradual hearing loss in both ears). The 1/9/26 MDS assessment revealed Resident #58 had severe cognitive impairment with a BIMs score of three out of 15. The MDS assessment documented that Resident #58 did not have any aggressive behaviors, wandering or rejection of care. The MDS assessment documented that Resident #58 was dependent on staff for most of his ADLs. 2. Resident #58's representative interview Resident #58's representative was interviewed on 3/24/26 at 10:32 a.m. The representative said a few months ago a female resident (Resident #80) had scratched Resident #58. He said that he did not think that it was anyone's fault. He said the facility let him know when it happened. He said he felt that the facility did the best job that they could and that the facility worked very hard to make sure his loved one feels loved. 3. Record review The elopement and wandering care plan, revised 7/15/25, documented Resident #58 was at risk for elopement, referring to attempting to leave the building. Pertinent interventions included participating in morning activities, monitoring the residents whereabouts, identifying patterns of wandering, and checking wander guard placement and functioning. The communication care plan, revised 7/15/25 documented Resident #58 had a communication problem referring to his diagnosis of bilateral hearing loss. The care plan documented he did not wear hearing aids. Pertinent interventions included in English, minimizing background noise, speaking on an adult level facing him and speaking clearly and slowly, and reporting any changes in ability to communicate. A nursing progress note, dated 11/15/25 at 9:22 p.m., documented Resident #58 sustained a scratch to the back of his neck by another resident (Resident #80). The note documented that the nurse on duty was informed and assessed the resident. A nursing progress note, dated 11/16/25 at 3:55 a.m., documented that the nurse was notified by the nurse working the 200 hall that Resident #80 had grabbed Resident #58 by his right ear from behind and scratched the back of his neck. The residents were separated and messages were left for the NHA and the DON. The residents' representatives were called, as well as the authorities. The note documented Resident #80 did not sustain any injuries. C. Resident #80 (assailant) 1. Record review A nursing note, dated 11/16/25 at 3:54 a.m., documented that the nurse was called to the 200 unit (on 11/15/26) because Resident #80 had grabbed Resident #58's ear and scratched his neck. The note documented that the nurse left messages for the NHA, the DON and the residents' representatives and the authorities were contacted. The note documented that Resident #80 did not obtain any injuries from the incident. A nursing note, dated 11/18/25 at 3:50 a.m., documented that Resident #80 had been on 15-minute checks and within line-of-sight while awake. D. Staff interviews CNA #6 was interviewed on 3/25/26 at 3:35 p.m. CNA #6 said Resident #80 went up and down the halls looking for a doctor. She said she would knock on doors and wander. She said Resident #80 was not aggressive, but would talk really loud because she could not hear very well. She said Resident #80 sometimes tried to grab other residents to try and get their attention. She said Resident #80 would do that often when she was in the lobby area and the residents were close together. She said she did not remember Resident #80 grabbing Resident #58. The NHA, the DON and the SSD were interviewed together on 3/26/26 at 3:35 p.m. The SSD said that Resident #80 was seen grabbing Resident #58's ear from behind and she scratched his neck. She said after that happened, the facility did a medical workup on Resident #80 to see if she had a fracture on her left arm. She said Resident #80 would often complain of pain. Resident #80 was unable to verbalize what was bothering her due to her cognitive ability. She said that activities would not hold her attention for long, she said even with one-on-one activities she would lose interest. The SSD said that Resident #80's behaviors would start out of the blue. She said the resident did not have any signs of when she would become agitated. IV. Incident of physical abuse by Resident #21 towards of Resident #27 on 2/25/26 A. Facility investigation The facility's investigation, dated 2/25/26, was provided by the NHA on 3/26/26 at 10:13 a.m. The investigation documented Resident #27 reported Resident #21 had grabbed her arm as she went outside to smoke. The investigation documented Resident #21 was in the lobby of hall 400, six feet from the door to the smoking area. Resident #27 attempted to go outside when Resident #21 grabbed her arm and told her she would not go out the door. The investigation documented Resident #27 told Resident #21 several times to leave her alone before she was able to get away from him. Resident #27 reported Resident #21 continued to reach out to grab her and yelled, There goes the waterboy. The investigation documented Resident #27 said she did not know who Resident #21 was talking to and there were no witnesses to the event. The facility investigation documented Resident #27 had no injuries. It documented the resident said she felt safe and the facility would escort Resident #27 to the smoking area to prevent further altercations. The facility investigation documented Resident #21 had no memory of the event with Resident #27. The facility documented Resident #21 had a history of being confused and believed he was working at his prior job as a prison guard. It documented Resident #21 made homicidal statements, which he later described as a joke. The facility investigation documented Resident #21 would be on 15-minute checks, and behavioral health services would be notified. The investigation documented Resident #21 would be removed from the common areas if he became agitated. The facility investigation substantiated the abuse of Resident #27 by Resident #21. B. Resident #27 (victim) 1. Resident status Resident #27, age less than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included diabetes mellitus type two, mild asthma, chronic kidney disease, adult failure to thrive, bipolar two disorder and myoneural disorder. The 1/29/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #27 was able to walk independently with intermittent use of a wheelchair on days when she felt muscle weakness. 2. Observations On 3/25/26 at 12:40 p.m. Resident #27 was sitting on a bench, smoking a cigarette in the smoking area. On 3/26/26 at 4:13 p.m. Resident #27 was walking into the 100 and 400 hallway common area from the smoking area outside. She walked down the hall independently. -Resident #27 did not have an escort or supervision, as identified as an intervention in the facility investigation (see facility investigation above). 3. Resident interview Resident #27 was interviewed on 3/23/26 at 4:40 p.m. Resident #27 was lying in bed and said she had been outside in the smoking area smoking for most of the day. She said she remembered the altercation with Resident #21. She said Resident #21 did not want her to go outside, but she handled the situation by herself. Resident #27 said she felt like the staff had not done anything to prevent the incident from happening again. 2. Record review Resident #27's behavior care plan, initiated 10/20/25, revealed the resident had a behavior problem related to not adhering to posted smoking times. - However, the care plan revealed no interventions for Resident #27 to be escorted out to the smoking area to prevent an altercation with Resident #21 as mentioned in the facility investigation (see facility investigation above). C. Resident #21 (assailant) 1. Resident status Resident #21, age [AGE], was admitted on [DATE] and discharged to the hospital on 3/23/26. According to the March 2026 CPO, diagnoses included diabetes mellitus type 2, unspecified dementia of unspecified severity with behavioral disturbance, insomnia, and depression. The 2/12/26 MDS assessment revealed the resident had a severe cognitive impairment, with a BIMS score of zero out of 15. Resident #21 used a wheelchair and was able to self-propel. 2. Record review A behavioral monitoring for antidepressant medication progress note, dated 2/19/26, documented a behavioral outburst from Resident #21. It documented Resident #21 had verbal aggression with staff, residents, and visitors. The progress note documented Resident #21 was confused and believed he worked in a prison or he was in Vietnam. The note documented Resident #21 became physically aggressive, grabbed a staff member's hand, and threatened to break their hand. The progress note documented Resident #21 let go of the staff member's hand, slammed a door, threw a can on the floor and grabbed a water bottle in an attempt to use the bottle as a weapon. The progress note documented Resident #21's behavior de-escalated after he ate dinner. Review of the progress notes revealed a nursing progress note, dated 2/21/26, which documented Resident #21 had a behavioral outburst. The nursing progress note documented that on 2/21/26, Resident #21 was in the 400 hallway, self-propelled his wheelchair into another resident's room, and yelled at the resident and their family member. The progress note documented Resident #21 also went into the common area of the 100 and 400 hallway and yelled at other residents to get back to their cells. The note documented Resident #21 was sent to the hospital for further evaluation. Review of the psychiatric progress notes, written on 12/27/25, 12/9/25, 10/28/25, and 10/27/25, revealed Resident #21 had chronic post-traumatic stress disorder. The psychiatric evaluation on 10/14/25 documented Resident #21 had reported a history of significant trauma. -However, Resident #21 did not have a care plan focus for his diagnosis of post-traumatic stress disorder, including a history of trauma. Resident #21's behavior care plan, initiated 3/2/26, revealed the resident had behavioral problems, including yelling out and grabbing residents, which was related to the resident's dementia diagnosis. The care plan documented Resident #21 was sometimes triggered by other residents being in the common area, people coming in and out of doors, and he sometimes believed he was at work as a prison guard. Pertinent interventions included behavioral monitoring, 15-minute checks, de-escalation techniques, and documentation of episodes to determine underlying causes. -However, the care plan was initiated five days after the incident with Resident #27. D. Staff interviews CNA #1 was interviewed on 2/24/26 at 1:25 p.m. CNA #1 said Resident #21 did not usually become agitated suddenly. CNA #1 said Resident #21 would gradually become agitated. CNA #1 said Resident #21 spent his time sitting in the lobby area. CNA #1 said Resident #21's behavior de-escalated after he was offered snacks or drinks and talked with staff about what was upsetting him. The DON and the SSD were interviewed together on 3/26/26 at 3:02 p.m. The DON said at the time of the altercation between Resident #21 and Resident #27, Resident #21 had experienced post-traumatic stress disorder (PTSD) episodes, in which he believed he still worked as a prison guard. The DON said Resident #21 was sent to the hospital on 2/21/26 for increased behavioral concerns, but he was not placed on any behavioral precautions when he returned to the facility. The SSD said Resident #21 was usually easy to de-escalate when he became agitated. The SSD said Resident #21 appeared more confused when he was agitated. The SSD said when Resident #21 returned from the hospital on 2/21/26, staff were supposed to monitor Resident #21 more frequently, even if no specific precautions had been placed.

Based on observations, interviews, and record review, the facility failed to maintain proper storage of medications for three out of three medication carts and one of three medication storage rooms.Specifically, the facility failed to:-Label insulin pens with the date they were opened;-Label inhalers with the date they were opened;-Discard opened medications for residents who had been discharged ; and,-Discard expired medications Findings include:I. Professional referenceAccording to the manufacturer Arkray USA, inc, revised 2019, Performing a Control Solution Test, retrieved on 3/30/26 from,https://cdn.boundtree.com/btm/products/Bound_Tree_Arkray_Assure_Prism_Multi_Control_Solution_Directions_for_Use_8854369468446.pdf, Check the expiration dates printed on the bottle. When you first open a control solution bottle, record the discard date (date opened plus [3] months) in the space provided on the label. Out of range results may occur due to the following factors . When the control solution is past its discard date.According to the manufacturer Biocon Biologics, 2023, Patient Information-Storing the Insulin Glargine yfgn pen, retrieved on 3/30/26 from, https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=3ac85ebb-5594-59c8-77fd-df254329d151&type=display#section-18m, Only use your pen for up to 28 days after its first use. Throw away the Insulin Glargine yfgn pen you are using after 28 days, even if it still has insulin left in it.According to the manufacturer [NAME] Lily, 2026, Highlights of Prescribing Information, retrieved on 3/30/26 from, https://pi.lilly.com/us/humalog-pen-pi.pdf, When stored at room temperature, Humalog (insulin lispro) can only be used for a total of 28 days, including both not in-use (unopened) and in-use (opened) storage time.According to the manufacturer GlaxoSmithKline, 2017, Highlights of Prescribing Information, retrieved on 3/30/26, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/204275s012lbl.pdf, Discard [NAME] Ellipta six weeks after opening the foil tray or when the counter reads 0, whichever comes first.II. Facility policy and procedureThe Medication Storage policy, revised November 2020, was provided by the nursing home administrator (NHA) on 3/26/26 at 11:21 a.m. It read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. III. Observations and interviewsOn 3/24/26 at 2:15 p.m. the 200 hall medication cart was observed with licensed practical nurse (LPN) #5. The following was observed:-A used Ellipta inhaler for Resident #42 was not labeled with the date it was opened. LPN #5 said she did not know how long the medication was good for after it was opened. LPN #5 placed the medication back into the cart.-A used insulin lispro pen for Resident #15 with an opened date of 1/21/26. LPN #5 said the insulin pen was expired based on the opened date on the pen. LPN #5 said insulin pens were good for 30 days after they were opened, and an expired insulin pen could be less effective.- A used insulin lispro pen for Resident #27 was not labeled with the date it was opened. On 3/24/26 at 2:34 p.m. the medication cart that was used for the 100 and 400 hallway was observed with LPN #4. The following was observed:-Two nitroglycerine 0.4mg vials labeled with the name of a resident who had been discharged on 3/3/26.-A used insulin lispro pen for Resident #76 was not labeled with the date it was opened. LPN #4 labeled the pen with the date 3/23/26. LPN #4 said she assumed the insulin was opened the day before because she had not opened it, and she knew the facility had gotten a new shipment of medication the day before.-A used insulin glargine pen for Resident #41 was not labeled with the date it was opened. LPN #4 labeled the insulin pen with the date 3/23/26. LPN #4 said she labeled the pen based on the same assumption as the insulin lispro for Resident #76On 3/24/26 at 2:46 p.m. the medication storage room for the 100 and 400 hallway was observed with LPN #4. The following was observed:-A Tuberculin Purified Protein 5 TU (tuberculin units) per 0.1 milliliter (ml) vial with an opened date of 2/9/26. LPN #4 said she thought the medication might be expired. LPN #4 placed the medication back into the medication refrigerator. On 3/24/26 at 3:15 p.m. the 300 hallway medication cart was observed with LPN #3. The following was observed:-An open glucometer test control solution labeled 11/29/25. LPN #3 said testing the glucometers was a night shift nurse's duty, and she did not know how long the solution was good for after opening. LPN #3 said she would have to ask the director of nursing (DON) how long the medication can be used for after it is opened. LPN #3 placed the solution back into the medication cart.IV. Staff interviewsThe clinical resource nurse was interviewed on 3/24/26 at 3:15 p.m. The clinical resource nurse said she had discarded the unlabeled insulin pens. The DON was interviewed on 3/25/26 at 10:40 a.m. The DON said LPN #4 should have discarded the unlabeled insulin pens instead of labeling them herself. The DON said LPN #4 had not opened the medications, which meant she did not know with certainty when the medications were opened. The DON said glucose control solutions should be used within 30 days of opening, and the glucose control solutions should have been discarded.

Based on observations, interviews, and record review, the facility failed to provide tube feeding management according to professional standards for one (#6) of one resident reviewed out of 36 sample residents.Specifically, the facility failed to:-Ensure the correct tube feeding formula was administered;-Ensure tube placement before tube feed administration; and-Provide flushes and water administration according to the physician's orders. Findings include:I. Facility policy and procedureThe Enteral Tube Feeding via Continuous Pump policy, revised 2/23/24, was provided by the nursing home administrator (NHA) on 3/26/26 at 11:04 a.m. It read in pertinent part, Steps in the procedure: 1. Place the equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Wash hands and dry thoroughly. 3. Wear clean gloves. 4. Position the head of the bed at 30 degrees to Fahrenheit (F) 45 degrees F (semi-Fowler's position) for feeding, unless medically contraindicated. 5. Check the label on the enteral formula against the physician's order. 6. Attach enteral feeding pump set to bag and prime tubing. Clamp tubing. 7. Clamp enteral tube. Remove the plug. 8. Verify placement of the tube per current professional standards. 9. If anything suggests improper tube positioning, do not administer feeding or medication. Notify the charge nurse or physician. 10. When correct tube placement has been verified, flush tubing with at least 30 ml (milliliter) warm water (or prescribed amount). 11. Remove the syringe and clamp tubing. Initiate Feeding.II. Resident #6A. Resident StatusResident #6, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician's orders (CPO), diagnoses included unspecified severe protein-calorie malnutrition, alcohol dependence, Alzheimer's disease, and benign prostatic hyperplasia (non-cancerous enlargement of the prostate).The 1/5/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 of 15. The MDS documented Resident #6 had pain or difficulty swallowing. Resident #6 received greater than 51% of his food and 501 ml of his fluid intake via a feeding tube.B. Record reviewReview of Resident #6's CPO revealed the following orders for his tube feed management:-Resident is to be NPO (nothing by mouth), only tube feeds, ordered 3/10/26.-Administer 250 ml of water after nutrition administration four times a day for hydration, ordered 12/11/25. -Jevity 1.5 calorie (cal)/fiber oral liquid nutritional supplement 270 ml enterally four times a day, ordered 10/16/25. Resident #6's tube feeding management care plan, initiated 10/2/25, revealed the resident had dysphagia (difficulty swallowing). The care plan documented the resident had poor fluid intake related to the resident's NPO status. Pertinent interventions included to administer the tube feeding and water flushes per the physician's order and to give water through the gastric tube per the physician's orders.III. Observations and interviewsOn 3/24/26 at 4:32 p.m., licensed practical nurse (LPN) #3 administered a tube feeding to Resident #6. LPN #3 said she had opened the tube feed formula bottle at 10:00 a.m. the same morning. The tube feed formula bottle read Glucerna 1.2 cal with carbsteady. -However, the physician's orders were for Jevity 1.5 cal formula tube feed.LPN #3 connected the tube feeding to Resident #6's gastric tube and pressed start on the tube feeding pump.-However, LPN #3 did not ensure the gastric tube was in place before administering the tube feeding. LPN #3 did not flush the gastric tube with 30 ml of water or administer 250 ml of water per the physician's order prior to administering the tube feed.On 3/25/26 at 10:01 a.m. LPN #2 administered tube feed to Resident #6. LPN #2 flushed Resident #6's gastric tube with 250 ml of water before administering the formula. LPN #2 said Resident #6 was not allowed to eat or drink by mouth, and his only hydration was water administered through the gastric tube. LPN #2 said Resident #6's physician orders included administration of 250 ml of water before and after tube feeding.-However, the physician's order was to administer 250 ml of water after tube feeding.IV. Staff interviewsLPN #3 was interviewed on 3/25/26 at 11:18 a.m. LPN #3 said after the observation on 3/24/26 at 4:32 p.m. she recognized something was not correct with the tube feeding. LPN #3 said she checked the physician's orders and discovered the order was for Jevity 1.5 cal. LPN #3 said she went into Resident #6's room, discontinued the incorrect tube feed formula, and then administered the correct tube feed formula per the physician's orders. LPN #3 said she should have double-checked the label on the tube feed formula bottle before administration to Resident #6.The director of nursing (DON) was interviewed on 3/25/26 at 11:18 a.m. The DON said he did not know LPN #3 had administered the incorrect tube feeding. The DON said LPN #3 should have notified someone after the error. The DON said tube feeds should be flushed with water before and after tube feed formula administration to prevent the gastric tube from clogging. The DON said the tube placement should be assessed before nutrition administration.

Based on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the past three years.Specifically, the facility failed to ensure three years of survey and investigation findings were available for the public, and where individuals wishing to examine survey results did not have to ask to see them. Findings include: I. Resident interviewsThree residents (#12, #14 and #59) who were identified as alert and oriented by facility and assessment were interviewed on 3/25/26 at 10:15 a.m. Resident #12, Resident #14 and Resident #59 said they did not know where to find the results of recent survey findings.II. Observations and staff interviewThe facility's survey results binder was not located in an area where individuals could examine results on 3/25/26 at 10:50 a.m. The nursing home administrator (NHA) provided a survey results binder on 3/25/26 at 11:00 a.m. The NHA said she had removed the binder from the facility's lobby the previous day in order to ensure the binder was up to date with previous survey findings. -The survey results binder provided was found to contain results from the recertification survey on 3/7/24 and one complaint survey 6/30/25. The binder failed to include the facility's last three years of complaint findings.The NHA said the complaint investigations and plans of correction for the past three years should have been included in the binder.

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#1) of three residents out of eight sample residents. Specifically, the facility failed to:-Ensure Resident #1's Medical Orders for Scope of Treatment (MOST) form was completed accurately; and,-Ensure Resident #1's MOST form matched the resident's wishes and the physician's order for a do not resuscitate (DNR) code status.Findings include: I. Facility policy and procedure The Advanced Directives policy, revised February 2024, was provided by the director of nursing (DON) on 12/9/25 at 2:05 p.m. It read in pertinent part, The facility recognizes advance directives, every attempt will be made to honor the resident's wishes unless to do so would violate the state or federal law. The advance directive and cardiopulmonary resuscitation (CPR) decisions will be reviewed in writing on admission and annually, when requested by the resident, or as needed.II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the November 2025 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus, paroxysmal atrial fibrillation (irregular heart beat), essential hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (build up of fats, cholesterol and other substances along the walls of the heart arteries), dysphagia (difficulty swallowing food or liquids) and osteoporosis. The 9/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental score (BIMS) score of zero out of 15. She required moderate assistance with toileting, showering and personal hygiene. She required supervision with oral hygiene and set up assistance with eating. B. Record reviewReview of Resident #1's November 2025 CPO revealed the resident's physician's orders for cardiopulmonary resuscitation were DNR, ordered 9/4/25, which indicated the resident/resident's representative did not wish for the resident to receive CPR. Review of Resident #1's Medical Orders for Scope of Treatment (MOST) form, which was signed upon the resident's admission to the facility on 9/4/25, revealed the following:Section A, (for CPR preferences) was marked yes for CPR, which indicated the resident/resident's representative wished for the resident to receive CPR. -However, the physician's order indicated the resident was a DNR (see physician's order above).Below the Yes for CPR box were directions indicating selecting Yes required choosing Full Treatment for medication interventions in Section B. -However, Section B on Resident #1's MOST form was marked Comfort-focused treatment and the primary goal was to maximize comfort. -Although the MOST form directions indicated section B should have been marked full treatment with the primary goal to prolong life by all medically effective means, Resident #1's MOST form was marked incorrectly and emphasized comfort focused treatment. -Review of Resident #1's comprehensive care plan did not indicate Resident #1's CPR wishes. Review of Resident #1's 9/6/25 initial psychosocial assessment indicated her CPR status was DNR. Review of Resident #1's 9/10/25 care conference indicated her CPR status was DNR. Review of Resident #1's 11/29/25 hospital transfer form indicated her CPR status was see MOST form.-However, Resident #1's MOST form was marked that the resident wished to receive CPR, which did not match the resident's physician order which indicated the resident was a DNR status.The 11/29/25 nurse progress note revealed Resident #1 had increased difficulty breathing and was seen by the nurse practitioner on 11/28/25 with new orders for nebulizer treatments only. At lunch on 11/29/25, Resident #1 started having increased difficulty breathing and then vomited. The nurse assisted Resident #1 to her room, cleaned her up and administered duo-neb (a nebulizer breathing medication) treatment without positive effects and Zofran for nausea. Vital signs were obtained and were within normal limits except oxygen saturations were 87 %to 90 % on 2 liters of oxygen per minute. A call was placed to the on-call provider who gave the order to send Resident #1 to the hospital for an evaluation. The responsible party and the DON were notified. The responsible party wanted an update once she was evaluated at the hospital. Resident #1 was transported at this time by the facility bus and accompanied by the driver and the receptionist. Resident #1 was actively vomiting on departure, respirations were very labored and the color around her mouth was pale. She was responsive when spoken to. A call was placed to the hospital emergency room and a report was given.The 11/29/25 hospital emergency room report revealed Resident #1 came from a nursing facility by van for shortness of breath and vomiting. The nurse at the nursing facility reported she had vomited brown liquid and was not responding upon arrival to the emergency room. Resident #1 was brought into a bed where she began to become unresponsive and immediately started vomiting what appeared to be feculent material. The resident had a room air saturation of 85%. The emergency room report documented that when reviewing the code information from the nursing facility, the form was filled out but was somewhat confusing as it said the resident's desire was CPR but also was comfort measures. At 2:47 p.m., the resident's oxygen flow rate was 2 liters per minute via nasal cannula and oxygen was 85%. After a very brief initial encounter in the emergency room she became agonal respirations without a pulse. Intravenous (IV) was to be established as she had poor IV access and intraosseous (IO) was started in her left tibia and she had full CPR and was being bagged by respiratory therapy. She was in asystole and remained in asystole after two separate doses of epinephrine. She was never in ventricular fibrillation or never had electrical activity on the monitor and the code was called and she died in the emergency department. The assessment plan was cardiac arrest and aspiration pneumonia due to inhalation of food and vomit.-Resident #1 was administered CPR in the emergency room based on her MOST form which indicated the resident wished to receive CPR, however, per the resident's November 2025 CPO, the resident had a physician's order for DNR (see physician's order above).III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/9/25 at 12:42 p.m. LPN #1 said the nurse who admitted the resident was responsible for completing the MOST form. He said he did not receive much training and he shadowed another nurse before he completed a MOST form on his own. He said after the MOST form was completed by the nurse, the MOST form went into the physician's box and the physician signed the form when he was in the building. LPN #1 said the physician came once a week. He said if the MOST form was not signed and he needed the code status, he talked to his unit manager or the DON. LPN #1 said once the MOST form was completed, the form went in a MOST binder that included the resident's face sheet. He said the medical records department reviewed the MOST form for completeness. LPN #1 said he was not familiar with Resident #1 and did not know her code status. LPN #2 was interviewed on 12/9/25 at 12:55 p.m. LPN #2 said the nurse who admitted the resident was responsible for completing the MOST form. She said she did not receive training at this facility and at previous facilities she saw social services complete the MOST forms. LPN #2 said the MOST form was completed at admission. LPN #2 said once the form was completed by the nurse, it went in the physician's box for the physician to sign the form when he was in the building. LPN #2 said once the physician signed the MOST form, the form was placed in the MOST binder for all residents in the unit. LPN #2 said she did not know how often the MOST form was reviewed. LPN #2 said she was familiar with Resident #1. She said she did not know Resident #1's code status by memory. LPN #2 reviewed Resident #1's MOST form and said it was marked yes for CPR, which meant life-sustaining measures should have been used if needed. LPN #2 said the second section of the MOST form did not match what was written in the first box. LPN #2 said the second section should have been marked full treatment indicating the primary goal to prolong life by all medically effective means. The DON was interviewed on 12/9/25 at 1:06 p.m. The DON said the nurse who admitted the resident was responsible for completing the MOST form. The DON said nurses received at least annual training on advanced directives. The DON said the MOST form was completed at the time of admission. The DON said the form went in the physician's box for the physician to sign when he was in the building. The DON said if the nurse needed to reference the MOST form when it was not signed, the nurse should treat the resident as a full code and contact the DON. The DON said he would contact the physician to see if they would be able to come in prior to their next visit to sign the MOST form. The DON said once the MOST form was signed, the form was placed in the MOST binder for all residents in the unit. The DON said medical records reviewed the form. The DON said the MOST form was reviewed quarterly at the care conference. The DON was familiar with Resident #1. The DON said he did not know Resident #1's code status. The DON looked at Resident #1's MOST form and the DON said the form was confusing. The DON said the nurse who completed Resident #1's MOST form was new to the facility when they completed the MOST form and no longer worked at the facility. The DON said he could see how the hospital staff was confused on the MOST form and based on Resident #1's MOST form, he would have provided CPR for the resident. The DON said Resident #1's wishes were for DNR and that was why the resident had a physician's order for DNR and not CPR.

Based on record review and interviews, the facility failed to maintain accurately documented medical records for two (#1 and #2) of three residents reviewed out of three sample residents.Specifically, the facility failed to ensure Resident #1 and Resident #2 wound assessments were documented accurately and include weekly measurements to reflect progression of the wounds in the residents medical records. Findings include:I. Facility policy and procedureThe skin and wound care management policy, undated, was provided by the director of nursing (DON) on 10/28/25 at 10:18 a.m. It read in pertinent part, The purpose of this procedure was to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record. The date and time the wound care was given, the position in which the resident was placed, any change in the resident's condition, all assessment data such as wound bed color, size, and drainage. Obtained when inspecting the wound. If the resident refused the treatment and the reason why. Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice.II. Resident #1 A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged on 10/16/25. According to the October 2025 computerized physician orders (CPO), the diagnoses included pulmonary embolism (sudden blockage of a lung artery, usually caused by a blood clot), type two diabetes, atrial fibrillation (irregular heart rhythm where the chambers of the heart beat chaotically and out of sync with the lower chamber), muscle weakness and needing assistance with personal care. The 7/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. She required substantial or maximal assistance with lower body dressing and putting on and taking off footwear.B. Record reviewA review of Resident #1's treatment administration record (TAR) revealed the following treatment orders:-Wound care to the back of the left heel. Cleanse with in-house wound cleanser, apply medihoney to wound bed and secure with adhesive foam dressing. Change daily and as needed every day. Order date 8/5/25. -Wound care to the weeping areas of the bilateral lower extremities. Apply absorbent pads to bilateral lower extremities, secure with ACE bandage and change four times a day and as needed. Order date 8/5/25 and discontinued date 9/10/25. -Wound care to the bilateral lower extremities. Cleanse legs with wound cleanser, apply Dermaphor to dry skin on legs, apply DermaSyn/Ag (an antimicrobial wound gel) to eschar and slough area wound beds only, cover with Telfa, secure with ACE wrap, every day. Ordered 9/10/25. Skin/wound notes documented on for the month of August, September and October of 2025 to date revealed wound assessments were completed for Resident #1. The note documented open areas to the bilateral lower extremities. The skin/wound notes provided no additional information.The skin/wound notes failed to document an assessment of the wounds with measurements, the wound progression and treatment effectiveness. The notes only provided the location of the wounds to the resident's bilateral lower extremities. The facility failed to ensure skin assessments were focused and detailed.III. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October, 2025 CPOs, diagnoses include cellulitis of the left lower limb, sepsis, muscle weakness and difficulty walking. The 10/2/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required partial to moderate assistance with lower body dressing and putting on and taking off shoes and socks.B. Record reviewA review of Resident #2's TAR revealed the following treatment orders:-Wound care. Cleanse wound area, pat dry, apply xeroform to areas on left leg, heel, and foot/toes, apply ABD (highly absorbant wound dressing), wrap with Kerlix then ACE wrap. Order date 5/2/25.A skin/wound note documented on for the month of August, September and October of 2025 to date revealed wound assessments were completed for Resident #1. The note documented a left lower leg vascular wound. The skin assessment did not include any additional information. The skin/wound notes failed to document an assessment of the wounds with measurements, the wound progression and treatment effectiveness. The notes only provided the location of the wound to the left lower extremity. The facility failed to ensure skin assessments were focused and detailed. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/27/25 at 3:44 p.m. LPN #1 said skin assessments were done once per week. She said skin assessments should include the wound measurements and other wound details. LPN #1 said she was wound care certified. She said she was recently hired by the facility for the position of wound nurse. She said each wound should have a documented complete assessment and a monthly tracking sheet for the providers to review. She said she had noticed a lack of details in the nursing skin assessment. The director of nursing (DON) and registered nurse (RN) #1 were interviewed together on 10/28/25 at 3p.m. The DON said he had worked at the facility for a little over a month and a half. The DON said he identified areas of the facility that needed improvement including having a wound nurse responsible for documenting accurate wound assessments. The DON said he was unsure who the wound nurse was prior to his arrival, however he did hire a new wound nurse last week. The DON said he wrote a performance improvement plan for the facility's lack of wound documentation.-However, current deficient practice was identified during the survey process with Resident #1 and Resident #2. See record review above.The DON said Resident #1 and Resident #2 wound assessments should include measurements and progression of the wounds in order to determine healing or deterioration. The DON said a full assessment of wounds should be completed each week due to the delicate nature of the skin for residents. RN #1 said LPN #1 was hired as the new facility wound nurse and was wound certified. The DON said the facility physician was responsible for determining what treatment was needed for wound care and relied on the skin assessment details to figure out if the current treatment was effective. The DON said the nurses should document any change of condition and notify the provider of the assessment. The DON said he was concerned the skin assessments did not include a description of the wounds from when the wound was first identified and the first wound care clinic visit. The medical director (MD) was interviewed on 10/28/25 at 1:31p.m. The MD said he was employed as the medical director and the in-house physician for the past year. The MD said his duties included seeing residents, conducting assessments and providing treatment when needed. He said assessments for wounds should include details such as visual assessment on the wound, comparative measurements, presence of drainage, vital signs, presence of odor or warmth, presence of edema, description of the tissue and pedal pulses if the wounds were vascular. He said he had limited experience with wound care and relied on the nursing staff to document, assess and report any changes to a resident's skin integrity. He said it was his understanding RN #1 was in charge of the wound care at the facility. He said the wound treatment was ordered based on his and the nursing assessment. The MD said he sought a referral to the wound clinic for Resident #2 because the resident's wounds were not improving with the current treatment. He said he was unsure of the wound care and skin assessment tracking the facility was doing and assumed the nursing staff would be following, monitoring and tracking the resident assessments. He said he ordered an antibiotic for Resident #2's wounds and wound cultures after the facility nursing staff reported a foul smell coming from the wound. He said the wound culture was positive for pseudomonas. He said he was not aware of any documentation issues. He said he did not know the nurses were not documenting the wound assessments accurately and completely.

Based on observations, record review and interviews, the facility failed to ensure an environment free of accident hazards for one (#1) of three residents reviewed for accidents/hazards out of three sample residents. Specifically, the facility failed to prevent Resident #1 from eloping on 4/27/25. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/20/25, resulting in the deficiency being cited as past noncompliance with corrective action date of 4/27/25. I. Elopement incident on 4/27/25 Resident #1 who was at risk for elopement, required 15-minute checks related to his elopement risk. The staff on the long term care (LTC) side of the facility, where Resident #1 resided, were to observe Resient #1 and document his behaviors every 15 minutes. On 4/27/25 at approximately 9:58 a.m. Resident #1 was taken to the church service that was held in the assisted living (AL) community by certified nurse aide (CNA) #2. The AL side of the community did not have a wanderguard system in place. Resident #1 was left unattended and out of staff sight on the AL side of the facility, where he exited the facility via a door which led to an unsecured area of the facility grounds. Resident #1 was able to leave the facility without staff supervision. At approximately 11:15 a.m. the nursing home administrator (NHA) and the director of nursing (DON) were notified by the staff that Resident #1 was missing. The facility began a search of the facility for Resident #1. When Resident #1 was not located inside the facility the search was extended to the facility grounds outside. Family and local police notified Resident #1 was missing. Facility staff then began to search for Resident #1 in the surrounding neighborhood via automobiles. The DON went towards the residents previous living address which was seven blocks from the facility, Resident #1 was not located. At approximately 12:15 p.m. Resident #1 was found three blocks (0.3 miles) away from the facility by staff in the opposite direction from his prior living address. Resident #1 was immediately placed on a one-to-one caregiver for safety upon his return. II. Facilities plan of correction The corrective action plan implemented by the facility in response to Resident #1's elopement on 4/27/25 was provided by the NHA on 5/20/25 at 4:21 p.m. It revealed in pertinent part: A. Action to correct the deficient practice for Resident #1 On 4/27/25 12:15 p.m. Resident #1 was placed on a one-to-one with staff and referrals were sent to other facilities that had locked units. Resident #1's wanderguard was reviewed and functioning correctly on 4/27/25. All of the doors that were equipped with a wanderguard system were checked and working appropriately. The doors that were not equipped with wanderguard were equipped with chimes on 4/27/25 and were checked every hour to ensure the chimes were functioning properly. A log was to be kept. Chime logs were to be in place until Mag Locks (specifically designed locks for doors to create a secure environment) were in place and functioning appropriately. The elopement binder was reviewed to ensure all residents who were at risk for elopement were identified in the binder. B. Identify others at risk The facility reviewed other residents at risk for elopement and identified any resident with a wanderguard were at risk for the alleged deficient practice. C. Systemic changes The facility completed staff education on 4/27/25 in preventing resident elopement, emergency procedure for a missing resident, wandering and elopement policies and procedures via electronic education software. The staff development coordinator (SDC)/designee educated the activities staffon residents at risk for elopement and that they should not be left unattended during an activity. All staff were educated by the SDC on 4/27/25 on residents who were identified as an elopement riskshould not be taken to the AL side of the facility for any reason unless they were supervised and not left unattended. D. Ongoing monitoring The NHA/designee was to ensure the door check logs were completed three times a week for one month, then weekly for one month, or until substantial compliance was met. Starting on 5/7/25, the main entrance door was switched to chime mode (sounds like a door bell) during business hours and when the receptionist was working. The main entrance door was switched to alarm mode at the end of reception shift. The activities director (AD) was to monitor activities that were on the AL side of the facility to ensure the residents who were at risk for elopement were not left unsupervised/unattended. The DON/designee would review three residents at risk for elopement weekly, then monthly for three months or until substantial compliance is met. This review included: a physician's order was in place for a wanderguard, consent was obtained and a care plan was in place. The NHA/designee, the SDC/designee and the DON/designee would report any issues identified through the audits in the QAPI. III. Facility policy and procedure The Elopement and Wandering policy and procedure, dated 2/29/24, was received from the NHA on 5/20/25 at 4:32 p.m. It revealed in pertinent part, To ensure the safety and well being of all residents with potential elopement risk. It is the goal of the facility to provide a safe environment using the least restrictive measure available in caring for residents who are exhibiting elopement behavior. The facility defines wanders as residents who move around the facility in a non-goal directed manner, but do not make efforts to leave the premises. Elopers are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. A Wander/Elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with change of condition. Nursing staff will address initial elopement risk concerns in the baseline care plan. If the resident is identified as an elopement risk, the following will be maintained: Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder. Implementing and care planning interventions to address safety and decrease risk of elopement. A Physical Restraint Use Consent shall be obtained from the resident's responsible party if an electronic device is utilized Physician order will be required for the use of monitoring the device. The order will include checking placement of device every shift and checking function of device daily. The care plan will be updated to include that an electronic alarm system is used for resident's safety. IV. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included dementia (abnormal memory) with behavioral disturbances, Wernicke's encephalopathy (neurological deficiency caused by Vitamin B1 deficiency) and amnesia (loss of memory). The 4/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status score (BIMS) of six out of 15. He required supervision/touch assistance assistance with dressing, transfers, ambulation, personal hygiene and bed mobility. He required set-up assistance with meals. The MDS identified the resident had wandering behaviors daily. B. Observations On 5/20/25 at 9:50 a.m. the facility tour revealed the LTC side and the AL side of the facility were open to all residents at all times. The wanderguard system was installed on all doors on the LTC side which led to the exterior of the facility. There was one wanderguard device in the hallway at the entry of the AL side of the facility from the LTC side. The AL side of the facility did not have any wander guard devices on any of the doors leading to the exterior of the facility. C. Record review Review of the May 2025 CPO, revealed the following physician's orders: Apply wanderguard to prevent the resident from going out of the facility unassisted. Monitor presence of wanderguard every shift for dementia and exit seeking, ordered on 4/22/25. Check wanderguard every shift for placement and functioning for wandering, ordered 4/22/25. The baseline care plan, initiated on 4/22/25, documented the resident was an elopement risk related to dementia, exit seeking and poor safety awareness. The care plan documented the goal was to minimize the risk of the resident leaving the facility. Pertinent interventions includedplacing the resident's identification form in the elopement binder, identifying patterns of wandering, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, monitoring the residents location every 15 minutes, documenting wandering behavior and attempted diversional interventions in behavior log, wander alert and checking the placement of the resident's wanderguard every shift. The 4/22/25 admission elopement risk assessment documented the resident was exit seeking and attempting to leave the facility immediately upon admission. Resident #1 was a high elopement risk due to dementia and poor safety awareness. The 4/22/25 physical restraint/assistive device evaluationdocumented the resident was to use a wanderguard for elopement risk. The assessment indicated the reasons the resident neededto use a physical restraint was related to his delirium/acute confusion, exit seeking and leaving the building. This placed the resident at an increased risk for injury due to dementia and poor safety awareness. It documented Resident #1 allowed the placement of a wanderguard but was unable to remember why. Review of the 15-minute checks documentation revealed the 15-minute checks were initiated on admission on [DATE] at 3:00 p.m. The facility completed the 15-minute checks as recommended until 4/27/25 at 10:15 a.m. On 4/27/25 at 10:00 a.m. the documentation indicated Resident #1 was in the 400 hall lobby. -There was no documentation that indicated the 15-minute checks were completed from 10:15 a.m. to 1:00 p.m. Review of Resident #1 progress notes in the electronic medical record (EMR) reveled: On 4/27/25 at 10:07 a.m. a nursing note documented resident continued to wander. Resident #1 attempted to exit from the back door. Resident #1's wanderguard was on and functioning properly. Resident#1 was easily redirected however only for a minute or two. Resident #1 did not want to participate in any suggested activities. On 4/27/25 at 2:32 p.m. a change of condition summary for providers documented Resident #1 had eloped from the facility. Resident #1 was found a few blocks from the facility with no adverse effects noted on assessment. Resident #1 was placed on a one-to-one monitoring by staff. All door alarms were routinely checked every 30 minutes by staff. On 4/27/25 at 2:49 p.m. a nursing progress note documented Resident #1 was wandering through the hallways this shift and was attempting to leave the facility through different doors. Resident #1's wanderguard was on and functioning properly. Resident #1 was only redirectable for short periods of time. The writer indicated they asked CNA to take Resident #1 to church services in the dining room. When the writer was rounding on Resident #1, he was not found in church services. Activities aide (AA) #1 said Resident #1 left with a CNA. The facility and the facility grounds were searched and Resident #1 was not found. A CNA said she did not take Resident #1 out of church services. The writer then notified the NHA, the resident's family and the police department. Several staff members searched for Resident #1 using vehicles. On 4/27/25 at 3:01 p.m. a nursing progress note documented the police and the resident's family were notified that Resident #1 was missing. Several staff members searched the surrounding neighborhood in vehicles. Resident #1 was found by the maintenance supervisor. Resident #1 returned to the facility with staff assistance. Nursing staff completed a skin and pain assessment. Resident #1 was placed on a one-to-one with staff for monitoring. All of the facility doors and alarms were placed on 30-minute checks. On 4/28/25 at 10:57 a risk management note documented on 4/27/25 Resident #1 eloped from the facility. The interdisciplinary team determined the cause of elopement was due to Resident #1's cognition and exit seeking behaviors. Resident #1 was placed on a one-to one caregiver. The facility sent referrals to locked facilities for Resident #1's safety. The physician and family were aware of the situation. V. Staff interviews The assisted living administrator was interviewed on 5/20/25 at 3:10 p.m. She said the facility held a church service in the AL dining room on Sundays where both residents from the AL and LTC side were able to attend. The assisted living administrator said once the residents passed the double doors in the hallway to the AL side the wanderguard system no longer worked. She said there was not a wanderguard system on the AL side of the facility.The assisted living administratorsaid the facility now has started the process of implementing wanderguards on all doors in the AL side which lead to the exterior of the building. The NHA, the DON and the regional director of operations (RDOO) were interviewed together on 5/20/25 at 3:53 p.m.They said Resident #1 was missing for approximately 20 minutes prior to the NHA being notified of the missing resident. The staff conducted a building wide search when a resident was missing. The NHA said if the resident was not located within the building they expanded to the facility grounds and then the surrounding neighborhood. The DON said Resident #1 was found approximately three blocks or 0.3 miles from the facility by the maintenance director. The DON said once Resident #1 returned to the facility he was assessed by a nurse for pain and injuries. Resident #1 did not sustain any injuries. The NHA said Resident #1 was last seen by staff at the church service being held on the AL side of the facility. The NHA said the facility held a church service that combined the AL residents with the long term care residents. The NHA said the LTC side of the facility had a wanderguard system placed on all exit doors, however the AL side did not have wanderguard system installed on their exit doors at the time of Resident #1's elopement. The NHA said a staff member assisted Resident #1 to the church service being held in the ALdining room. The NHA said the staff member would have had to turn off the last alarm in the hallway once they entered into the AL side of the facility.The NHA said once they were past that alarm there was not another system in place to prevent a resident from exiting the building through AL doors to the community. The NHA said based on the investigation it was determined CNA #2 assisted Resident #1 to the AL side for church services, although the church services was ending, and left Resident #1 there. The NHA said CNA #2 returned to their assigned floor on the LTC side of the facility and beganproviding care to another resident. The NHA said activities assistant (AA) #1 had started to assist residents out of the AL dining room as church services had ended and Resident #1 was left unsupervised in an unsecured part of the facility. The NHA said tt was determined during investigation that Resident #1 exited the AL side of the building through a door that was not equipped with a wanderguard system that led the resident to an unsecured area of the facility grounds, which allowed the resident to leave the facility. The NHA saidit was determined by the facility and the resident's family that Resident #1 was better suited for a secure unit related to his behaviors and his elopement on 4/27/25. The NHA said the facility began sending out referrals to locked facilities for Resident #1's safety. Qualified medication administration personnel (QMAP) #1 was interviewed on 5/20/25 at 5:30 p.m. QMAP #1 said she worked on theAL side of the community. QMAP #1 said she can turn off the wanderguard alarm in the hallway of the AL side of the building. QMAP #1 said if she found a resident from the LTC side she would turn off the alarm and assistthe resident back to the LTC side. She said she would ensure a staff member knew where the resident was found. QMAP #1 said she did not see a lot of residents from the LTC side on the AL side, except on Sundays whena church service was held in the AL dining room. QMAP #1 said AA #1 was present for the church service. QMAP #1 said she saw the staff come to get the residents after the service ended and assistedthem to the LTC side of the facility. AA #1 was interviewed on 5/20/25 at 6:12 p.m.She said the church service started at 9:00 a.m. on Sundays in the main dining room on the AL side of the facility. AA #1 said she helped transport residents to and from the church services if they needed assistance. AA #1 said she did not invite Resident #1 to services ashe was new to thefacility and they were still getting to know him. AA #1 said the church service was finishedwhen CNA #2 assisted Resident #2 to the dining room on the AL side. AA #1 said she told CNA #2 the servicewas ended, but CNA #2 left Resient #1 in the dining room and left the area. AA #1 said she was starting to assist residents back to the LTC side of the facility and the last time she saw Resident #1 was at approximately 9:58 a.m.AA #1 said she had saw CNA #2 and told her that services had ended and to assistResident #1 back to the LTC side. AA #1 said when she returned to the AL dining room,Resident #1 was not there. AA #1 said she continued with her daily activities schedule with a second church service of a different denomination starting at 10:30 a.m. on the LTC side. AA #1 said the church service was about an hour long in the facility and she kepta log of the residents who attended the services. AA #1 said she would see staff peek into activities at times when residents were on 15-minute checks. AA #1 said she was not aware Resident#1 was missing till the middle of the second church service that had started at 10:30 a.m. AA #1 said she assisted in the search for Resident #1. at approximately 11:45 a.m. once she finished the second church service and assisted residents back to their room. CNA #2 was interviewed on 5/20/25 at 6:28 p.m. She said she was asked by the nurse to take Resident #1 to the church services on the AL side. CNA #2 said she informed the nurse the services started at 9:00 a.m. and would be finishing soon, but the nurse still said to take Resident #1 there. CNA #2 said she took the resident to the AL side and turned off the last wanderguard alarm in order to get the resident to the dining room. CNA #1 said the church service was still going on so she left Resident #1 there,returned to her assigned wing and assisted other resident needs. CNA #2 said she was busy with resident cares and thought the AA #1 had assisted Resident #1 back. CNA #2 said she was informed by another CNA that Resident #1 was missing and then she was assigned to help look for Resident #1. CNA #1 said she was in her hallway alone with the nurse from before 10:00 a.m. to 10:30 a.m. as the other CNA was not available.

Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#7, #17, #18 and #13) of seven residents out of 16 sample residents. Specifically, the facility failed to ensure Resident #7, Resident #17, Resident #18 and Resident #13's call lights were answered in a timely manner. Findings include: I. Facility policy and procedure The Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) on 3/20/25 at 11:08 a.m. It read in pertinent part, Answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request is something you can fulfill, complete the task within five minutes if possible. Document any significant requests or complaints made by the resident and how the request or complaint was addressed. II. Observations and resident interviews Resident #7 was interviewed on 3/19/25 at 11:45 a.m. Resident #7 said at times, she waited for 20 to 40 minutes for the staff to answer her call light. Resident #7 said she filed a grievance about the long call light response times. Resident #7 said when staff did not respond to call lights in a timely manner, it made her anxious and insecure that something serious could happen while she waited. Resident #7 was observed pointing to her left forearm. The forearm had a scar, approximately one inch by one half inch in size. She said in January 2025, she cut her left forearm on the door latch of her bathroom. She said she pressed her call light and then applied tissue to the bleeding wound. Resident #7 said staff did not respond to her call light, so after 30 minutes she walked to the nurses station to request first aid for the wound. Resident #18 and Resident #17, who resided in the same room, were interviewed together on 3/19/25 at 3:47 p.m. Resident #18 said there had been times when she was unable to wait and she had a bowel movement accident because staff did not respond to her call light. Resident #17 said he and Resident #18 had waited 45 minutes or more for staff to respond to their call lights. Resident #18 and Resident #17 were interviewed together a second time on 3/20/25 at 10:55 a.m. Resident #18 said it made her anxious when staff did not respond quickly to her call light because she was afraid she might have a urine or bowel movement accident. Resident #18 said she had a urine accident the morning of 3/20/25 while she waited for staff to answer her call light. Resident #17 said it made him feel like staff thought other residents were more important than him and Resident #18 Resident #17 said he sometimes felt angry when he and Resident #18 waited for extended periods of time for staff to answer their call lights. Resident #13 was interviewed on 3/20/25 at 11:35 a.m. Resident #13 said she was aggravated when staff did not answer her call light timely. Resident #13 said she had waited extended periods of time for staff to respond to her call light. III. Record review Resident council meeting minutes were provided by the assistant director of nursing (ADON) on 3/19/25 at 1:35 p.m. The resident council meeting minutes revealed the following: On 10/9/24 at the 10:00 a.m. meeting, residents said that call lights were still slow and took over 30 minutes to be answered. On 11/13/24 at 10:00 a.m., residents said call lights were taking too long. A frequent visitor at the meeting said the call light issues had been ongoing for seven months. On 12/11/24 at 10:00 a.m, residents reported call lights took a long time to be answered and certified nurse aides (CNAs) were not responding quickly when the residents yelled for assistance. On 1/8/25 at 10:00 a.m., residents said call lights took a long time to be answered. On 2/28/25 at 11:00 a.m., there was one resident compliment that the call light response times were improving. On 3/12/25 at 10:00 a.m., call lights were not mentioned in the meeting minutes. -However, despite the February 2025 and March 2025 resident council meeting minutes indicating call light response times were not a concern, Resident #7, Resident #17, Resident #18 and Resident #13 all expressed continued concerns with call light response times during the survey (see resident interviews above). The facility's call light system data for Resident #7, Resident #18 and Resident #13, from 12/20/24 to 3/19/25, was provided by the assistant director of nursing (ADON) on 3/20/25 at 8:22 a.m. The call light data revealed the following: Staff response time to Resident #7's call light was greater than 20 minutes 55 times out of 539 calls, or 10.2% of the time. Staff response time to Resident #18's call light was greater than 20 minutes 105 times out of 768 calls, or 13.6% of the time. Staff response time to Resident 13's call light was greater than 20 minutes 44 times out of 341 calls, or 12.9% of the time. IV. Staff interviews CNA #6 was interviewed on 3/20/25 at 11:47 a.m. CNA #6 initially said she was not sure how quickly the response time to call lights should be, but then said she thought 15 minutes was the correct response time. CNA #4 was interviewed on 3/20/25 at 11:56 a.m. CNA #4 said call lights should be answered in less than five to seven minutes. CNA #4 said there had been safety issues in the past because call lights had not been answered in a timely manner. CNA #5 was interviewed on 3/20/25 at 1:33 p.m. CNA #5 said she was not always able to meet the residents' needs, particularly taking the time to address emotional needs. CNA #5 said the call lights should be answered in seven to 10 minutes and she said that residents' call lights were not always answered in less than 10 minutes if staff were busy with other residents. She said there were instances of residents not being able to hold their bowel or bladder because the call light response time was too long. CNA #5 said long call light response times were very frustrating for both residents and staff. Licensed practical nurse (LPN) #2 was interviewed on 3/20/25 at 2:13 p.m. LPN #2 said the response time to call lights should be under three minutes. LPN #2 said she monitored call lights and answered them, but she said there were nurses who did not answer call lights. CNA #7 was interviewed on 3/20/25 at 2:25 p.m. CNA #7 said call lights should be answered in five to 10 minutes, however this did not always happen. CNA #7 said residents had told her it took too long for the call lights to be answered. Registered nurse (RN) #1 was interviewed on 3/20/25 at 3:52 p.m. RN #1 said the response time to call lights should be less than two to three minutes. She said residents had told her it took too long for the call lights to be answered. RN #1 said that Resident #7 injured her arm on 1/2/25. She said Resident #7 told RN #1 she had turned her call light on, however nobody responded, so she went to the nurses station to have the wound treated. RN #1 said she had seen call lights on for a long time and said she knew there was at least one resident's call light without a prompt response on 3/19/25. The ADON and the NHA were interviewed together on 3/20/25 at 4:40 p.m. The ADON said call lights should be answered in less than 15 minutes. The ADON said residents had complained to her about long call light waiting times and some residents had complained about soiling themselves due to long call light response times. The ADON said if the call lights were not answered in a timely manner, the residents could soil themselves, experience falls or experience other injuries. The NHA said the facility was aware the call light response times were longer than they should be. The NHA said the facility planned to address extended call light response times at the quality assurance and performance improvement (QAPI) meetings and would perform audits of the call light response times and elicit input from the staff for improvement.

Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for three (#7, #8 and #13) of five residents reviewed for notifications out of 16 sample residents. Specifically, the facility failed to provide Resident #7, Resident #8 and Resident #13 with.timely written and/or verbal notification of room and/or roommate changes. Findings include: I. Facility policy and procedure The Room Change/Roommate Assignment policy, undated, was provided by the assistant director of nursing (ADON) on 3/20/25 at 9:33 a.m. The policy revealed changes in room or roommate assignments were made when the facility deemed it necessary or when the resident requested the change. Resident preferences were taken into account when such changes were considered. Prior to changing a room or roommate assignment, all parties involved in the change/assignment (residents and their representatives) were given at least a five-day advance written notice of such change. Advance written notice of a roommate change included why the change was being made and any information that would assist the roommate in becoming acquainted with his or her new roommate. Residents had the right to refuse to move to another room in the facility if the purpose of the move was to relocate the resident from a skilled nursing unit within the facility to one that was not a skilled nursing unit. Residents had the right to refuse to relocate the resident from a nursing unit within the facility to one that was a skilled nursing unit. Residents had the right to refuse to move solely for the convenience of the staff. If a resident exercised his or her right to refuse a room change, this would not affect the resident's eligibility or entitlement to Medicare or Medicaid benefits. Documentation of a room change would be recorded in the resident's medical record. II. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included mild cognitive impairment, major depression, chronic pain syndrome, fibromyalgia, asthma, edema, diabetes mellitus and chronic embolism and thrombosis of deep veins of the right lower extremity. The 2/20/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independent for toileting, upper and lower body dressing. B. Resident representative's interview On 3/19/25 at 2:55 p.m., Resident #7 was asleep in her room. The resident's representative was in the room. The representative said Resident #7 was moved from a room on one hall to a different room on another hall because the hall that the initial room was on was being converted to private pay rooms. C. Record review -Review of Residents #7's electronic medical record (EMR) revealed no documentation to indicate the resident or the resident's representative was informed of the room change, that the resident had the right to refuse relocation from a nursing unit within the facility to one that was a skilled nursing unit or that the resident had the right to refuse to move rooms solely for the convenience of the staff. III. Resident #8 A. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia, diabetes mellitus, anxiety, chronic pain syndrome, polyneuropathy and macular degeneration. The 2/20/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required partial/moderate staff assistance (staff member did less than half of the effort) for toileting. The resident required substantial/maximal staff assistance (staff member did more than half of the effort) for upper and lower body dressing. B. Resident's representative interview On 3/19/25 at 2:55 p.m., Resident #8 was asleep in his room, which he shared with Resident #7. The resident's representative was in the room. The representative said Resident #8 was moved from a room on one hall to a different room on another hall because the hall that the initial room was on was being converted to private pay rooms. C. Record review -Review of Residents #8's EMR revealed no documentation to indicate the resident or the resident's representative was informed of the room change, that the resident had the right to refuse relocation from a nursing unit within the facility to one that was a skilled nursing unit or that the resident had the right to refuse to move rooms solely for the convenience of the staff. IV. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included stage 4 chronic kidney disease, lymphedema, gout, polyarthritis and history of malignant neoplasm of the breast. The 1/17/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent for toileting, upper and lower body dressing. B. Resident interview Resident #13 was interviewed on 3/19/25 at 3:20 p.m. Resident #13 said she did not know why she was moved from her previous room, which was a private room, or why she now had a roommate. She said the facility did not give her a written notice before they moved her to her current semi-private (shared) room. C. Record review -Review of Residents #13's EMR revealed no documentation to indicate the resident or the resident's representative was informed of the room change, that the resident had the right to refuse relocation from a nursing unit within the facility to one that was a skilled nursing unit or that the resident had the right to refuse to move rooms solely for the convenience of the staff. V. Staff interviews The nursing home administrator (NHA), the ADON, and the regional director of operations (RDO) were interviewed together on 3/20/25 at 3:37 p.m. The NHA, the ADON and the RDO agreed the Resident #7 was moved from one room to another room on a different hall. The NHA, the ADON and the RDO agreed there were no progress notes in Resident #7's EMR about the room move and there was no documentation to indicate that a room/roommate change form had been completed. The NHA, the ADON and the RDO agreed there should have been progress notes and/or documentation of the completion of the form. The NHA, the ADON and the RDO agreed Resident #8 was moved from one room to another room on a different hall. The NHA, the ADON and the RDO agreed there were no progress notes in Resident #8's EMR about the room move and there was no documentation to indicate that a room/roommate change form had been completed. The NHA, the ADON and the RDO agreed there should have been progress notes and/or documentation of the completion of the form. The NHA, the ADON and the RDO agreed the Resident #13 was moved from a private resident room to a semi- private room room. The NHA, the ADON and the RDO agreed there were no progress notes in Resident #13's EMR about the room move and there was no documentation to indicate that a room/roommate change form had been completed. The NHA, the ADON and the RDO agreed there should have been progress notes and/or documentation of the completion of the form. The NHA, the ADON and the RDO agreed there were no progress notes to indicate Resident #13 was introduced to her new roommate before the room move occurred or that the two residents agreed to the room change.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for four (#1, #5, #6 and #8) of five residents reviewed for hospice services out of 11 sample residents. Specifically, the facility failed to: -Obtain a complete physician's order for hospice care for Resident #1 and Resident #8; -Ensure hospice agency notes were easily accessible to facility staff and have consistent documentation of hospice care visits and updates for Resident #5, Resident #6 and Resident #8; -Initiate a hospice care plan timely for Resident #6. Findings include: I. Facility policy and procedure The Hospice policy, dated 2/29/24, was provided by the regional clinical director (RCD) on 9/16/24 at 5:39 p.m. It read in pertinent part, When a facility resident elects to have hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based upon an assessment of the resident's needs and living situation in the facility. Develop a plan of care that reflects the participation of the hospice agency and the facility, and the resident and family to the extent possible. Ensure that the plan of care identifies the care and services which the facility and hospice agency will provide in order to be responsive to the unique needs of the resident and their expressed desire for hospice care. Hospice communication will be reviewed and added to the medical record. Provide revisions to the plan of care to reflect the resident's most current status. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and passed away on 8/15/24. According to the September 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage in multiple body parts), osteoarthritis (degeneration of joint cartilage causing pain and stiffness), chronic pulmonary embolism (blood clots in arteries of the lung), atrial fibrillation (irregular heartbeat) and mild vascular dementia (cause by impaired blood supply to the brain). The 7/27/24 minimum data set (MDS) assessment revealed the resident had revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment documented Resident #1 was dependent on staff transfers and used a wheelchair for mobility. The MDS assessment did not indicate the resident was receiving hospice services. B. Record review The 8/16/24 nursing progress note documented the hospice nurse was called at 10:30 p.m. on 8/15/24 to notify her of the resident's passing. -A review of Resident #1's electronic medical record (EMR) did not include a physician's order for hospice care. III. Resident #5 A. Resident status Resident #5, age 89, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, peripheral vascular disease (narrowing of blood vessels), and hypertension (high blood pressure). The 8/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to complete the brief interview for mental status (BIMS). She required minimal assistance with walking and required substantial to maximal assistance with dressing and personal hygiene. The assessment indicated Resident #5 was receiving hospice services. B. Record review The hospice care plan, initiated on 8/8/23 and revised on 3/4/24, indicated Resident #5 was receiving hospice services since August 2023. A physician's order, dated 8/8/23, for hospice evaluate and treat for primary diagnosis of non traumatic subdural hemorrhage. A review of the hospice notes in the facility EMR revealed the last hospice notes uploaded into the facility EMR were dated 7/18/24. There was no documentation in the resident's EMR indicating Resident #5 had been discharged from hospice services. -However, the director of nursing (DON) indicated Resident #5 was discharged from hospice services on 8/16/24 (see interview below). IV. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included pulmonary fibrosis (scarring of lung tissue causing shortness of breath and fatigue), chronic respiratory failure with hypoxia (low oxygen level), cardiomegaly (enlarged heart), chronic kidney disease, anxiety disorder and hypertension (high blood pressure). The 8/10/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of five out of 15. She required partial to moderate assistance with personal hygiene and transfers and used a wheelchair for mobility. The assessment indicated Resident #6 was receiving hospice services. B. Record review The physician's order indicated Resident #6 was admitted to hospice care on 4/1/24 with a diagnosis of chronic kidney disease stage 3. The facility hospice care plan was initiated on 4/27/24. -The care plan was initiated 26 days after the resident was admitted to hospice services. -A review of the facility EMR did not reveal hospice progress notes from August 2024 or September 2024 in the EMR. V. Resident #8 A. Resident status Resident 81, age 80, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included multiple sclerosis (disease that affects the nervous system), Alzheimer's dementia and chronic pain. The 6/29/24 MDS assessment revealed Resident #8 had severe cognitive impairments with a BIMS score of three out of 15. He required total assistance from staff with personal hygiene, dressing, transfers and did not walk. He was independent with wheelchair mobility. The assessment did not indicate Resident #8 was receiving hospice services. B. Record review A hospice care plan for Resident #8 was initiated on 12/19/23. The care plan did not include specific interventions for Resident #8 or indicate what care hospice staff would be providing. According to Resident #8's physician's orders, his level of care was changed to hospice on 1/8/24. -However, the physician's order did not include a diagnosis for the need for hospice care. -A review of the resident's EMR did not reveal hospice progress notes from August 2024 or September 2024. VI. Interviews The DON was interviewed on 9/16/24 at 4:45 p.m. The DON said if a resident's family asked for hospice services, the facility contacted the provider to request a physician's order for a referral to hospice services. She said the physician's order was entered into the EMR and a referral was sent to the hospice agency. The DON said she was not sure how long it usually took for hospice to respond and do an assessment because she had only worked at the facility a couple of months. The DON said the referral for Resident #1 was a special situation, because she requested hospice to come out right away since the resident was declining. She said Resident #1 was admitted to hospice the same day of the referral. The DON said the steps she took to refer and admit Resident #1 to hospice should have been documented in the resident's EMR and she should have obtained a physician's order. The DON said hospice notes were usually sent to the facility within a week of their visits. She said sometimes the facility had to ask for them. The DON said when they received the notes, the medical records staff uploaded the notes into the EMR. She said it was important for these notes to be accessible to nursing staff so they were aware of any changes in the hospice plan of care. The DON said Resident #5 had been discharged from hospice care on 8/16/24 which was documented on the hospice discharge form. The DON said the discharge form should have been included in Resident #5's EMR. The DON said the floor nurses entered the care plans into the EMR. The DON said the care plan should be updated within 24 to 48 hours of a resident being admitted to hospice care. The DON said the care plan for Resident #6 was not initiated timely. She did not know why it was not completed since she was not working at the facility during this time. The assistant director of nursing for the hospice agency was interviewed on 9/16/24 at 3:53 p.m. She said that when a nursing home resident requested hospice services the nursing home was responsible for obtaining the physician's order for hospice care and creating the plan of care in the resident's EMR. She said the hospice agency faxed their progress notes weekly to the nursing home.

Based on record review and interview, the facility failed to develop and implement an effective discharge plan for one (#5) out of three residents reviewed for discharge planning out of 11 sample residents. Specifically, the facility failed to: -Ensure the discharge planning process was documented in Resident #5's electronic medical record (EMR); and, -Ensure Resident #5's representative was informed of the discharge planning process. Findings include: I. Facility policy and procedure The Transfer and Discharge policy, dated 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 3:36 p.m. It read in pertinent part, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. Non-emergency transfers or discharges - initiated by the facility, return not anticipated. Document the reasons for the transfer in the medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facility attempts to meet the resident needs, and the services available at the receiving facility to meet the needs. Document any danger to health or safety of the resident or other individuals that failure to transfer or discharge would pose. II. Resident #5 A. Resident status Resident #5, age 89, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, peripheral vascular disease (narrowing of blood vessels) and hypertension (high blood pressure). The 8/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to complete the brief interview for mental status (BIMS). She required minimal assistance with walking and required substantial to maximal assistance with dressing and personal hygiene. The assessment indicated Resident #5 had physically aggressive behaviors towards others and wandered, which had worsened since the last assessment and put the resident and others at risk for injury. The resident's discharge goal was not indicated on the assessment. III. Resident #5's representative interview Resident #5's representative was interviewed on 9/17/24 at 11:57 a.m. Resident #5's representative said she was not kept informed of what the facility was doing to assist Resident #5 in discharging to a secured environment. She said she was informed on 7/18/24 that her mom needed to move to a secured unit because of her behaviors and elopement risk. She said she was sad she had to move but agreed in order to keep her safe. She said the facility started to send out referrals but did not keep her informed throughout the process and was not informed that a local facility did an on-site visit recently. The representative said she requested a referral to a facility in Nebraska,since she thought the local facility had denied the referral, but it was not sent. She said the NHA told her it was not a secured facility so they could not send a referral there, however, Resident #5's representative said it was confirmed with that facility there was a secured unit. The representative said she selected specific facilities for referrals to be sent that were within a reasonable distance from her home so she could continue to visit Resident #5 frequently. IV. Record review The social services care plan, updated 5/28/24, indicated Resident #5 would remain in the facility and was receiving hospice services. -A review of the comprehensive care plan did not reveal the residents' need for discharge planning. The 7/18/24 multidisciplinary care conference summary documented the facility's concern for Resident #5's safety due to her wandering and exit seeking. There was discussion about moving Resident #5 to a secured unit for her safety and wellbeing. The resident's representative was not in favor of moving Resident #5 to another facility because she felt her needs could be met at this facility and did not want her moved far from here. The 7/18/24 hospice physician progress note documented Resident #5 was ambulatory within the facility and often walked around with her eyes closed. She did not tend to wander into other resident rooms, nor had she successfully eloped. She wears a wander guard, which had been a successful intervention to prevent elopement. -A review of the resident's EMR did not reveal documentation indicating the resident had attempted to elope from the facility in July 2024 or August 2024. The 7/19/24 physician note documented a care conference was held on 7/18/24 and the facility administration stated they could not adequately monitor Resident #5's wandering. The facility made a case to transfer the resident to a memory care unit but the resident's representative did not agree to this. The 7/22/24 social services progress note documented Resident #5's representative was notified that a referral packet was sent to the preferred long term care communities for Resident #5's placement in a secured community. -However, there was no documentation the representative agreed to the referrals and there was no documentation that the facility provided a facility initiated discharge notice. The 8/1/24 social service progress note documented Resident #5 was not accepted at two of the facilities where she was referred and the representative was notified. The 8/9/24 nursing progress note documented Resident #5's representative was in the facility. The resident's representative agreed to move Resident #5 to a secured memory care unit and referrals would be sent out the next Monday (8/12/24). The 8/12/24 nursing progress note documented a referral was sent to another facility and the representative was notified. The representative also requested another referral be sent. The 8/14/24 nursing progress note documented Resident #5 was accepted by another facility and the representative was notified. -However, there was no documentation in the EMR indicating why Resident #5 was not transferred to the accepting facility. -A review of the resident's EMR from 8/15/24 to 9/16/24 revealed there were no progress notes regarding discharge planning or communication with the representative regarding the status of discharge to another facility and no documentation of a facility initiated discharge notice. A 9/6/24 fax cover sheet was reviewed. It was handwritten, did not include a time stamp and showed the fax referral was sent to a facility in Nebraska on 9/6/24. V. Staff interviews The social service director (SSD) was interviewed on 9/17/24 at 9:40 a.m. The SSD said Resident #5 was exit seeking frequently and eloped a few times. The SSD said she discussed the concerns with the family. The SSD said the representative requested referrals be sent to specific facilities with secured units. The SSD said they had recently sent a referral to a facility in Nebraska, that the representative requested. She said one facility accepted Resident #5 but that facility changed their decision and declined. The SSD said another facility did an onsite visit last week. The SSD said she did not document everything in the resident's EMR. She said she did not save the referral packets that were sent but she may have emails. The SSD was interviewed again on 9/17/24 at 1:50 p.m. The SSD said she thought the director of nursing (DON) sent the referral to the facility in Nebraska but the DON told her she did not. The SSD said the referral was not sent. The NHA was interviewed on 9/17/24 at 2:30 p.m. The NHA said a referral to the a facility in Nebraska had not been sent because they did not have a secured unit. The NHA said she communicated this to Resident #5's representative. The regional clinical resource (RCR) was interviewed on 9/17/24 at 2:45 p.m. The RCR said the facility in Nebraska did have a secured unit and a referral was sent last week.

Based on interviews and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (#1 and #5) of three residents out of 11 sample residents. Specifically, the facility failed to: -Ensure the as needed (PRN) pain medication had parameters for Resident #1; and, -Appropriately assess pain for Resident #5. Findings include: I. Professional reference The American Medical Directors Association (AMDA) The Society for Post-Acute and Long-Term Care Medicine Pain in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline. [NAME], MD (2021), was retrieved on 9/18/24 from www.paltc.org, read in pertinent part, When several options for administering analgesics are ordered for a patient, nursing staff need adequately detailed guidance concerning how and when to select a PRN medication from among the several options that have been ordered. II. Facility policy and procedure The Pain Management policy, dated 5/3/23, was provided by the regional clinical director (RCD) on 9/16/24 at 5:39 p.m. It read in pertinent part, Purpose: to accurately assess and achieve pain control. Pain evaluations will be documented on the Pain Evaluation in the electronic medical record and/or the Medication Administration Record as applicable, to include location, intensity rating, and response to pain management interventions. When a resident complains of pain, ask the resident to rate the level of pain using the Numerical Scale using a pain level of zero (none) to ten (severe). Cognitively impaired residents or residents unable to respond verbally may not be able to rate their pain using a numeric scale. Non-verbal indicators of pain include: increased agitation, crying, grimacing, holding the area where the pain is located, calling out, decreased appetite, and any other behaviors which are unusual for the resident. Cognitively impaired residents have pain evaluated using the PAINAD (Pain Assessment in Advanced Dementia) scale. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and passed away on 8/15/24. According to the September 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage in multiple body parts), osteoarthritis (degeneration of joint cartilage causing pain and stiffness), chronic pulmonary embolism (blood clots in arteries of the lung), atrial fibrillation (irregular heartbeat) and mild vascular dementia (cause by impaired blood supply to the brain). The 7/27/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment documented Resident #1 was dependent on staff for transfers and used a wheelchair for mobility. B. Record review The comprehensive pain assessment, completed on 7/24/24, indicated Resident #1 had diabetic nerve pain and muscle pain that affected her mood. The assessment documented pain relief interventions for Resident #2 were routine pain medication and relaxation. The pain care plan, initiated on 5/30/24, indicated the resident had pain related to peripheral neuropathy, intervertebral disc degeneration and osteoarthritis. Interventions included administering medication per orders, evaluating the effectiveness of intervention, identifying, recording and treating existing conditions which increased pain, monitoring, recording and reporting non-verbal signs of pain, notifying the physician if interventions were unsuccessful and offering non-pharmacological interventions for pain prior to administering medication. According to the August 2024 CPO, Resident #1 had the following physician orders for pain management: -Gabapentin 600 milligrams (mg) one tablet every morning and at bedtime related to polyneuropathy, ordered on 7/17/24; -Acetaminophen extra strength 500 mg (Tylenol) one tablet every six hours as needed for pain level of one to ten out of 10, ordered on 6/10/24; -Morphine sulfate oral Solution 100 mg/5 milliliters (ml), 0.25 ml every two hours as needed for pain, ordered on 8/14/14; and, -Roxicodone intensol 20mg/ml concentrated solution. Give 0.5ml every four hours as needed for end of life pain, ordered on 8/13/24. -The physician's orders did not include pain parameters for morphine sulfate or Roxicodone indicating when to administer the Tylenol 500 mg versus the morphine sulfate or Roxicodone. According to the August 2024 medication administration record (MAR), the acetaminophen and Roxicodone were not administered. The morphine was administered 21 times for pain levels between 0 and 6 out of 10. According to the August 2024 MAR (8/1/24 to 8/16/24), morphine sulfate was administered at the following times when there was no pain documented. -On 8/13/24 at 11:47 p.m. morphine sulfate 100 mg/5ml, 0.25 ml was administered. The nurse documented it was administered per family request and no indication of pain was noted. The nurse documented the resident's pain level was 0 out of 10 at the time of administration. -On 8/15/24 at 8:15 a.m. morphine sulfate 100mg/5ml, 0.25ml was administered. The nurse documented it was routine morphine per family request for resident comfort. The nurse documented the resident's pain level was 0 out of 10 at time of administration. -On 8/15/24 at 2:22 p.m. morphine sulfate 100mg/5ml, 0.25ml was administered. The nurse documented the morphine was routine for comfort care and the resident's pain level was 0 out of 10. -On 8/15/24 at 4:22 p.m. morphine sulfate 100mg/5ml, 0.25ml was administered. The nurse documented the morphine was routine for comfort care and the resident's pain level was 0 out of 10. III. Resident #5 A. Resident status Resident #5, age 89, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, peripheral vascular disease (narrowing of blood vessels), and hypertension (high blood pressure). The 8/10/24 MDS assessment revealed the resident was severely cognitively impaired and unable to complete the BIMS assessment. She required minimal assistance with walking, required substantial to maximal assistance with dressing and personal hygiene and was on hospice care. B. Record review The pain care plan, initiated on 8/10/24, indicated the resident had pain related to traumatic subdural hemorrhage, peripheral vascular disease, Alzheimer's disease, heart failure, and chronic kidney disease. Interventions included administering analgesia per physician orders, evaluating the effectiveness of pain intervention, notifying the physician if interventions were unsuccessful and offering relaxation, walking, routine pain management, and a quiet environment. According to the August 2024 CPO, Resident #5 had the following physician's orders for assessing the resident's pain: -Pain check every shift using the PAINAD scale (pain assessment in advanced dementia) every shift for monitoring, ordered on 6/10/2024. According to the medical record, the PAINAD was not utilized on a consistent basis for determining Resident #5's pain level. Nurses documented a numerical pain scale (0-10) was utilized 24 days out of the past 30 days (8/18/24 to 9/17/24.) C. Staff interviews The director of nursing (DON) was interviewed on 9/16/24 at 4:45 p.m. The DON said the facility utilized a numerical pain scale for pain assessments and the PAINAD for residents who were unable to communicate or if their cognition was impaired. She said if the physician's order indicated to use the PAINAD the nurses needed to follow that. The DON said Resident #5's pain should have been assessed using the PAINAD due to her cognitive impairment and the physician's order. She said the nurses were not following the physician order when they used the numerical pain scale. The DON said if a resident had more than one as needed pain medication ordered there should be pain level parameters or an indication for use for each medication. She said the nurses should follow the parameters to determine what pain medication to administer. The DON said the nurses should assess pain before administering an as needed pain medication.

Based on record review and interviews, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (#1 and #2) of three residents out of four sample residents. Specifically, the facility failed to: -Offer person-centered non-pharmacological pain interventions for Resident #2; -Ensure pain medication was administered as ordered and the as needed (PRN) pain medication had parameters for Resident #2 and Resident #1; -Follow-up on documented ineffective pain medication for Resident #2; and, -Appropriately assess Resident #1's pain level. Findings include: I. Professional reference The American Medical Directors Association (AMDA) The Society for Post-Acute and Long-Term Care Medicine Pain in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline. [NAME], MD (2021), retrieved on 5/31/24 from www.paltc.org. It read in pertinent part, When several options for administering analgesics are ordered for a patient, nursing staff need adequately detailed guidance concerning how and when to select a PRN medication from among the several options that have been ordered. II. Facility policy and procedure The Pain Management policy, dated 5/3/23, was provided by the clinical nurse consultant (CNC) on 5/28/24 at 2:23 p.m. It read in pertinent part, Purpose: To accurately assess and achieve pain control. All residents will be evaluated for pain by utilizing a pain evaluation tool in (the electronic medical record). The pain evaluation will be completed on admission, readmission, quarterly, and with any significant change in condition. When a resident complains of pain, ask the resident to rate the level of pain using the Numerical Scale, using a pain level of zero (none) to ten (severe). Cognitively impaired residents have pain evaluated using the Pain Assessment in Advanced Dementia (PAINAD) scale. Do not forget the non-pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage, and humor therapy. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan. III. Resident #2 A. Resident Status Resident #2, age 71, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included orthopedic aftercare following surgery related to spondylolisthesis (fracture of a vertebra in the spinal column causing it to slip out of place), spinal stenosis (narrowing of the spinal canal), chronic obstructive pulmonary disease, (lung disorder causing breathing difficulty) and unspecified diastolic (congestive) heart failure. The 4/29/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial to moderate assistance with transfers and walking. The assessment documented he received routine and as needed (PRN) pain medication. The resident did not receive non-medication interventions for pain during the review period. B. Interview and observation Resident #2 was interviewed on 5/28/24 at 1:05 p.m. Resident #2 was in his room sitting in a wheelchair. He said he had a lot of pain due to recent back surgery. He said he took Tylenol, ibuprofen and Norco (hydrocodone-acetaminophen). He said the Norco was cut back to every 12 hours and sometimes it did not relieve his pain after he took it. He said he could take Tylenol as needed but it really did not help. He said he did get a Lidocaine patch (pain patch) which he said helped. He said sometimes the staff forgot to give it to him. He said it was in a different drawer than his pills and the nurses would forget to give it to him. He said the thing that helped the most with his back pain was a bath. He said he could only have a bath two times per week at the facility. He said on a follow-up doctor's appointment, the doctor did a scan and the screws in his back were loose, which was causing him increased pain. C. Record review The comprehensive pain assessment, completed on 4/22/24, indicated Resident #2 had back pain that interfered with his sleep, activities of daily living (ADL) and limited his physical activity. Resident #2 described the pain as sharp and throbbing. According to the May 2024 CPO, Resident #2 had the following physician's orders for pain management: -Celebrex capsule 100 milligrams (mg) two times per day for post-operative pain, ordered 5/24/24; -Norco (hydrocodone-acetaminophen) 10-325 mg one tablet every 12 hours as needed for low back pain, ordered 4/30/24; -Biofreeze External Gel 4 % (menthol topical analgesic) apply to lower back every four hours as needed for pain, ordered 4/29/24; -Ibuprofen tablet 200 mg, give 400 mg three times per day for back pain, ordered 4/23/24; -Tylenol extra strength (acetaminophen) 500 mg, give two tablets every eight hours as needed for back pain, ordered 4/23/24; and, -Lidocaine HCl external patch 4 %, apply to back one time per day and remove per schedule, ordered 4/22/24. According to the May 2024 medication administration record (MAR), the Norco was ineffective for pain rated by Resident #2 as 8 out of 10 on 5/4/24 at 2:35 a.m. and ineffective for pain rated as 7 out of 10 on 5/5/24 at 7:13 pm. -A review of Resident #2's electronic medical record (EMR) did not reveal as needed pain medications were administered when the resident reported ineffective pain follow-up on 5/4/24 and 5/5/24 and there was no documentation indicating non-pharmacological pain interventions were offered. According to the May 2024 MAR (reviewed from 5/1/24 to 5/28/24), the Lidocaine patch was not administered six out of 28 days for the following reasons: -On 5/4/24 the resident declined the patch due to having a bath. There was no documentation that it was applied after the bath. -On 5/8/24 the medication was out of stock. There was no documentation indicating the physician or the pharmacy was notified. -On 5/11/24 the medication was unavailable and the facility was awaiting the order. There was no documentation that the physician or the pharmacy were notified. -On 5/15/24 the medication was not available. There was no documentation that the physician or the pharmacy were notified. -On 5/21/24 the MAR was blank and there was no documentation indicating why the medication was not given. -On 5/23/24 the resident was taking a bath.The charge nurse was notified to apply the patch after the resident finished his bath. There was no documentation indicating the patch was applied after the bath. The MAR was blank. According to the May 2024 MAR (reviewed from 5/1/24 to 5/28/24), Celebrex Capsule 100 mg was not documented as administered on two out of 24 days. The MAR did not indicate the resident received the Celebrex on 5/6/24 and 5/12/24 at 6:00 p.m. According to the May 2024 CPO, Resident #2 had a physician's order for Tylenol 500 mg two tablets every eight hours as needed, Norco 10-325 mg one tablet every 12 hours as needed and Biofreeze external gel every four hours as needed. -The physician's order did not specify when to give the Tylenol 500 mg versus the Norco 10-325 mg. A review of Resident #2's May 2024 MAR (from 5/1/24 to 5/28/24) documented the resident was administered Norco 10-325 mg when Resident #2 reported his pain level at a 3 out of 10 two times. The resident was administered Norco 10-325 mg when Resident #2 reported a pain level at a 4 out of 10 two times. The resident was administered Norco 10-325 mg when Resident #2 reported a pain level at a 5 out of 10 four times. The resident was administered Norco 10-325 mg when Resident #2 reported a pain level at a 6 out of 10 seven times. The resident was administered Norco 10-325 mg when Resident #2 reported a pain level at a 7 out of 10 nine times. The resident was administered Norco 10-325 mg when Resident #2 reported a pain level at an 8 out of 10 fourteen times. The resident was administered Norco 10-325 mg when Resident #2 reported a pain level at a 9 out of 10 one time. The resident was administered Tylenol 500 mg when Resident #2 reported his pain level at a 9 out of 10 on 5/1/24. The resident was administered Tylenol 500 mg when Resident #2 reported his pain level at an 8 out of 10 on 5/4/24. The resident was administered Tylenol 500 mg when Resident #2 reported his pain level at a 6 out of 10 on 5/7/24 and 5/17/24. The resident was administered Tylenol 500 mg when Resident #2 reported his pain level at a 7 out of 10 on 5/14/24. The Biofreeze was applied as needed on 5/2/24, 5/3/24, 5/8/24 and 5/9/24. -However, a review of the EMR did not reveal a pain level was assessed or documented when the resident was administered the Biofreeze external gel. The pain care plan, initiated on 4/22/24, indicated the resident had pain. Interventions included administering medication per orders, reporting to the nurse any complaints of pain, evaluating the effectiveness of the pain interventions and notifying the physician if the interventions were unsuccessful. -A review of the Resident #2's EMR did not reveal documentation of person-centered non-pharmacological pain interventions or documentation that non-pharmacological pain interventions were attempted. D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 5/28/24 at 11:25 a.m. LPN #1 said if a medication was not in the medication cart she would check the medication room where extra medications were stored. She said if the medication was not there she would double check the cart. She said if she could not find the medication in the medication cart she would get it from the medication dispensing machine that contained back-up medications. She said she would order the medication from the pharmacy right away. She said the pharmacy delivered medications to the facility daily at 7:00 p.m. and 1:00 a.m. She said the pharmacy would deliver up to four times per day if needed. She said if a medication was not available in the medication dispensing machine, she would notify the provider to put the medication on hold until it arrived. LPN #2 was interviewed on 5/28/24 at 1:15 p.m. LPN #2 said if a pain medication was not effective, she would do a full pain assessment. She said she would check to see when pain medication was last given to the resident and check to see if the resident had any PRN pain medications that could be administered.She said if there were no physician's orders or if the medication could not be given yet, she would call the on-call provider to ask for additional medication. She said she also offered non-pharmacological interventions such as relaxation, music, massage or asked the resident what worked for them. IV. Resident #1 A. Resident status Resident #1, age 80, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included multiple sclerosis (disease that affects the nervous system), Alzheimer's dementia and chronic pain. The 3/29/24 minimum data set (MDS) assessment revealed Resident #1 had severe cognitive impairment with a BIMS score of two out of 15. He required total assistance with transfers and did not walk. He was independent with wheelchair mobility. B. Resident representative interview The representative for Resident #1 was interviewed on 5/28/24 at 10:20 a.m. Resident #1's representative said his pain medication was recently changed from Fentanyl patches to pills. She said he had missed some doses of the new medication because the pharmacy did not deliver it right away. C. Record review The comprehensive pain evaluation, dated 11/27/23, documented the resident was unable to verbalize his pain level and a non-verbal faces pain indicator was utilized. The May 2024 CPO revealed the resident had a physician's order for staff to monitor the resident's pain level every four hours and document what the resident was doing at the time of the assessment and if the resident was having pain, ordered on 5/15/24. -The physician's order did not specify to utilize the PAINAD scale instead of a numerical scale due to the resident's cognition. -A review of Resident #1's EMR revealed the licensed nurses were not utilizing the PAINAD scale for Resident #1 on a consistent basis. During May 2024 (from 5/1/24 to 5/28/24), the PAINAD scale was utilized 40 times out of 207 opportunities when pain was assessed. The numerical pain scale was used 167 out of 207 opportunities. The pain care plan, initiated on 9/22/17 and revised on 3/24/24, revealed the resident had pain related to multiple sclerosis, bladder neck obstruction, chronic pain and muscle spasms. The care plan indicated the resident was able to call for assistance when in pain, ask for medication, say how much pain he was experiencing and explain what increased or alleviated pain. Pertinent interventions included administering medications as ordered, anticipating the resident's need for pain relief and responding immediately to any complaint of pain, monitoring/recording/reporting to nurse any signs of non-verbal pain, monitoring for probable cause of each pain episode and removing or limiting causes of pain when possible. -A review of Resident #1's EMR did not reveal documentation of person-centered non-pharmacological pain interventions or documentation that non-pharmacological pain interventions were attempted. The May 2024 CPO revealed the resident had a physician's order for Methadone HCL 5 mg, 0.5 tablet two times per day for pain management, ordered on 5/16/24. A review of the May 2024 MAR (from 5/1/24 to 5/28/24) revealed the resident was not administered the Methadone HCL 5 mg 0.5 tablet on 5/16/24 at 7:00 p.m. and on 5/17/24 at 5:00 a.m. -There was no documentation indicating the physician or the pharmacy were notified the medication was not given. The 5/17/24 nursing progress note documented the nurse called the pharmacy at 9:40 a.m. The pharmacy technician advised the nurse the prescription had been received that morning (5/17/24) and would be delivered to the facility at 2:00 p.m. C. Staff interviews The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 5/28/24 at 11:39 a.m. The DON said the medical director reviewed the pain regimen for Resident #1 on 5/15/24. She said the medical director ordered Oxycodone 10 mg three times a day. She said on 5/16/24, the hospice doctor changed the Oxycodone to Methadone HCL 5 mg, 0.5 tablet two times a day. The DON said the hospice physician recommended continuing the Oxycodone until the Methadone was delivered by the pharmacy. -However, the Oxycodone was discontinued on 5/16/24 at 11:07 a.m. leaving Resident #1 without routine pain medication the evening of 5/16/24 and the morning of 5/17/24. LPN #1 was interviewed on 5/28/24 at 3:00 p.m. LPN #1 said pain assessments were completed every shift. She said she completed pain assessments on all of the residents on her assigned unit in the morning at the beginning of her shift. She said she asked the residents to verbalize their pain from 0 to 10. She said if the resident could not verbalize, or if they had dementia, she used the non-verbal assessment. She said she thought the pain assessment order should specify if the licensed nurses were to use the PAINAD. Registered nurse (RN) #1 was interviewed 5/28/24 at 3:05 p.m. RN #1 said she completed a pain assessment if the resident asked for as needed pain medications. She said she used the numerical pain scale. RN #1 said the physician's order specified when to give as needed pain medications. She said after she administered a PRN pain medication she followed-up with the resident about two hours after the medication was given to see if the pain had improved. She said if the pain had not improved then she looked to see if there was another medication she could administer. She said if the resident had dementia she used non-verbal signs of pain like facial expressions.

Based on observations, interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for three (#46, #43 and #25) of six residents reviewed for falls out of 33 sample residents. The facility failed to timely and appropriately implement interventions including assistance with all activities of daily living. The facility failed to provide staff education and increase residents' supervision to prevent falls when all three residents could not ask for staff assistance by using the call light due to severely impaired cognition for Residents #46, #25 and #43. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple falls for Resident #46, including falls that resulted in injuries requiring transfer to a hospital and one fall which resulted in a right hip fracture requiring surgical repair. Findings include: I. Facility policy The Falls and Fall Risk, Managing policy, undated, was provided by the nursing home administrator (NHA) on 3/7/24 at 10:55 a.m. It read in pertinent part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-centered approaches to managing falls and fall risk included: -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. -Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. -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. II. Resident #46 A. Resident status Resident #46, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included essential hypertension, fracture of unspecified part of neck of right femur, presence of right artificial hip joint, presence of left artificial hip joint, osteoporosis, acute respiratory failure with hypoxia (low blood oxygen) and Alzheimer's disease. The 1/15/24 minimum data set (MDS) assessment revealed the resident required supervision with transfers and walking (with a walker). He had one fall, no injury, since the prior assessment. The most recent MDS assessment dated [DATE] revealed severely impaired cognition with a brief interview for mental status (BIMS) score of two out of 15. He required moderate assistance with transfer sit to stand and bed to chair. He received scheduled pain medication for occasional mild pain. The resident had a fall prior to readmission, with a fracture, surgery and partial hip replacement. Medications included an anticoagulant and diuretic. B. Resident observation and representative interview Resident #46 was observed on 3/6/24 at 10:40 a.m. A large blue color bruise was around his right eye. The resident's representative said the resident fell when he lived at home and fractured his left hip. He said Resident #46 did not remember he was weak and unsteady on his feet and still tried to be independent in his room. C. Record review On 1/4/22 Fall Risk Assessment documented a score of five (at risk 10 or higher), indicating Resident #46 was not considered a high fall risk. -However, he had falls prior to admission with a fracture (see representative interview). On 1/23/24 the resident's Fall Risk Assessment score was 13, considered high risk for falls. A review of the resident's comprehensive care plan revealed: (Resident) has an ADL (activities of daily living) self-care performance deficit r/t hx (related to history) of fractures, weakness, hx (history) of falls, heart disease, tricuspid insufficiency (heart valve insufficiency), Alzheimer disease, spondylosis of cervical region (arthritis of the neck). Date initiated 1/4/22 and revised 3/2/22. Interventions included: Toilet use with limited, one person assistance. Encourage the resident to use call bell for assistance (understands use, does not consistently use). Revised 3/2/22. (Resident) is at risk for falls r/t (related to) unsteady on feet, potential side effects of medication, use of assistive devices, altered cardiac status, hx (history) of fx (fracture), left artificial hip, impaired cognition, impaired communication/hearing, incontinence. Date initiated: 1/4/22. Interventions included: Purposeful rounds. Tab alarm in wheelchair and recliner, pad alarm while in bed (initiated 2/7/24). 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. Date Initiated: 1/4/22. (Resident) has impaired cognitive function AEB (as evidenced by) BIMS (brief interview for mental status) score r/t (related to) Alzheimer's. Date initiated 1/4/22, revision 3/2/22. Interventions included: Call bell within reach, answer promptly. Assist with decision making by giving simple choices in daily cares. Keep the resident's routine consistent. -The facility failed to appropriately assess Resident #46's call light use ability. -After Resident #46's fall with major injury, hospitalization and surgery (see below), the only intervention added in the care plan to prevent falls was tab alarm in wheelchair and recliner, pad alarm while in bed. 1. Fall #1 On 1/12/24 a nurse documented: CNA (certified nurse aide) reported that resident is on the floor laying on a blanket. RN (registered nurse) assessed resident, H/T (head to toe) assessment with no injury noted. Staff showered resident and no red/bruised or open areas noted. Resident did not say if he fell or not. When asked by this nurse at breakfast he grinned and shrugged his shoulders. Resident resumed normal activities of the day. Denies any c/o (complain of) pain or discomfort. On 1/12/24 an incident description completed by a registered nurse revealed the following: staff reported that resident was laying on the floor on his blanket, saw resident on his right side with his blanket spread out under him, in no distress. No injuries, up and ambulating to the bath without change in gait, with walker. No injury noted in the bath. Call bell on the bed, not activated. On 1/12/24 a nurse documented: Resident complained that his shoulders and right leg are hurting. When LPN (licensed practical nurse) went in to reassess resident and asked about his pain, he denied pain. Family states that he doesn't like to complain. They are taking him to ER (emergency room ) to be evaluated. Resident left facility via POV (private vehicle) in stable condition. On 1/14/24 a nurse documented: New complaints of pain and action taken: 7/10 (seven out of ten), given 2 (two) extra strength Tylenol at 12:00 a.m. with + (positive) effect. On 1/15/24 a restorative nurse aide (RNA) documented: Fall intervention: Resident found on floor next to bed. Fall intervention is low bed and fall mat. On 1/15/24 the interdisciplinary team (IDT) post fall review revealed: (Resident) has not fallen since April of 2023. He currently resides in a room by himself at the end of the hallway. Per his most recent MDS, he scored a 2/15 indicating severe cognitive impairment. He has communication difficulties with minimal difficulty hearing others, he does not use HA (hearing aids), understands others and is understood. He uses a FWW (front wheeled walker) with ambulation and needs some assistance with his ADLs. This fall occurred in his room as he was wrapped up in a blanket. He had gripper socks on at the time of the fall. Per the nursing notes, this fall occurred before 0700 (7:00 a.m.) that morning. No injuries were noted at the time of the fall and post fall. He did not use his call light, but it was within reach prior to the fall. This fall occurred likely due to him getting up for the morning. Staff assist him PRN (as needed) with bed mobility and dressing. Due to his significant cognitive impairment, he is not able to recall the reason for the fall. An electric low bed was implemented, and a fall mat was placed next to his bed for when he is in his bed, to prevent fall related injuries. Care plan reviewed. -However, according to progress notes (see above) the resident had new complaints of pain following the fall. -The resident's care plan was not updated with the new fall interventions. 2. Fall #2 On 1/16/24 RN documented: Date and time of fall 1/16/2024 at 1700 (5:00 p.m.). MD (physician) notified .New complaints of pain and action taken: c/o (complaints of) right hip pain, slight internal rotation noted. Resident roller chair noted in middle of room, appropriate nonskid shoes noted, floor dry free of other hazards, call light not within reach. On 1/16/24 a nurse documented: Contacted (hospital) ER (emergency room ) to inquire of res. (resident's) status, res(ident) has been admitted to the hospital with dx (diagnosis) of rt. (right) femur fracture. The 1/16/24 orthopedic consultation report revealed the following: The patient is [AGE] years old. He is assessed through the ER (emergency room ) on 1/16/24 with right hip pain following a fall at a nursing facility. He has a subcapital fracture with displacement and is a candidate for surgical management .Right hip procedure will include cemented endoprosthesis to bipolar arthroplasty. Resident #46 was hospitalized for seven days. On 1/18/24 a RNA documented: Fall intervention: resident had a fall on 1/16/23 he was found on floor with roller chair behind him. Fall intervention is room change to more visible room and had family take roller chairs out of room and replaced with regular chairs. On 1/19/24 IDT note revealed: (Resident) was admitted (to hospital) on 1/16/24 for right femur fx (fracture) with scheduled procedure for 1/17/24 and anticipated return within 3-5 days. (Resident's) room is currently located at the end of the 200 hallway and due to the recent falls, his poor safety awareness d/t (due to) progression of dementia it is the recommendation of the committee to relocate (Resident) to a room closer to nurses' station for closer monitoring. We will also ask the family to remove the kitchen roller chairs. (Resident) will be relocated to (room #) a highly visible room that is close proximity to 1/4 wing nurse station. Care plan will be reviewed and updated at time of readmission. Family was in agreement with recommendations and have taken the chairs home. On 1/23/24 a Nursing Admission Assessment revealed Resident #46 had right femoral fracture repaired. On 2/5/24 social worker documented: Following RCC (resident care conference) with daughter, (name) and son (name), a communication board was hung in (Resident) room, WBing (weight bearing) status, reminders of no ice with water and use of tab alarm in chair and pad alarm in bed for tracking patterns of movement and to help protect the integrity of hip frx (fracture) repair. (name) DON (director of nursing) also is performing an in-service with the 100 (unit) nurses. On 2/6/24 a nurse documented: POA (power of attorney) called and asked if any family could come to help with resident. He wanted to go to his room, but he transfers himself and if he falls and breaks his hip, it won't be good. On 2/12/24 a nurse documented: Alarm on wc (wheelchair), recliner, and bed for resident's safety. He forgets he needs assistance with transfers. The alarm does help resident to hesitate before actually continuing to transfer self. 3. Fall #3 On 2/14/24 a nurse documented: Date and time of fall: 2/14/24 at 1715 (5:15 p.m.) No newly observed injuries. -The details of the fall were not indicated. On 2/15/24 a RNA documented: Fall Intervention: Resident found on the floor on 2/14/24. Intervention is staff education on purposeful rounds. On 2/15/24 IDT post fall review revealed: (Resident) has not fallen this month until this fall. He has poor safety awareness and requires staff assistance with his ADLs due to recent hip fracture. He has been moved to a room closer to the nurses' station within the past month and family has removed his rolling chairs out of his room with his most recent fall. He has severely impaired cognition with a BIMS score of 2/15 per his most recent MDS. He has minimal difficulty hearing, usually is able to make his needs known and to understand others and usually understood by others. His vision is adequate with glasses. He is WBAT (weight bearing as tolerated) and is working with therapy. He was wearing proper footwear at the time of the fall. He does not consistently use his call light. Due to significant cognitive impairment and communication deficits, he does not recall the reason why he was up by his table and the cause of the fall. However, he tested positive for RSV (respiratory synctial virus) and is now under precautions. Deconditioning could also be a potential cause of the fall due to recent surgery and now testing positive for RSV. Restorative has done education with staff for purposeful rounds. He remains in a high traffic hallway where staff are aware to observe him in his room and to monitor for unassisted transfers, and his activity while he is in his room. Continue to work with therapy to maintain strength. Care plan reviewed. 4. Fall #4 On 2/28/24 a nurse documented: (name) in activities came and told this nurse, '(Resident) is on the floor, it looks like it's been awhile because there is dried blood all over the floor.' Grabbed vs (vital signs) equipment while calling (number), asked (name) to send an RN to (Resident #46's) room. Attempted to print paperwork to ship resident out . (name) trying to dress wounds on R (right) head and R (right) arm and hand. Resident c/o (complained of) R (right) hip pain. (name) was helping to hold resident back up, (name) was attempting to keep right leg still. Resident was getting tired of sitting on the floor. I walked EMTs to room while giving report. They left at 1530 (3:30 p.m.). Room is without clutter. Appeared resident walked toward closet and fell then scooted himself back to recliner where he was found. 1455 (2:55 p.m.) (name), CNA and this nurse had redirected resident from another room and since he was going into restroom we took him back to his room and was going to set him on the toilet. Resident refused and wanted in recliner. As I left I reminded (name) to put his alarm on. She said she would and had already picked it up to apply alarm. It appears resident took alarm off and stuck it in his drawer that is beside his recliner. (POA), (name) and (physician) are aware of resident's fall and injuries. ER was given report and EMT's took resident from building at 1530 (3:30 p.m.). The 2/28/24 emergency department report revealed the following: BIBA (brought in by ambulance) from (facility) after fall with head injury over right eye. Does not remember what happened. Skin tear to right elbow. On 2/28/24 a nurse documented: Returned at 1730 (5:30 p.m.). Changed dressing and approximated R (right) elbow. On 2/29/24 a nurse documented: Bruising to eyebrow is now around eye and onto cheek. On 2/29/24 the IDT review revealed: (Resident) has poor safety awareness and requires staff assistance with his ADLs due to recent hip fracture. He has been moved to a room closer to the nurses' station within the past month and family has removed his rolling chairs out of his room with his most recent fall. He has severely impaired cognition with a BIMS score of 2/15 per his most recent MDS. He has minimal difficulty hearing, usually is able to make his needs known and to understand others and usually understood by others. His vision is adequate with glasses. He is WBAT and is working with therapy. He does not consistently use his call light. Due to significant cognitive impairment and communication deficits, he does not recall the reason why he was up by his table and the cause of the fall. However, he tested positive for RSV within the past two weeks and potential deconditioning due to recent hip fracture, and recent RSV. He was sent to the hospital due to c/o hip pain and abrasion to head. Due to significant cognitive impairment, he is not able to recall the cause of the fall. He is on skilled therapy. Restorative placed hipsters on him to prevent fall related injuries due to hx of fracture and repeated falls due to his poor safety awareness. Staff to continue with purposeful rounds to monitor his in-room activities and to help mitigate falls, as he will wear them. Care plan reviewed. C. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/6/24 at 1:30 p.m. She said the staff were to check on the resident within hour increments. She said to prevent further falls the resident should not be left alone in his room because he would try to get up from his recliner. She said the resident could not use the call light. She said the staff frequently brought Resident #46 by the nurses' office and placed him in his wheelchair in front of the television to keep an eye on him. CNA #2 was interviewed on 3/6/24 at 1:40 p.m. She said before the fall with hip fracture, the resident was independent in his room. The staff interventions were to help him to the bathroom before he tried to go without assistance. She said he should call for staff assistance but he did not remember to use the call bell. She said the resident should be checked by staff more frequently, like every 15 minutes, but this intervention was not in the care plan. She said the purposeful rounds intervention did not have a time attached and when staff was busy they did not check on the resident for a couple of hours. The RNA was interviewed on 3/7/24 at 8:07 a.m. She said after a fall, a registered nurse assessed the resident for injuries and let the RNA know of the accident. She said she reviewed the care plan, added new approaches and wrote a note. She said the IDT reviewed each fall once a week. III. Resident #25 A. Resident status Resident #25, age 86, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), the diagnoses included Parkinson's disease with dyskinesia (involuntary movement of the face, arms, legs or trunk), muscle weakness, right artificial hip joint, restless leg syndrome, hypertension and hyperlipidemia. The 1/15/24 minimum data set (MDS) assessment documented the resident was moderately cognitively intact with a brief interview for mental score (BIMS) of 10 out of 15. He required substantial assistance with showering, dressing, toileting and transfers. The resident fell two or more times since he was admitted and since the last assessment. B. Resident interview Resident #25 was interviewed on 3/4/24 at 4:39 p.m. He said he slipped out of his reclining chair when he transferred himself to or from his wheelchair. He thought he slipped because of the bed sheet on the reclining chair. He slept in his chair instead of a hospital bed. He did not know what the facility was doing to prevent him from slipping or falling. He felt like falling was one of those things in life that would happen. C. Observations On 3/4/24 at 1:11 p.m., the resident transferred himself from the wheelchair to the reclining chair. An unidentified housekeeper entered the room as the resident transferred himself. She did not ask if he needed help and no staff entered the room. The housekeeper was in the room until 1:26 p.m. A continuous observation occurred on 3/6/24 from 9:25 a.m. until 11:01 a.m. The resident was sleeping in his bed with his door open. The resident's room was the second to last room in the hallway and according to previous interventions he was supposed to be moved closer to the nursing station. A staff member looked in the resident's room at 9:33 a.m. The staff member did not walk into the resident's room. An unknown dietary aide walked in and out of the resident's room at 9:47 a.m. At 9:58 a.m. an unidentified nurse walked in the resident's room and closed the door. The nurse left the room at 10:01 a.m. and kept the door open approximately 30 degrees. The resident was not visible with the door opened at 30 degrees. At 10:33 a.m., an unidentified staff member walked from an office at the end of the hallway. The staff member did not enter the resident's room. At 10:36 a.m. the same unidentified nurse walked by all rooms in the hallway. She did not enter Resident #25's room. At 10:54 a.m. laundry entered the resident's room and woke the resident up. She put the resident's clothes away and closed the door at 30 degrees. She did not ask the resident if he needed anything. D. Record review The fall care plan, revised 5/10/23, revealed the resident had a care plan for falls. The resident was at risk for falls related to his history of falls, muscle weakness, potential medication side effects, potential vision impairment, cognitive impairment, Parkinson's, psychotropic medication use, potential vision impairment, history of furniture walking, incontinence, increase in tremors, decrease range of motion to bilateral lower extremities (hips), does not consistent call for assistance, refuses the use of slideboard, arthropathy of right hip, benign prostate hyperplasia, right artificial hip, refusal to let staff assist with transfer, potential medication side effects and refusal to use sit to stand lift. Interventions included anti-roll brakes placed on wheelchair (initiated 6/30/21), call do not fall sign placed at bedside (initiated 10/9/19), extra grab bar placed in bathroom to facilitate easier and safer transitions between toilet and wheelchair (initiated 4/12/23), high back wheelchair for proper positioning (initiated 10/20/22), offer and encourage a room closer to the nurse's desk or a high visible room (initiated 11/4/23), purposeful rounds (9/2/18), sign to alert staff of high fall risk on outside of resident's door (initated 10/20/23), extensive two assist and use gait belt (initiated 11/20/23). -The fall risk care plan did not consistently include interventions added after he fell (see below). The 1/19/24 fall risk assessment revealed the resident had intermittent confusion, had one to two falls in the past three months, was chair bound, had a change in medication and had Parkinson's disease. The resident scored a 19 which indicated the resident was a high fall risk. 1. Fall incident on 2/19/24 The 2/19/24 nurse initial fall note revealed the resident was found on the floor between his recliner and his wheelchair. The resident tried to transfer himself from his wheelchair into his recliner to take a nap and slipped between the chairs. The new intervention was resident education on call for staff assistance. -The root cause was not identified. -The physical assessment of the resident was not documented. -The fall care plan did not reveal new interventions. 2. Fall incident on 1/5/24 The 1/5/24 nurse's initial fall note revealed the resident was found on the floor. The resident tried to transfer from his recliner to his wheelchair. The new intervention was staff training to offer toileting after meals. -The root cause was not identified. -The fall care plan did not reveal new interventions. 3. Fall incident on 11/29/23 The 11/29/23 nurse's progress note revealed the resident was found on the floor in front of the recliner. The resident tried to transfer to his wheelchair. The intervention was to call for assistance when toileting. -The root cause was not identified. -The fall care plan did not reveal new interventions. 4. Fall incident on 11/13/23 The 11/13/23 nurse's progress note revealed the resident was found on the floor. The resident tried to transfer to his recliner because he was uncomfortable in his wheelchair for a long period of time. The intervention was to call for assistance when he wanted to transfer to and from his wheelchair. -The root cause was not identified. -The fall care plan revealed there was a call don't fall sign at the bedside initiated on 10/9/19. The care plan revealed to offer and encourage a room closer to the nurse's station or a high visible room initiated on 11/14/23. 5. Fall incident on 9/29/23 The 9/29/23 nurse's fall progress not revealed the resident was found on the floor. The resident had to transfer from his recliner to the wheelchair and slid to the floor. -The root cause was not identified. -There was no intervention documented. -The fall care plan did not reveal new interventions. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 3/7/24 at 11:14 a.m. The CNA said she knew a resident was a high fall risk because therapy told her and when she rounded. She said if a resident fell , she would turn the call light on, ensure the resident was safe and notify the charge nurse. She said typical interventions included to check on residents frequently to see if they had to use the bathroom, if they were thirsty or if they were hungry. She said purposeful rounding was walking up and down the hallway and look in the resident's room. She said Resident #25 was a high fall risk. His interventions were to help him to the bathroom before he tried to go without assistance. Registered nurse (RN) #1 was interviewed on 3/7/24 at 9:52 a.m. She said she knew a resident was a high fall risk based on the resident's cognition and gait. If the resident was restless or their gait was unsteady, she told the CNAs to keep an eye on the resident and keep the resident close to the nurse's station. She said if a resident fell , the registered nurse would do an initial assessment. The assessment included a cognition check and a physical check to see how their gait was and if they had fractures, bruising and skin tears. If the fall was not witnessed, she would monitor for 72 hours with a neurological check. She would notify the provider and the family. She said Resident #25 was a high fall risk because he felt confident to transfer himself. She said CNAs knew he was not compliant with his call light so purposeful rounding was important for his safety. The director of nursing (DON) was interviewed on 3/7/24. The DON said if a resident fell , the nurse responded to do an assessment. The fall assessment was documented in the electronic medical record. After an unwitnessed resident fall, neurological checks started, the provider and family were notified, the care plan was updated to include new interventions and the interdisciplinary team reviewed the fall. She said a nurse knew a resident was a high fall risk based on the fall risk assessment and a CNA knew a resident was a high fall risk based on Kardex (care instructions for CNA). She said one typical intervention was purposeful rounding. She said purposeful rounding was walking into the resident's room to ask if the resident needed something to drink, if the resident was in pain, if the resident needed to go to the bathroom. She said if the resident was asleep, the staff should to go in the room to see if the resident was restless. She said she did not have a frequency for purposeful rounding because the staff were going up and down the hallway to help residents. She said the ideal frequency was an hour. She said Resident #25 was a high fall risk. She said a room closer to the nurse's station opened yesterday and the resident was moving. She said staff that went up and down the hallway should have went into Resident #25's room with the door closed and if he was sleeping. -Resident 25's Kardex did not reveal purposeful rounding to prevent falls. IV. Resident #43 A. Resident status Resident #43, age 99, was admitted on [DATE]. According to March 2024 CPO, diagnoses included nonexudative age-related macular degeneration, bilateral, intermediate dry stage, osteoarthropathy, saddle embolus of pulmonary artery without acute cor pulmonale, history of falling, age-related osteoporosis, insomnia and dementia. The 1/19/24 MDS assessment revealed severely impaired cognition with a BIMS score two out of 15. She required supervision with bed mobility and transfers. She had one fall, no injury. B. Record review The fall risk assessments review revealed: On 10/20/23 Fall Risk Assessment score 14, which indicated high fall risk. On 1/19/24 Fall Risk Assessment score 14, which indicated high fall risk. The comprehensive care plan revealed: (Resident) has an ADL (activities of daily living) self-care performance deficit r/t (related to) external devices, impaired balance, limited mobility, limited ROM (range of motion), musculoskeletal impairment. Date initiated 7/17/22 Resident) is at high risk for falls r/t (related to) confusion, gait/balance problems, hx (history) of falls, right femur fx (fracture). Date initiated 7/17/22. Interventions included: Apply tape to floor bedside bed to aide in unassisted transfers out of bed. Fall leaf to door frame alerting staff high fall risk. Date initiated 2/10/24. Keep w/c (wheelchair) positioned close to bed with wheels lock for unassisted transfers out of bed. Date initiated 2/10/24. Move to a room where she is more visible. Purposeful rounds. Sign to alert staff of high fall risk placed on outside of resident's door. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate nonskid footwear when ambulating or mobilizing in w/c (wheelchair). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. -The facility failed to define a time frame for purposeful rounds. -The facility failed to appropriately assess severely cognitively impaired Resident #43 for the use of a call light. 1. Fall #1 On 12/17/24 a nurse documented: Resident was resting in bed, was trying to get up into w/c (wheelchair) and sustained unwitnessed fall. Resident w/c was at bedside and locked. Resident was sitting on floor with back towards the frame of her bed, feet facing the opposite side of the room. Call light within reach, lying next to resident in bed. 2. Fall #2 On 1/27/24 a nurse documented: CNA reported (Resident) had to be lowered to the floor in her room by her bed. When entering the room this nurse observed (Resident) sitting on her buttock with her back resting against the bed with legs straight and hands at her side. Wheelchair is sitting at bedside with brakes engaged, floor is clean/dry and clutter free. She had her slippers on. C/O (complained of) slight right shoulder pain 1/10. She reports she had just come from the bathroom and was transferring to the bed when she got dizzy. When asked what happened she stated 'I'm keeping the floor warm' and laughed. ROM WNL (range of motion within normal limits), mentation is at baseline. She was assisted up by this nurse and CNA. (Resident) was able to help in getting herself up and into bed. Assisted her to stand and get into bed, notified RN on call, instructed CNA to apply gripper socks due to use of TED hose and ensure pad alarm is on and functioning. On 1/29/24 RNA documented: Fall Interven[TRUNCATED]

Based on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to follow up with residents' concerns brought up by the resident council during regular meetings. Findings include: I. Facility policy A policy for grievances was requested on 3/7/24 at 8:30 a.m. but was not received. II. Resident group interview Resident #27, Resident #30 and Resident #45 were interviewed on 3/5/24 at 4:13 p.m. Resident #27 said there were not enough sit to stand devices (mechanical lifts) so she had to wait a long time to use the bathroom. She said there were two devices for the facility. One device was too big to use in the bathroom. She told a certified nurse aide (CNA) and it was not resolved. Resident #27 and Resident #30 said they met in the main dining room with the doors opened. They said staff went through the dining room during the meeting. The same residents said they did not have an opportunity to talk without staff present at resident council meetings. III. Frequent visitor interview A frequent visitor, with knowledge of the facility, was interviewed on 3/6/24 at 4:47 p.m. She attended both January and February 2024 resident council meetings. She said the sit to stand lift concern was not resolved. She said the meetings were held in an open space and staff attended resident council meetings. The residents did not have an opportunity to speak without staff present. She said the February 2024 meeting was initially held in an open area but moved to a closed dining room. She said two staff members were present at the meeting. IV. Resident council notes Resident council notes from 1/9/24 documented the residents said there was only one sit to stand lift and the residents always had to wait because another resident used the lift. The facility said they had two sit to stand lifts and three hoyer lifts (a different mechanical lift). The devices required two staff members for safety. Resident council notes from 2/14/24 documented no follow up for the sit to stand lift concerns in January 2024 and the residents again expressed concerns over the wait time for the sit to stand lift. -The resident council notes did not document what the facility did to resolve the issue. The old business section of the minutes was left blank. V. Staff interview The nursing home administrator (NHA) was interviewed on 3/6/24 at 3:30 p.m. She said the staff responsible for running the resident council were not available. The staff was the facility driver and was in the community with a resident. She said the January 2024 resident council meeting was managed by the frequent visitor. No staff were allowed to attend. She said the concerns discussed in the resident council were considered grievances. She resolved a grievance by working on solutions in between monthly resident council meetings. The grievance was brought up at the following meeting to confirm the concern was resolved. She said a closed space was challenging because they had outbreaks. She said the February 2024 meeting was initially in an open space area and then moved to a small closed dining room. The NHA was interviewed on 3/7/24 at 8:22 a.m. She reviewed the grievance for sit to stand lifts that were filed after the February 2024 resident council meeting. She said Resident #27 ate her meals in her room because she had Parkinson's disease and she recently had increased shaking. The facility had a psychotropic review on 3/4/24 to change the medications to reduce her shaking so she could eat in the dining room. Since she ate in her room instead of the dining room, she was ready to use the bathroom sooner. -However, the grievance was not resolved (see interview above).

Based on observations, interviews and record review, the facility failed to use a person-centered approach when determining the use of bed rails for ten (#2, #22, #26, #36, #43, #58, #59, #62, #68 and #71) residents with bed rails out of 33 sample residents. Specifically, the facility failed to ensure for Residents #2, #22, #26, #36, #43, #58, #59, #62, #68 and #71: -Assess the resident for risk of entrapment prior to installing bed rails; -Obtain consent from the resident and/or the responsible party prior to bed rail installation; and, -Follow guidelines for maintaining bed rails. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA) Clinical Guidance for the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, updated 2/27/23 and retrieved on 3/5/24 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails included bed rail safety guidelines, read in pertinent part: -Any decision regarding bed rail use or removal from use should be made within the framework of an individual patient assessment. -Bed rail use for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan. -The equipment (beds/mattresses/bed rails) should be inspected, evaluated, maintained, and upgraded to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors. -The patient's needs should be re-assessed and the equipment re-evaluated if an episode of entrapment or near-entrapment occurred, with or without serious injury; this was done immediately because fatal 'repeat' events could occur within minutes of the first episode. -The bed, mattress and any accessories should be monitored and maintained on an ongoing basis. II. Facility policy and procedure The Bed Safety and Bed Rails policy, revised August 2022, was received by the nursing home administrator (NHA) on 3/7/24 at 10:55 a.m. read in pertinent part: The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation (IDT), resident assessment, and informed consent. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This IDT evaluation includes: -An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; -The resident's risk associated with the use of bed rails; -Input from the resident and/or representative; and, -Consultation with the attending physician. The resident assessment to determine the risk of entrapment includes medical diagnoses, conditions, symptoms and/or behavioral symptoms. The resident assessment determines potential risks to the resident associated with the use of bed rails including the following, accident hazards, restricted mobility and psychosocial outcomes. Before using bed rails the staff shall inform the resident or resident representative regarding the benefits and potential hazards associated with bed rails and obtain informed consent. III. Resident #2 Resident #2, over the age of 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included arthritis, fracture and asthma with a history of respiratory failure. The 11/28/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of ten of 15. The resident was independent with dressing, bed mobility, personal hygiene, transfers, toileting and required partial assistance from staff for showers. -The assessment revealed the resident did not use bed rail physical restraints. On 3/4/24 at 10:20 a.m. and 3/5/24 at 9:35 a.m., Resident #2's bed was observed to have bed rails. -Review of Resident #2's EMR revealed no evidence that Resident #2 was assessed/evaluated by the IDT for the reason for using bed rails and there was no Bed Rail Risk Assessment in the record. Additionally, the EMR revealed no evidence of a CPO for bed rails, consultation from the physician for the use of bed rails, documentation of tried and failed alternatives or informed consent for the use of the bed rail(s). The care plan for Resident #2, dated 11/14/22, read the resident was independent with bed mobility. -However, the resident had a left side helper rail/bed rail to aid in transfers and bed mobility. The care plan was not updated to include the resident's current need, assessed 11/28/23, for substantial assistance from staff for bed mobility and transfers. IV. Resident # 22 Resident #22, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease and anxiety. The 12/23/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. The resident required substantial assistance for dressing, bed mobility, personal hygiene and was dependent on staff for transfers, toileting and showers. -The assessment revealed the resident did not use bed rail physical restraints. On 3/4/24 at 10:20 a.m. and 3/5/24 at 9:35 a.m., Resident #22's bed was observed to have bed rails. -Review of Resident #22's EMR revealed no evidence that Resident #22 was assessed/evaluated by the IDT for the reason for using bed rails and there was no Bed Rail Risk Assessment in the record. -The EMR revealed a CPO for a bed rail dated 11/18/18, which read the bed rail was ordered to assist the resident in and out of bed. -However, the date of the order was two years prior to the current admission. Resident #22's care plan, dated 3/4/17, read the resident required total assistance from two staff members for bed mobility and transfers. -The EMR did not reveal evidence of consultation/reevaluation from the physician for the use of bed rails, documentation of tried and failed alternatives or informed consent for the use of the bed rail(s). -Resident #22's care plan failed to include a focus of care, goals and interventions for bed rails. V. Resident #26 Resident #26, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included depression, anxiety and spinal cord cancer. The 1/4/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident required substantial assistance for dressing and personal hygiene and was dependent on staff for bed mobility, transfers, toileting and showers. -The assessment revealed the resident did not use bed rail physical restraints. On 3/4/24 at 10:20 a.m. and 3/5/24 at 9:35 a.m., Resident 26's bed was observed to have bed rails. -Review of Resident #26's EMR revealed no evidence Resident #26 was assessed/evaluated by the IDT for the reason for using bed rails and there was no Bed Rail Risk Assessment in the record. Additionally, the EMR revealed no evidence of a CPO for bed rails, consultation from the physician for the use of bed rails, documentation of tried and failed alternatives or informed consent for the use of the bed rail(s). Resident #26's care plan, revised 11/3/23, read the resident had a helper rail/bed rail to assist the resident with positioning and the resident required total assistance from two staff members for bed mobility. VI. Resident #43 Resident #43, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included history of falls, dementia and macular eye degeneration. The 1/19/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of two out of 15. The resident required substantial assistance for dressing, bed mobility, personal hygiene, transfers, toileting, and showers. -The assessment revealed the resident did not use bed rail physical restraints. On 3/4/24 at 10:20 a.m. and 3/5/24 at 9:35 a.m., Resident #22's bed was observed to have bed rails. -Review of Resident #43's EMR revealed no evidence that Resident #43 was assessed/evaluated by the IDT for the reason for using bed rails and there was no Bed Rail Risk Assessment in the record. Additionally, the EMR revealed no evidence of a CPO for bed rails, documentation of tried and failed alternatives or informed consent for the use of the bed rail(s). Resident #43's care plan, revised 3/5/24 (after the start of survey), read the resident had bilateral helper rails to assist the resident with bed mobility and the resident required extensive assistance from two staff members for bed mobility. VII. Resident # 59 Resident #59, age 79, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included chronic kidney disease and muscle weakness. The 12/18/23 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 12 out of 15. The resident required substantial assistance for dressing, bed mobility, personal hygiene, transfers, toileting, and showers. -The assessment revealed the resident did not use restraints or bed rails. On 3/4/24 at 10:20 a.m. and 3/5/24 at 9:35 a.m., Resident #22's bed was observed to have bed rails. Review of Resident #59's EMR revealed an assistive device evaluation for use of a bed rail handle, dated 2/15/24. -The evaluation failed to document Resident #59's cognitive status, pertinent diagnosis, evaluation of gaps between the mattress and the side rail(s), assessment that the mattress will not slide/that it was securely in place and the bed rail was secured to the bed frame. Additionally, the EMR revealed no evidence of a CPO for bed rails, consultation from the physician, documentation of tried and failed alternatives or informed consent for the use of the bed rail. Resident #59's care plan, revised 3/5/24 (after the start of survey), read the resident had bilateral helper rails to assist the resident with bed mobility and the resident required extensive assistance from two staff members for bed mobility. VIII. Resident # 71 Resident #71, age 85, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included spine fracture and need for assistance with personal care. The 2/4/24 MDS assessment revealed the resident was not cognitively impaired with a BIMS score of 14 out of 15. The resident required supervision with oral and personal hygiene, partial assistance for transfers and dressing upper body, substantial assistance for toilet hygiene and was dependent on staff for dressing lower body. The resident refused assessment for bed mobility, showers and transfers for showers. -The assessment revealed the resident did not use restraints or bed rails. On 3/4/24 at 10:20 a.m. and 3/5/24 at 9:35 a.m. Resident #22's bed was observed to have bed rails. -Review of Resident #71's EMR revealed no evidence that Resident #71 was assessed/evaluated by the IDT for the reason for using bed rails and there was no Bed Rail Risk Assessment in the record. Additionally, the EMR revealed no evidence of a CPO for bed rails, consultation from the physician for the use of bed rails, documentation of tried and failed alternatives or informed consent for the use of the bed rail(s). Resident #71's care plan, revised 3/5/24 (after the start of survey), read the resident had a right side helper rail to assist with bed mobility and the resident was independent with bed mobility. IX. Resident #36 Resident #36, age 89, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included heart disease, dementia, behavioral disturbance, psychotic disturbance, mood disturbance, depression, anxiety, osteoporosis (bone disease), pulmonary edema (too much fluid in the lungs), post polio, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and hypokalemia (low potassium). The 1/14/24 MDS assessment documented the resident was severely cognitively impaired with a BIMS of four out of 15. She required substantial assistance with toileting, showering, dressing, personal hygiene and mobility. On 3/4/24 at 10:36 a.m. and on 3/4/24 at 3:02 p.m. a bed rail was on the left side of the resident's bed. The care plan was reviewed. It revealed the resident had an self care performance deficit related to dementia, impaired balance and limited mobility revised on 11/3/23. One intervention initiated on 2/16/21 revealed the resident had a helper rail to assist with bed mobility. -The resident's electronic medical record revealed Resident #36 was not evaluated to use a bed rail, there was not a physician order for bed rails and there was no documentation about the benefits and risks to use a bed rail was explained to the resident or family. X. Resident #58 Resident #58, age 82, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease, insomnia, chronic kidney disease, prediabetes, anxiety and depression. The 1/4/24 minimum data set (MDS) assessment documented the resident was unable to complete the brief interview for mental status score (BIMS). She was dependent on toileting, showering, dressing, personal hygiene and mobility. She required substantial assistance with oral hygiene and she required moderate assistance with eating. On 3/5/24 at 9:14 a.m., rails were on both sides of the resident's bed. The resident's electronic medical record revealed Resident #58 was not evaluated to use a bed rail, there was not a physician order for bed rails and there was no documentation about the benefits and risks to use a bed rail was explained to the resident or family. XI. Resident #62 A. Resident status Resident #62, age 90, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included emphysema (lung disease), history of falling, atrial fibrillation (irregular heart rhythm), macular degeneration (eye disease that effects vision), anemia (low red blood cells) and hyperglycemia (high blood sugar). The 1/17/24 MDS assessment documented the resident was moderately cognitively intact with a BIMS of 11 out of 15. She required partial assistance with showering and mobility. On 3/4/24 at 3:30 p.m. and on 3/5/24 at 8:57 a.m. rails were on both sides of the resident's bed. -The care plan was reviewed on 3/4/24. It revealed bed rails were not identified on how bed rails would help the resident. -The resident's electronic medical record revealed Resident #68 was not evaluated to use a bed rail, there was not a physician order for bed rails and there was no documentation about the benefits and risks to use a bed rail was explained to the resident or family. XII. Resident #68 A. Resident status Resident #68, age 76, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Parkinson's disease with dyskinesia (involuntary movement of the face, arms, legs or trunk), transient ischemic attack (brief blockage of blood flow to the brain), scoliosis and depression. The 11/27/23 MDS assessment documented the resident was moderately cognitively impaired with a BIMS of ten out of 15. He required supervision for oral hygiene, substantial assistance with toileting, showering, dressing and personal hygiene. On 3/4/24 at 3:30 p.m. and on 3/5/24 at 8:57 a.m. rails were on both sides of the resident's bed. Resident #68 was interviewed on 3/5/24 at 8:57 a.m. He said the rails were used to help him roll to the left side when the staff changed his briefs. He said the right side rail was used to help him get out of bed in the morning. -The care plan was reviewed on 3/4/24. It revealed bed rails were not identified to help the resident in transfers and mobility. -The resident's electronic medical record revealed Resident #68 was not evaluated to use a bed rail, there was not a physician order for bed rails and there was no documentation about the benefits and risks to use a bed rail was explained to the resident or family. XIII. Staff interviews Registered nurse (RN) #1 was interviewed on 3/7/24 at 9:52 a.m. She said a helper rail was used when a resident was alert and oriented and could help themselves instead of waiting for a staff member to help them. A resident should be evaluated prior to using a helper rail. The evaluation was based on their level of care based on their everyday needs. She said an example was if they required minimal or extensive assistance. She said consent should be obtained by the resident or family member. The consent went over the risk and benefits of using a rail. It should be reviewed with the doctor and an interdisciplinary team conference should be completed. The director of nursing (DON) was interviewed on 3/7/24 at 10:20 a.m. She said beds were received from the vendor with the side and/or helper rails attached. She said the rails were difficult to remove and were subsequently left attached to the bed frames. The DON said the facility had evaluated all residents for bed rails from bed frames where the rails were not used. The DON said of the remaining residents an audit was completed on 3/4/23 for those residents that needed bed rails. The DON said bed rail evaluations and consents were obtained on 3/5/24 and 3/6/24. Certified nurse aide (CNA) #1 was interviewed on 3/7/24 at 11:14 a.m. She said a helper rail were handles added to the side of the bed. She said rails helped a resident if used appropriately for bed mobility and when the resident went in and out of bed. XIV. Facility follow-up On 3/5/24 the NHA provided additional documentation completed during the survey: Resident #2 signed an informed consent on 3/6/24 for a helper rail. Nursing completed an assistive device evaluation and Resident #2's care plan was revised on 3/5/23 for a left side helper rail. Resident #26 informed consent was obtained from Resident #26's power of attorney for a helper rail. Nursing completed an assistive device evaluation. Resident #43 signed an informed consent on 3/6/24 for bilateral helper rails. Nursing completed an assistive device evaluation and Resident #26's care plan was revised 3/5/24 for the use of bilateral helper rails. Resident #59 signed an informed consent for the use of bilateral helper rails. Resident # 59's care plan was revised on 3/5/24 for the bilateral helper rails to assist with bed mobility. Documentation failed to include trial and outcome of less restrictive measures. Resident #71 signed an informed consent for a helper rail. Nursing completed an assistive device evaluation and Resident #71's care plan was revised on 3/5/24 for the use of a helper rail. -The documentation provided by the NHA on 3/5/24 did not include physician consultation or IDT review for the residents. The assistive device evaluations failed to include evaluations of gaps between the mattresses and the side rail(s), assessments the mattress would not slide, it was secured and the bed rails were secured to the bed frame. For Resident #36 the care plan was updated on 3/6/24 to remove the helper rail intervention. For Resident #58 the care plan was updated on 3/6/24 to remove the helper rail intervention. For Resident #62 a physician order was obtained on 3/5/24 for the resident to have a helper rail. For Resident #68 the care plan was updated on 3/5/24 care plan revealed the resident used bilateral helper bars to maximize independence with transferring and bed mobility. A physical restraint and assistive device evaluation was completed on 3/5/24. It revealed the rail was an assistive device as a helper rail. A physician order was obtained on 3/5/24 for the resident to have a helper rail. 48112

Based on observations, record review and interviews; the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by severe or significant weight loss for three (#76, #68, and #34) of four residents reviewed for nutrition of 35 sample residents. Resident #76 with a [DIAGNOSES REDACTED]. No immediate interventions were put into place to distract or prevent the resident from subsequently pulling out is own [DEVICE] on 10/2/19. After this occurred the failed to; initiate additional interventions to prevent weight loss which contributed to severe weight loss; and implement the registered dietician (RD) recommended interventions to increase caloric intake and prevent severe weight loss. Based on observations, the facility consistently failed to assist and encourage the resident in the dining room which resulted in low meal intakes. The resident received a frozen nutritional supplement orally twice a day upon admission, however, the supplement was frequently refused. No new nutritional interventions were initiated. The resident's significant weight loss occurred on 10/23/19 and his severe weight loss occurred on 10/30/19. Additionally, the most recent nutritional assessment was completed on 9/6/19. There were no current nutritional assessments completed after the resident removed his [DEVICE] and began oral intakes. The most recent nutrition progress note was completed on 10/9/19, which revealed the RD suggested an additional nutrition supplement three times a day. This intervention was not implemented by the facility. There were no additional nursing or interdisciplinary team (IDT) notes evaluating the resident's current oral intake following the removal of his [DEVICE]. The facility failed to assess Resident #68's nutritional status; provide adequate meal assistance in the dining room; evaluate the effectiveness of past nutritional interventions; and implement the RD recommended interventions to prevent significant weight loss. The most recent nutritional assessment was completed on 9/17/19. The resident went to the hospital on [DATE] and experienced a rapid decline in his cognitive function. The facility failed to reassess the resident's nutritional status after his hospitalization which resulted in significant weight loss. In addition, the facility failed to act upon the RD's recommendations to prevent significant weight loss. The facility failed to consistently provide meal assistance and implement care planned interventions to prevent weight loss for Resident #34. The resident was assessed as dependent with activities of daily living (ADLs) which included eating. Observations revealed the facility consistently failed to provide the assistance needed for adequate nutritional status which resulted in significant weight loss. The resident had an open area on his coccyx in addition to his poor nutritional status. Findings include: I. Facility policy and procedure The Nutrition and Unplanned Weight Loss policy, revised (MONTH) (YEAR), was provided by the director of nursing (DON) on 10/31/19 at 1:00 p.m. It read, in pertinent part, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Treatment decision should consider all pertinent evidence and relevant issues (e.g., food intake, resident/patient wishes, overall condition and prognosis, etc.), and should not be based solely on lab or diagnostic test results. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting). The Medication Orders policy, revised (MONTH) 2014, was provided by the DON on 10/31/19 at 1:00 p.m. It read, in pertinent part, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. When recording orders for commercial dietary supplements, specify the type, amount, and frequency. The Acute Condition Changes clinical protocol, revised (MONTH) (YEAR), was provided by the DON on 10/31/19 at 1:00 p.m. It read, in pertinent part, Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. II. Resident #76 [NAME] Resident status Resident #76, age above 80, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/18/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. He required supervision and set up help only with eating and extensive assistance with other activities of daily living (ADLs). Documented was the resident's height: 66 inches and weight: 166 pounds. He experienced a loss of liquids/solids from his mouth when eating or drinking and had no known significant weight loss. He received nutrition through a feeding tube and accepted 51% (percent) or more of total calories through tube feeding. B. Observations Lunch observations on 10/29/19 at 12:19 p.m. revealed the resident received his meal in the assisted dining room. The resident was observed to take a few bites of food then said he was not hungry and left the dining room. The facility failed to offer the resident an alternative option for food. Dinner observations on 10/29/19 at 5:34 p.m. revealed the resident received his meal in the assisted dining room, and again took a few bites of food before he left the dining room. Staff did not approach the resident to encourage eating. Breakfast observations on 10/30/19 at 8:30 a.m. revealed the resident received his meal in the assisted dining room. He did not consume any food before he left the dining room and staff did not encourage the resident to eat his breakfast. Lunch observations on 10/30/19 at 12:15 p.m. revealed the resident received his meal in the assisted dining room. He ate a few bites of his food before he left the dining room. He was asked if he wanted anything else to eat, but was not offered specific items of his liking (to communicate more effectively with a resident who has dementia). Staff did not further encourage him to eat his lunch. Breakfast observations on 10/31/19 at 8:50 a.m. revealed the resident received his breakfast in the assisted dining room. He did not receive prompting or assistance with eating. He left the dining abruptly room and did not eat any of his food. C. Record review The comprehensive care plan, revised 9/19/19, revealed Resident #76 had an activities of daily living (ADL) self-care performance deficit and required supervision and set up assistance with eating. Interventions included, to provide finger foods when the resident had difficulty with utensils, eat in the assisted dining room, and provide milkshakes or liquid food supplements when the resident refused or has difficulty with solid food, or provide nutritious foods that can be taken from a cup or a mug. The Nutrition Admission Assessment, completed on 9/6/19 by the Registered Dietician (RD), revealed Resident #76's weight as 169 pounds upon admission on 9/5/19. It documented his usual body weight as 190 pounds and he experienced a 20 pound loss prior to admission, from his usual body weight. His comprehension was documented as alert and aphasic. The resident's intake was through enteral feeding and he received 2,004 calories per 24 hours with 85.2 grams of protein per day. Review of the weights and vitals summary revealed the following: -9/5/19: 169.0 pounds; -9/18/19: 166.0 pounds; -9/25/19: 167 pounds; -10/2/19: 166.0 pounds (the resident removed his own [DEVICE] on 10/1/19); -10/9/19: 162.0 pounds; -10/16/19: 162.0 pounds; -10/23/19: 156.0 pounds (6.59% weight loss in one month); and -10/30/19: 149.0 pounds (10.24% weight loss in one month). The (MONTH) 2019 CPO revealed the following pertinent orders: -Magic cup ice cream after lunch and after dinner two times per day for weight loss started on 9/6/19; -[MEDICATION NAME] 1.5 calorie liquid nutritional supplement, 334 milliliter via [DEVICE] three times per day for nutrition ordered on [DATE]; The [MEDICATION NAME] was decreased from three times per day to two times per day on 9/13/19. Staff were to provide assistance with oral intake meals at lunch time. The 9/20/19 speech therapy progress note revealed the resident's tube feeding was decreased due to an increase in the resident's oral intake. It was then discontinued on 10/2/19 when the resident removed his [DEVICE]. The (MONTH) 2019 Medication Administration Record [REDACTED]. He refused the magic cup supplementation 18 times, he consumed 50% or less 25 times, and consumed 75-100% 8 times during the month of September. Additional meal intakes for (MONTH) 2019 were unavailable. The (MONTH) 2019 CPO revealed the following pertinent orders: -Magic cup ice cream after lunch and after dinner two times per day for weight loss started on 9/6/19; -[MEDICATION NAME] 1.5 calorie liquid nutritional supplement, 334 milliliter via [DEVICE] at bed time for nutrition ordered on [DATE] and discontinued on 10/2/19; -[MEDICATION NAME] 1.5 calorie liquid nutritional supplement, 334 milliliter via [DEVICE] in the morning for nutrition ordered on [DATE] and discontinued on 10/2/19. The (MONTH) 2019 MAR indicated [REDACTED]. He refused the magic cup supplementation 19 times, he consumed 50% or less 33 times, and consumed 75-100% eight times. The (MONTH) 2019 meal intakes revealed: -Intake was 0-25% for 31 out of 89 meals. (34.8%) -Intake was 26-50% for 21 out of 89 meals. (23.6%) -Intake was 51-75% for 27 out of 89 meals. (30.3%) -Intake was 76-100% for seven out of 89 meals. (7.9%) -The resident refused two out of 89 meals. (2.2%) The 10/2/19 skilled nursing progress notes revealed the resident pulled out his [DEVICE] overnight. His daughter was notified of the incident and said she did not want the [DEVICE] placed again. The physician was notified on 10/2/19 and per the family's request all [DEVICE] orders were discontinued. The facility failed to complete skin assessments to monitor the healing of the [DEVICE] site after it was not replaced. The 10/9/19 RD progress note revealed Resident #76 experienced 4.1% weight loss over 30 days and 2.4% weight loss since the tube feeding was discontinued. She documented the Resident's food and beverage intake was inadequate and recommended the facility provide additional supplementation of choice three times per day. The facility failed to implement the RD's recommended interventions for additional supplementation. The comprehensive care plan, revised 10/9/19, revealed the resident was at risk for a potential nutritional problem due to a history of cerebral infarction with residual effects, missing teeth, nutritional [MEDICAL CONDITION], dysphagia, and history of artificial nutrition support. Interventions included invite resident to activities that promote additional intake, monitor for signs or symptoms of dysphagia and malnutrition, and night time nourishment Magic Cup two times per day. His diet was regular diet, ground meat texture, and nectar thickened liquids. Additional interventions were RD to evaluate and make diet change recommendations, weekly weights, and regular diet, ground meat texture, and thickened liquids. The care plan was revised seven days after the resident removed his [DEVICE] and experienced a weight loss of 4 pounds (2.41%). The 10/10/19 and 10/11/19 speech therapy progress notes revealed the resident was upgraded to regular textured diet, but he required verbal cues for adequate intake. He needed limited distractions during meals for safe and adequate meal intake. -Observations during survey revealed the resident did not receive verbal cues and limited distractions during meals. The 10/11/19 speech therapy note revealed the resident would continue speech therapy two times per week for dysphagia with a new speech therapist. On 10/15/19 the new speech therapy initial assessment was completed, however additional therapy had not been provided at the time of survey. The 10/16/19 physician progress notes [REDACTED]. Additional behavior monitoring and interventions were not implemented at this time. D. Interviews Licensed practical nurse (LPN) #3 was interviewed on 10/30/19. She said Resident #76 pulled out his own [DEVICE] on 10/2/19 during the overnight shift. She said the daughter was contacted the next morning and she did not want the [DEVICE] replaced. She said the physician was contacted after and discontinued the resident's tube feeding. She said the resident was then put on a puree and thickened liquids diet at the time and was upgraded to mechanical soft. She said the facility did weekly weights to monitor the resident's nutrition after he pulled out his [DEVICE] but she did not know who reviewed his recorded weights. Unit manager (UM) #1 was interviewed on 10/30/19 at 1:13 p.m. She said an incident report was not completed when the resident pulled out his own [DEVICE], however, a skilled nursing note was made by the nurse on 10/2/19. The 10/1/19 skilled nursing note, revealed the nurse on the 3 p.m. to 11 p.m. shift, documented the resident continued to improve and was able to make his needs known. The 10/2/19 skilled nursing note, revealed the nurse on the 3 p.m. to 11 p.m. shift on 10/1/19 reported to the oncoming nurse the resident was putting the [DEVICE] down the front of his brief on their shift. The nurse on the 11 p.m. to 7 a.m. shift documented the resident's roommate turned on his call light to notify staff the resident pulled out his [DEVICE] and was trying to sit up in bed. The facility failed to implement interventions to prevent the resident from pulling out his [DEVICE] after he exhibited behaviors of putting his [DEVICE] down the front of his brief. The director of nursing (DON) was interviewed on 10/30/19 at 5:17 p.m. She said the facility did not have a new nutritional assessment completed after the resident pulled out his own [DEVICE]. She said the care plan was updated with his diet texture. She said the resident was able to eat independently but needed some set-up assistance and cueing to eat. She said the staff in the assisted dining room should offer alternative foods if the resident refused to eat what he was served to encourage increased intakes. She said the resident received a frozen nutritional supplement twice a day, but there was not an additional supplement added after the resident's [DEVICE] was pulled out. The DON said after the resident's stimulant medication was discontinued on 10/16/19 she noticed the resident was sleeping more often and his appetite decreased. She said the physician was contacted on 10/24/19, however, additional interventions were not implemented and the resident continued to lose weight. The RD was interviewed on 10/31/19 at 9:16 a.m. She said she was in the facility monthly to see residents in person and reviewed charting every other week, however, she was unable to visit the facility in person during the month of (MONTH) 2019. She said she reviewed any notes in the electronic medical records that referenced the resident's diet changes, weights, and nutritional concerns. She said she evaluated trends in weights if nursing staff notified her, however, she only evaluated weights if they experienced significant weight loss (5% or more in one month or 10% or more in six months). She said she expected nursing staff to notify her of any changes that may affect the resident's nutrition. -Interviews with nursing staff revealed they did not know who monitored weight trends (see interview above). The RD said she was notified when the resident removed his [DEVICE] and she identified initial weight loss on 10/9/19. She said she recommended an additional supplement three times per day at that time, however, she did not follow up to see if the facility started the resident on a supplement. She said she was scheduled to visit the facility on 10/23/19 (the same day the resident had significant weight loss), however, she was unable to go to the facility that day and she did not review the resident's weight loss. She said the facility did not notify her of any significant weight loss and he was not reviewed until 10/30/19 (the day the resident had severe weight loss) when his weight loss was questioned during survey. She said the resident should have received a nutritional supplement in addition to his frozen nutritional supplement. III. Resident #68 [NAME] Resident status Resident #68, age above 80, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/25/19 MDS assessment revealed the resident had a BIMS of four out of 15. Documented was the resident's height: 66 inches and weight: 161 pounds. He had no identified weight loss and no swallowing disorder. The assessment revealed he required supervision and set up help only with eating. -Observations revealed this was incorrect, the resident required assistance in the dining room to eat. B. Observations Breakfast observations on 10/29/19 from 10:23 a.m. to 10:32 a.m. revealed the resident was served breakfast in his room. He was observed pushing and pulling his table back and forth and did not eat his food. He did not receive assistance and was not offered alternative food in his room before the tray was picked up by nursing student (NS) #2 and taken away. Dinner observations on 10/29/19 at 5:44 p.m. revealed the resident did not eat independently when his food was served. His food was served and he waited 20 minutes before he received assistance with his meal. The CNA provided hands on assistance to encourage the resident to eat a few bites. The resident appeared sleepy and disengaged while she attempted to assist for 4 minutes. She did not offer alternative options and he was not provided further prompting to eat his food. He consumed approximately three ounces of juice. Breakfast observations on 10/30/19 from 8:38 a.m. to 5:58 a.m. revealed the resident was sleeping in his wheelchair in the assisted dining room. He consumed approximately 10% of his meal and was not offered an alternative option. The resident was still sitting at the table alone and dietary aide (DA) #2 cleaned his plate and juice off the table. Breakfast observations on 10/31/19 at 8:49 a.m. revealed the resident was sitting in his wheelchair in the assisted dining room. He was served his meal, but did not receive assistance to eat until 20 minutes after his meal was served. The resident was unbuttoning his shirt at the table while he waited for assistance with his breakfast. He ate a few bites and when another resident was offered a chocolate shake the resident requested one also. He consumed chocolate milk but did not eat his breakfast. C. Record review The CPO revealed the resident was ordered weekly weights on 9/16/19 and nourishment of choice in the evening daily on 9/16/19. Review of the weights and vitals summary revealed the following: -9/16/19: 161 pounds; -10/7/19: 151 pounds (6.2% weight loss); and -10/14/19: 149 pounds (7.45% weight loss). The facility failed to obtain weekly weights as ordered upon admission. The admission nutritional assessment was completed on 9/17/19 by the RD. It revealed the resident's usual body weight was 160 pounds and no weight change was identified 180 days prior to admission. His comprehension was identified as disoriented/confused, he was independent to feed himself, and his meal intake was greater than 50%. Additional notes revealed the resident's intake was variable due to dementia and he would benefit from additional nutrition supplementation twice a day to maintain weight. The facility failed to implement the RD's recommendation intervention for additional supplementation twice a day. The (MONTH) 2019 MAR indicated [REDACTED] -120 milliliter (ml) of protein supplement seven out of 15 nights (46.7%). -120 ml of juice five out of 15 nights (33.3%). -He refused two out of 15 nights (13.3%) -There was no documentation one out of 15 nights (6.7%). The (MONTH) 2019 documented meal intakes were unavailable. The (MONTH) 2019 MAR indicated [REDACTED] -240ml of protein supplement one out of 29 nights (3.4%). -120 ml of protein supplement 14 out of 29 nights (48.3%). -120ml of juice one out of 29 nights (3.4%). -90 ml of protein supplement two out of 29 nights (6.9%). -60 ml of protein supplement four out of 29 nights (13.8%). -120 ml of juice one out of 29 nights (3.4%). -He received no supplements three out of 29 nights (10.3%). -He received water as a supplement three out of 29 nights (10.3%). The facility failed to document the type and amount of supplementation in the physician orders [REDACTED]. The resident received inconsistent caloric intakes and water was documented as a supplement. The facility was unable to identify the effectiveness of his nightly nourishment. The (MONTH) 2019 meal intakes revealed: -Intake was 0-25% for 19 out of 89 meals (21.3%). -Intake was 26-50% for 21 out of 89 meals (23.6%). -Intake was 51-75% for 30 out of 89 meals (33.7%). -Intake was 76-100% for 8 out of 89 meals (9%). -He was hospitalized for [REDACTED]. The facility failed to provide or encourage additional supplementation twice a day to prevent weight loss, as identified in the admission nutrition assessment. On 10/20/19, a physician order [REDACTED].#68 to the emergency room for evaluation and treatment for [REDACTED]. The 10/21/19 hospital discharge documentation revealed the resident was diagnosed with [REDACTED]. The 10/21/19 nursing progress note revealed upon the resident's return from the hospital the family requested the resident be taken to the assisted dining room for meals because he needed more assistance with eating. The 10/22/19 social services progress note revealed the facility met with Resident #68's family upon return from the hospital. The family expressed concerns for a rapid decline in the resident's decline in cognitive function. The resident's nutritional status and ability to feed himself was not reassessed upon return from the hospital or after the families concerns regarding the residents' cognitive decline (see above). Observations revealed the resident was unable to feed himself and required hands on assistance from staff. Breakfast observations on 10/29/19 (see above) revealed the facility did not provide assistance with dining; the resident required and as requested by the family. D. Interviews The assistant director of nursing (ADON) was interviewed on 10/30/19 at 5:30 p.m. She said the resident went to the hospital on [DATE] and she noticed a decline in the resident's cognition and ability to feed himself. She said the resident's family requested comfort care at that time, however, that would still allow nutritional supplements and assistance with meals to meet required caloric intake. She said he received occasional supplements at night but he did not receive the recommended additional supplements twice a day. CNA #2 was interviewed on 10/31/19, she said the facility obtained weekly weights for every resident unless otherwise ordered by the physician. She said Resident #68 would not be weighed today because he was already weighed that week. -The facility failed to provide documentation of consistent weekly weights. The RD was interviewed on 10/31/19 at 9:16 a.m. She said she assessed Resident #68 in the facility on 9/25/19 and recommended a nutritional supplement of the physician's choice in addition to the nightly one he was ordered. She said the facility should review the RD recommendations and notify the physician to order the supplements. She said she did not follow up with the facility or monitor the resident to ensure the supplement was provided and ensure the resident met his intake needs. She said she did not speak with nursing staff directly regarding the recommended nutrition supplement. She said she did not review the resident's significant weight loss on 10/14/19. She said the facility implemented the recommended supplement on 10/31/19, after the significant weight change was identified during the survey. She said the facility policy was to obtain weekly weights on all residents to monitor any significant changes in body weight. She said upon review of the resident on 10/31/19, at the time of the survey, she requested a new weight to be obtained. IV. Resident #34 [NAME] Resident #34 Resident #34, age 89, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/24/19 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired and a brief interview for mental status (BIMS) score could not be completed. The MDS indicated the resident had short and long term memory loss, inattention and disoriented thinking. The resident required extensive with most activities of daily living, including on person physical assistance for eating. B. Observations Resident #34 was observed in a reclining wheelchair in the dining room with his eyes closed on 10/29/19 at 12:16 p.m. All other residents were served their meals. There was no attempt to arouse the resident. -At 12:19 p.m., Resident #34 opened eyes as his lunch was placed on the table beside him. -At 12:23 p.m., student nurse (SN) #1, proceeded to feed the resident his meal of pureed chicken fried steak. For each bite SN #1 referred to the as Mister. Between 12:23 p.m. and 12:35 p.m. The SN did not interact with the resident other than to refer to him as Minster or take a bite. She did not sit in front of Resident #34, but beside him having to reach across his chair to reach his mouth. Resident #34 consumed 2 small bites of pureed steak and several sips of his glass of thickened juice. -At 12:35 p.m., Resident #34 coughed slightly as he chewed the last bite. SN diverted her attention away from Resident #34 to feed another resident. -At 12:36 p.m., the resident finished chewing. Between 12:36 p.m. and 12:43 p.m. the resident sat next to his meal, with her eyes open. He was not offered additional food or drink. The NS continued to feed another resident and talked to other staff members. -At 12:43 p.m., she offered another him another sip of thickened juice and a bite of his pureed carrots. The resident accepted the offers. -At 12:44 p.m., NS #1 left the resident to speak to another staff member at the next table. -At 12:45 p.m., she sat next to Resident #34 as she continued to speak to another staff member. Between 12:47 p.m. and 12:49 p.m., she offered the resident two more bites of pureed steak referring to the resident as mister. -At 12:49 p.m. she diverted again to focus on a conversation between other staff members next to her. Between 12:51 p.m. and 1:00 p.m., the NS offered more juice and 2 more small bites of his meal as she continued to focus on staff conversations and looking around the dining room. She did not interact with the resident. - At 1:00 p.m., she got up and walked around the dining room. - At 1:01 p.m. offered the resident another drink, placed his chair in a reclined position. Resident #34 then coughed and sneezed. She did not attempt to offer the resident more food. From 1:01 p.m. and 1:05 p.m. the resident sat awake next to the remainder of his meal. - At 1:05 p.m. NS #1 left without offering or asking if he wanted more food. - At 1:11 p.m. CNA #1 took the resident out of the dining room. - At 1:18 p.m. DA #1 recorded his meal intake at 25%. On 10/30/19, Resident #34 was observed during lunch between 12:10 p.m. and 12:44 p.m. - At 12:14 p.m., the lunch meal was placed next to Resident #34. The resident sat in his wheelchair with his eyes closed. The resident was not prompt to open his eyes nor was there attempts to feed him. - At 12:23 p.m., certified nursing aide (CNA) #3 sat beside him to the resident an attempt to feed by placing a spoon on the resident's lips. She did not speak to the resident. The resident did not accept the two offered bites. -At 12:24 LPN #4 provided the resident his med pass. CNA #3 left the resident. -At 12:27 p.m., CNA #1 sat next to Resident #34. She did not speak to the resident or attempt to encourage him to open his eyes and she made two offers to feed the resident by placing the spoon on his lips. -At 12:30 p.m., CNA# placed his chair in a reclined position and left Resident #34 to feed another resident. -At 12:31 p.m. the director of nursing (DON) approached CNA # 1. The CNA told her Resident #34 would not eat. Between 12:31 p.m. and 12:44 p.m., the DON sat in front of the resident. She called him by his name, rubbed his arm, encouraged and cued him to eat starting with his dessert. His chair remained in a reclined position. The resident consumed four spoon fills of his thickened juice, a portion of his whipped creamed Jell-O and two bites of his entree before he stopped accepting offers. The DON assisted him out of the dining room. 2. Record review The (MONTH) 2019 CPO identified the resident was on a pureed diet with honey thickened liquids. According to the CPO, the resident had an order for [REDACTED]. The 5/23/19 annual history and physical physician assessment read the resident was Declining to nearly non-restorative state with full dependence .comfort care only .tolerated current diet. The 7/17/19 and 9/28/19 physician notes indicated the resident did not have a change in condition. The weight summary record was reviewed for weight loss. According to the record, the resident lost 10 lbs. in a month indicating a 7.30% loss between 10/1/19 and 10/29/19. The resident had a 9.29% total loss between 8/27/19. All recorded weights were taken with the tub scale. The weight change note on 10/23/19 identified the resident was recommended by the registered dietitian for liquid prostat at 30 ml twice a day. The (MONTH) 2019 Medication Administration Record [REDACTED]. The 10/29/19 physician phone order read the prostat was not advised, Does not accept thickened fluids very well. The 10/29/19 nurse note read the physician did not advise prostat. According to the note, the resident does not accept thickened fluids very well. The care plan for (TRUNCATED)

Based on observations, record reviews, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for residents, including six of 47 sample residents (#8, #39, #34, #99, #79, #81). Specifically, the facility failed to: -Ensure appropriate interventions were implemented and followed to prevent actual elopements for cognitively impaired residents #8, #39, and #81 and potential elopements for cognitively impaired residents #34, #99, and #79), who were deemed elopement risks by the facility. -Ensure oxygen was stored appropriately The findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy for Serious Harm Record review and interview revealed resident #8, who was cognitively impaired, ambulatory, and who was deemed an elopement risk by the facility, was seen ambulating near the front lobby on [DATE] at approximately 2:45 a.m. The resident was not approached, redirected, or further monitored. She then exited the facility at approximately 3:00 a.m. on [DATE] via the front door. The front door was equipped with an alarm which sounded until deactivated. A staff member, assuming it was the newspaper delivery person, deactivated the alarm although she did not see a newspaper. An immediate search was not conducted outside to ensure a resident had not eloped. The resident was discovered missing at approximately 3:30 a.m. on [DATE], after a routine "bed check." Although the resident was seen ambulating near the front lobby and a door alarm sounded, the interior of the facility was searched initially by facility staff. When the resident was not found, the search was expanded outside. A staff member, who clocked out on [DATE] at 4:40 a.m., got into her vehicle, turned her headlights on, and saw the resident on the ground near a church approximately 350 feet away from the facility. The resident was assessed, brought into the facility, and an attempt was made to warm her. The resident's body temperature would not rise and she was admitted to the hospital with [REDACTED]. The facility's elopement policy only instructed facility staff to provide "increased vigilance" with no further instruction after an elopement attempt. Moreover, it did not instruct facility staff what to do if a resident deemed to be at high risk of elopement was seen wandering near egresses in the facility. After this elopement, the facility had no plans to conduct formal inservicing of their staff on their elopement policy, no plan to review and amend their elopement policy as appropriate, or further implement measures to prevent additional resident elopements. This failure created a situation of immediate jeopardy for serious harm. On [DATE] at 3:45 p.m., the nursing home administrator (NHA), assistant administrator (AA), and director of nursing (DON) were informed the facility's failure to ensure appropriate interventions were implemented and followed to prevent actual and potential elopements for cognitively impaired residents created a situation of immediate jeopardy for serious harm. B. Plan to Remove Immediate Jeopardy On [DATE] at 5:01 p.m., the fifth draft of the facility's plan to remove immediate jeopardy was presented, reviewed, and accepted. The plan documented in its entirety: "The elopement policy has been updated in light of the incident of [DATE]: The following items will be used to further define the policy: --The door alarms have been inspected by the Maintenance Director and the volume was elevated so the sound could be heard more clearly. --Magnetic alarms have been installed by the Maintenance Director for doors without alarms. --The 200 Nurse will be in charge of activating the night alarm at dark. (The night alarm sounds and remains sounding until manually switch off.) --The door alarm will be placed in night mode by the oncoming ,[DATE] shift nurse assigned to the 200 nurses' station. --The door alarm will be placed in the day mode by the ,[DATE] shift nurse assigned to the 200 nurses' station at the end of the shift. --Phone paging will be done by the charge nurse to alert all staff of a missing person. --The nursing staff will make rounds every ? hour to check every resident at risk for elopement using the wandering elopement monitoring form. The monitoring form will be posted in each resident's room either in the bathroom or inside the closet door. Rounds will be individualized for specific resident per assessment. --Elopement drills will be done on a quarterly basis and monitored by the Quality Assurance Nurse. --The Quality Assurance nurse will report to the Administrator, Medical Director and Utilization Committee on a quarterly basis. The report will be discussed and recommendations made as necessary. --The Care Plans were updated on [DATE] for all Residents on Elopement Risk List. In-service Training: --All nursing staff, currently working and those working the oncoming shifts, have been and will be in-serviced one on one to discuss revisions to the elopement policy. All other staff will be notified and participate in the one on one in-service of the elopement policy upon arrival at work or by pay day [DATE]. Staff will sign the elopement policy in-service training sign in sheet. The policy in-service will highlight measures to take when a person is missing and updates made to the policy. Staff will again be notified of those residents who are at risk. Finally, staff will be advised of the action taken when a person is missing from the facility. Every staff member is responsible for recognizing the door alarms and notifying the charge nurse. When the door alarms sound the charge nurse will immediately begin the search outside; surveying the immediate perimeter and further expanding the search as needed. --The facility doors will be locked and alarms set in place to sound when anyone exits the building at night. (The alarms will be set in night mode so the alarm must manually be turned to the off position.) Administrator and DON will be notified as needed for further directives. Define Staff: --The 200 nurses' station is located at the front of the building near the front entrance. --The 200 charge nurse will be responsible for locking and unlocking the front door and turning the alarm switch to the appropriate mode. The ,[DATE] charge nurse will lock the doors at 7:00 p.m. and place the switch in the night mode. The ,[DATE] charge nurse will unlock the front doors and place the switch in the daytime mode at 7:00 a.m. --The facility is always staffed with a charge nurse at each of the 3 nurses' stations. --The 200 charge nurse is responsible for rooms ,[DATE] and room ,[DATE]. --The ,[DATE] charge nurse is responsible for rooms ,[DATE] and ,[DATE]. --The 300 charge nurse is responsible for rooms ,[DATE]. When it is determined that a resident is missing, the charge nurse on the respective unit of the missing resident will be notified. The charge nurse will notify all staff through the multi-phone paging system. All charge nurses will be trained in the use of the phone paging system by the maintenance director or designee at the beginning other shift. Elopement In-service --The elopement policy has been reviewed by 75% of the staff members. --Multiple in-services were held to discuss protocol and sign-in sheets were completed. --Staff member who have not reviewed in-service training will do so prior to the start of their next scheduled shift. Elopement Drills: --The first elopement drill training sessions will be conducted on Thursday, [DATE] at 10:00 a.m. and 2:00 p.m. The drills will be mandatory for all staff. --Once the initial training has been conducted drills will begin weekly for 1 month, monthly for 1 quarter and quarterly thereafter for each shift. Drill process --The drill coordinator will place a mannequin in an undisclosed location and determine at that time whether the drill will be conducted inside or outside. --Staff will be alerted via the phone paging system of a missing resident. --Drill will be conducted per facility protocol --The first drill will be conducted on ,[DATE] beginning on the night shift. Inside drill --The search will begin in the immediate location and extended through the building until mannequin is found. --Staff members will search their assigned hallways then extend their individual search areas as directed by coordinator. --Rooms that have been searched will be identified with a red ring hung on the outside door knob. --When resident is found, all staff will be notified by phone. --Appropriate documents will be completed per policy. --In-Service Sign-in Sheet will be completed by participants. Outside Drill --The search will begin when door alarm sounds. --Four staff members will be sent to pre-determined zones in search of mannequin. --Staff conducting outdoor search will be equipped with packs containing flashlights, water and space blanket. --When resident is found, all staff will be notified by phone. --Appropriate documents will be completed per policy. --In-Service Sign-in Sheet will be completed by participants. --Once every zone has been searched or within 30 minutes, and resident is still missing, the local police department will be notified. --A list of on call Staff members will is available for additional assistance during overnight hours. Quality Assurance Audit --Audits will begin weekly for 1 month, monthly for 1 quarter and quarterly thereafter for each shift. --Random door alarms will be sounded to monitor staff response. --Coordinator will note the appropriate position of alarm switch. --Quality Assurance nurse will evaluate the performance of staff during drills and audits to determine areas of improvement and in-service needed corrections. Door Alarms --All exit doors have either wired security alarms or magnetic alarm monitored by the maintenance director. --Staff is instructed whenever possible to use the 200 break room door to enter and exit the building to reduce the frequency of sounding alarms. --A key pad will be install on the break room door reducing the number of alarms sounding as staff enter and exit the building. The device was installed ,[DATE]. --In addition to general surveillance at risk residents will be assessed for the use of a door alarm, nurse alarm, yellow Velcro barrier or other devices as appropriate Resident Monitoring --Residents will be assessed on admission per policy --Based on determination of Elopement Assessment resident will be monitored per protocol --The charge nurse will assign a C.N.A. to observe the residents at risk and complete a resident monitoring form. --Resident monitoring forms will be done on all residents at risk for elopement --Resident monitoring forms will be audited each shift by the charge nurse for 1 week, weekly for one month, monthly for one quarter and quarterly thereafter. --Resident monitoring forms will be collected monthly and reviewed by the Quality Assurance nurse. --Other residents will be assessed for potential elopement risk and observed per above protocol. --If an elopement occurs, to ensure resident's safety, staff will conduct one to one intervention for a range of 4 to 12 hours until notification and further intervention can be made; then checks every 15 minutes for 24 hours using the elopement monitoring form. Charge nurse will assign C.N.A. to said resident. At risk residents --Residents are assessed on admission per policy. --A Wandering Risk Assessment is completed on all residents at risk for elopement. --A list of residents at risk for elopement is posted at all nurses' stations. --Elopement Care plans are completed for all at risk residents. The following interventions may be implemented to prevent wandering/elopement --Avoiding events that lead to wandering behavior, i.e., crowded events, loud noises --Reviewing medications that may cause anxiety, impaired visions, or poor balance such as sedative drugs, with ongoing assessment of their effectiveness --Decorating their room with favorite pictures, books, etc. to provide a sense of comfort and familiarity --Permitting the residents to look outside a window to keep track of the seasons of the year --Having residents who wander wear a designated item of clothing for ease of identification Monitor response/reaction to events/activity in surroundings at time of wandering --Anticipate needs based upon wandering triggers and patterns --Acknowledge resident's behaviors as an attempt to communicate needs --Encourage verbalization, identify etiology and recognize feelings --Support and identify need for wandering, and develop individualized activity plan in response, i.e., ambulation program, movement program, exercise and dance --Determine resident's walking pattern (day, night, etc.) --Identify triggers indicating resident's need for walking assistance. --Evaluate unit/facility for potential hazards for this resident --Walk with resident after lunch daily on the grounds - family will do this on Saturday and Sunday --Offer resident participation in walking club --Offer resident out of house nature trips, apple picking, leaf looking, etc. --Obtain "wandering" history/patterns from family --Provide with coffee, pastry, and newspaper each morning in lounge area and wine/cheese and crackers in dining room before supper --Show resident "Field and Stream" videos/magazines or family albums/videos when he appears overly tired from walking --Encourage resident to participate in the above activities --Provide activity at change of shift to keep resident busy at time of high noise and exiting of staff --Identify activities for the residents based on their past work life/habits/hobbies --Communicate resident's potential for wandering to staff at the unit and exit areas --Assess resident's psychological or psychiatric status --Utilize volunteers to visit with residents A revised policy is in place to address extended needs of resident at risk for elopement." C. Removal of immediate jeopardy On [DATE] at 5:01 p.m. the nursing home administrator (NHA) and assistant administrator (AA) were informed the immediate jeopardy was abated based on observations of residents and staff interviews. However, deficient practice remained at a G level (actual harm that is isolated). II. Failure to Ensure Cognitively Impaired Residents were Safe from Elopement A. Elopement Policy 1. The facility's elopement policy, last adapted/reviewed on [DATE], reads as follows: "The purpose: To reduce harm from resident elopement from the facility. It involves prevention and missing person protocol. Prevention -Families are informed in pre-admission interviews that (the facility) is NOT a locked/secure facility, meaning that anyone is able to exit the facility from any exterior door, and that the facility is not fenced. -If a resident makes attempts to elope, or is successful in the attempt, the family is notified. -Residents are assessed on admission and continually for risk of elopement. A resident is considered high risk for elopement if there is a history of elopement or elopement attempts, the resident makes comments that could indicate he plans to leave, or the resident behaves in such a way that may indicate he wants to exit. -If a resident makes attempts to elope, or is successful in the attempts, the staff is notified, through shift report and through resident care conference, that increased vigilance is required to prevent elopement of the resident. -Yellow Velcro barriers are available and may be used to deter residents at high elopement risk. These barriers do not prevent passage but may deter a resident with dementia or confusion. -Major exterior doors have alarms that activate when the door is opened. Employees have been trained to check who has entered or exited the facility when the door alarm is activated. -If indicated, employees can be assigned one to one time with the resident at risk. -Distractions are utilized to divert attention from elopement attempts. Diversions may include nourishment, activities, or other redirection efforts. -Residents at high risk for elopement may be assigned a room nearer to the nurses' station or farther from an exit if one is available. -Employees have been taught that certain times of the day are higher risk times for elopement such as change of shift, after meals, and evening shift. These times may require increased vigilance of the high risk resident. Ongoing continuing education for all staff is provided. Missing Person Protocol: -If there is a witnessed elopement and the resident is deemed to be at risk if left unattended, an employee will immediately be sent to attend to the resident to redirect him and accompany him back into the building. -If staff becomes aware of an elopement or possible elopement, all on-duty staff will be notified immediately and will assist in the search as they become available. -When searching for a missing resident, employees will start within the building, checking all rooms and on the facility grounds. The search will be expanded as needed. -All elopements will be recorded on an incident report. -In the event of an elopement, notification of proper authorities will be done as follows: A. Director of Nursing or Nursing Home Administrator is the resident is missing more than ? hour. B. Police Department if the resident is missing more than 1 hour. C. Department of Health if the resident is missing more than 8 hours or if the resident is at risk and has not been found by the conclusion of the search." 2. Failures in facility policy The facility's elopement policy instructed facility staff to provide "increased vigilance" with no further instruction after an elopement attempt. Moreover, it did not instruct facility staff what to do if a resident deemed to be at high risk of elopement was seen wandering near egresses in the facility. B. History of Resident Elopements 1. Resident #81 (closed record), an [AGE] year-old male, was admitted to the facility on [DATE]. According to the face sheet, the resident, His [DIAGNOSES REDACTED]. The resident expired in the facility on [DATE]. Elopement with injury: Review of a hospital transfer form and facility incident report revealed the resident eloped [DATE]. The documents read in pertinent part: -According to a resident transfer form, on [DATE], the resident was transferred to the hospital to evaluate a head injury and to receive sutures on his left eye after an elopement. -A [DATE] incident report showed the resident was found at 7:00 p.m. The report documented, "At 7 p.m., another resident's daughter reported, "Someone's outside." States she came in to report this and when she went back outside to go home "he fell ". Observed resident laying on L(eft) side on sidewalk as stated above. Bleeding from 3 x .5 lac(eration) above L eye. ST (skin tear) lateral hand. Neuro checks initiated, assisted up to w/c. Bleeding stopped. The resident was found outside on the sidewalk next to the handicapped parking in front of the front entrance. On [DATE], the date of the resident's elopement, the facility developed a care plan to address his elopement risk due to wandering, altered mental status and new environment. Approaches included: --Monitor whereabouts --Offer diversional activities to direct behavior away from elopement: activities, nourishment, one on one, TV, music, group activities, redirection, etc. --Monitor comments/actions that may indicate possible plans to leave: "I'm going home.", "How do you get out of here?", repeatedly looking out the door, etc. --If available, provide a room closer to the nurses desk for closer monitoring --All staff aware of potential risk and the need to redirect to appropriate area of facility --Add name to elopement risk list --Respond promptly to door alarms --If elopement occurs, follow directives in elopement policy Facility Failures (1) Review of the resident's nursing progress notes, reviewed back to [DATE], revealed the resident was at risk for elopement prior to [DATE]. However, see above, no care plan to address this risk was developed until after the resident eloped and sustained injuries. Specifically, the notes read, in pertinent part: --[DATE]: "Res up in a w/c, alert with confusion. Noncompliant with cares. Verbally aggressive. Res states, "Am gonna walk out of this building, find a car with a key to I can head to my own funeral, better than stay here." "Am going to be rough with you guys until you allow me to get out of here." Res walks constantly around the facility, refuses to use the walker, get(s) into other resident's rooms ..." --[DATE]: "Resident awake and agitated, strikes out at staff up in w/c and refuses to go to bed. "I'll sleep on the floor, there is plenty of it ..." --[DATE]: "Resident agitated after dinner, calling out into hallway for his daughter. Attempted multiple times to calm resident down with negative effect. Resident became aggressive x 4 with staff stating he was going to "bash her face in." Resident also swatted at staff along with trying to shove staff with walker. Notified oncoming staff." --[DATE]: "Resident cooperative with cares prior to dinner. Upon return, resident became aggressive with staff and refused cares. Staff attempted x 3 to put resident to bed but he continued to refuse. Will continue to monitor." --[DATE]: "Resident up walking at times, alert with confusion. Res agitated, combative, verbally aggressive, and physically aggressive as well. Unable to be reoriented. Res became so agitated after his wife left the facility, res constantly asked for her. Res stated, "Bring my wife back, call or am gonna punch you in your face. Take me out of here or am gonna kill myself." Res was verbally offensive to other residents around him." --[DATE]: " ...Was up walking around til appox(imately) 10:00 p.m. Was given snacks and enjoyed talking with staff ..." --[DATE] (11 - 7:00 a.m.): "Resident has slept in recliner, calm but up and out of room. Found by staff in tubroom in other resident's gerichair. Redirected with assist back to his recliner. No noted injury or complaint of pain." --[DATE]: "Sleeps on and off assisted to recliner per his wishes. Restless at times but calms with staff redirection." (2) Record review and staff interviews on [DATE] with the NHA revealed the facility did not review the facility policy on elopements after the [DATE] incident and did not ensure staff was retrained on their responses to elopements and attempted elopements in an effort to prevent recurrence. 2. Resident #39, an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Quarterly Minimum Data Set (MDS) noted the resident was cognitively impaired with a BIMS (cognition) score of seven. The resident was independent with bed mobility, transfers, and walking. She utilized a walker for support when ambulating. Elopement [DATE]: The social service progress notes were reviewed back to [DATE] and revealed, in pertinent part, that the resident eloped from the facility [DATE]. The note read: [DATE]: "(Resident) was again talking about how no one loves her or wants her tonight and has threatened to leave the facility and walk down the middle of (the street) until a car hit her. She actually did walk out the main entry and was heading across the parking lot toward (the street) when a nurse and I stopped her and tried to convince her to come back in to the facility. She finally did comply and came in the facility, however, she continued to be angry and talked about how her parents and her children did not want her." Facility response to elopement [DATE]: Review of the social service progress notes revealed a note dated [DATE] that read, " ...She did attempt to leave the facility on one occasion earlier this month and is now considered an elopement risk ..." An elopement care plan was initiated [DATE]. It read the resident was at risk for elopement related to a persistent mental disorder and showed the resident had left the building on [DATE] and returned with some coaxing. Approaches included: --Monitor whereabouts --Offer diversional activities to direct behavior away from elopement: activities, nourishment, one on one, TV, music, group activities, redirection, etc. --Monitor comments/actions that may indicate possible plans to leave: "I'm going home." "How do you get out of here?" repeatedly looking out the door, etc. --All staff aware of potential risk and the need to redirect to appropriate area of the facility. --Add name to elopement risk list --Respond promptly to door alarms --If elopement occurs, follow directives in elopement policy Facility Failures: (1) Review of the resident's care plan revealed no plan to address the resident's elopement behavior was initiated until [DATE], approximately a month after her elopement. (2) Review of the resident's record did not reveal monitoring of comments or actions that may indicate possible plans to leave such as "I'm going home", "How do you get out of here?" or repeatedly looking out of the door. The resident's interdisciplinary progress notes were reviewed back [DATE]. The notes revealed, in pertinent part: --[DATE]: "Patient very angry after breakfast, "Is this the way to hell because that's where everyone wants me to go." Also said, "Next time you see me I hope it's in a coffin." Unable to redirect resident. Planned ignoring utilized. Resident in better spirits this afternoon." --[DATE]: "Attempted to leave facility several times. Difficult to re-direct. Agitated and yelling at staff and other residents. Called daughter-in-law. She came into visit. Calmed resident. Was pleasant and cooperative the remainder of her shift." --[DATE]: "Reports of resident threatening other residents by staff. Any resident that would stop in front of her door, she would yell at and make notions like she was going to hit them. Very hard to redirect ..." --[DATE]: "No behaviors til 8:00 p.m. Staff was trying to close drapes in residents room when resident got agitated with how they were closing the drapes. She started yelling, mocking, and tried to slap staff. She followed staff to nursing station yelling at them. Visits were at the nurse desk, resident turned toward the visitors and was yelling, "What are you looking at!" She started to approach the visitor (who happened to be a child) and this nurse intervened walking resident back to her room and fixed her drapes. Resident remained in her room the rest of the night." --[DATE]: "..She got angry because she thought people in lobby area were talking about her. Nurse tried to re-direct and her anger escalated. She did come back to her hallway but tried to go outside kept saying she would "stand in the middle of street." Call placed to son, message left on cell phone. She did calm down some and went to her room" --[DATE]: " ...Staff monitor her for a target symptom of "negativity" and have documented several incidents of this symptom in August and September. Staff one-on-one contact, redirection, providing food and fluids, and returning (resident) to her room have been effective in relieving this symptom in most instances. (Resident's) mood can change quickly and episodes of anger, depression, talk of self-destruction, and agitation generally pass quickly ..." (3) Record review and staff interviews on [DATE] with the NHA revealed the facility did not review the facility policy on elopements after the resident's [DATE] elopement and did not ensure staff was retrained on their responses to elopements and attempted elopements in an effort to prevent recurrence. Observations: --[DATE] at 10:00 a.m., the resident was observed to be walking from the front door up and down the 100 Hallway continuously until directed to the dining room for lunch. --On [DATE] from 1:30 p.m. - 2:00 p.m. the resident was continuously observed. She was observed walking from the front door to the nurse's station on the 400 hallway and then back to the front door. --On [DATE] at 3:45 p.m., the resident was ambulating in hallways with front wheeled walker. --On [DATE] at 2:00 p.m., the resident was observed to be wandering up and down the hallway. C. Current Elopement Resident #8, a [AGE] year-old female, was admitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. Resident Status - known to be at risk for elopement: The [DATE] quarterly Minimum Data Set (MDS) showed the resident's cognition was severely impaired scoring three of 15 possible points on the brief interview of mental status (BIMS). The resident experienced delusions and daily wandering. She was independent with bed mobility and walking in her room and the corridor. She required supervision with transfers. The resident utilized a walker when ambulating. The elopement care plan, dated [DATE] showed the resident was at risk for elopement related to wandering and altered mental status. Approaches included: --Monitor whereabouts --Offer diversional activities to direct behavior away from elopement: activities, nourishment, one on one, TV, music, group activities, redirection, etc. --Monitor comments/actions that may indicate possible plans to leave: "I'm going home," "How do you get out of here?," repeatedly looking out the door, etc. --If available, provide a room closer to the nurses' desk for closer monitoring --All staff aware of potential risk and the need to redirect to appropriate area of facility --Add name to elopement risk list --Respond promptly to door alarms --If elopement occurs, follow directives in elopement policy The resident's nursing progress notes were reviewed back to [DATE] and revealed, in pertinent part, that the resident ambulated independently around the facility and was confused. The notes read: --[DATE]: " ...Ambulates with walker. Attended both meals. Pleasant all shift." --[DATE]: "...Ambulates in hallway with walker per normal routine..." --[DATE]: " ...Ambulated in hallway with walker without difficulty." --[DATE]: "Resident alert with confusion. Maintained usual routine. Ambulates around facility with walker. Denies any pain or complaints.." --[DATE]: "At 9:30 p.m. resident was found by apt (apartment) dining room sitting on floor. No apparent injuries observed ..." The resident's nursing summaries documented exit seeking behaviors, wandering, and elopement attempts. They read, in pertinent part: (1) The [DATE] nursing monthly summary, dated [DATE], showed the resident wandered and was, "Monitored for exit seeking elopement." (2) The [DATE] nursing monthly summary, dated [DATE], showed the resident wandered, had elopement attempts and entered other resident rooms. (3) The [DATE] nursing monthly summary, dated [DATE], showed the resident wandered, had elopement attempts, and entered other resident rooms. (4) The [DATE] nursing monthly summary, dated [DATE], showed the resident wandered, had elopement attempts, and entered other resident rooms. The social services progress notes were reviewed back to [DATE] and also documented about the resident's elopement behavior. The notes read, in pertinent part: --[DATE]: " ...(Resident) has trouble following conversation and, although she may be willing to talk to others, will often lose track of the discussion. She does suffer short term and long term memory deficiencies ..." --[DATE]: " ...Historically, (resident) has been easily annoyed at times, and has displayed inappropriate physical and verbal behaviors toward staff, although no incidents of these behaviors have been documented this quarter. She has also shown some delusional thinking and often has rejected cares. (Resident) continues to routinely wander in the facility. She does not attend most social activities as her ability to focus on these activities is limited. Staff has monitored her for episodes of "elopement" and "entering the rooms of other residents". One incident of entering another resident's room was documented in June ..." A [DATE] quarterly

Based on observation, record review and resident and staff interviews, the facility failed to provide the highest practicable physical, mental and psychosocial well being for five (#32, #33, #67, #2, and #72) of 47 residents. Specifically: -The facility failed to ensure resident #32's pain was managed, contributing to the resident experiencing unrelieved pain. -The facility failed to ensure resident #33 was appropriately positioned in her wheelchair. -The facility failed to assess resident #67 for potential non-verbal indicators of pain. -The facility failed to identify, assess, and/or monitor skin changes for residents #2 and #72. The findings include: I. Pain Management A. Facility policy The 2/20/13 Pain Policy stated in pertinent part ... "Nursing home residents experience a magnified degree of pain and this is one of the many exacerbating factors present in this population. Three identified barriers to effective pain management are: 1. Lack of identifying pain as a priority in patient care 2. Inadequate knowledge of pain relief among health care providers 3.A. A system that fails to hold health care providers accountable for pain relief B. Lack of policies to deal with poor pain treatment outcomes C. Beliefs and myths about addiction, dependency and narcotic side effects. Additionally the pain policy noted: A. Assess pain systematically; i.e frequency, intensity, nature and location. B. Believe family and residents in their reports of pain. C. Choose appropriate control options for treatment per physician order. D. Deliver intervention and assess effectiveness. E. Enable patients to control their course as much as possible. Adopt a policy to treat pain before it returns. Maintain a constant blood level of the [MEDICATION NAME] at all times. This is best achieved by around the clock medication rather than PRN (as needed), especially with those that suffer intractable pain. Pain is considered the fifth vital sign. ...Frequency of the pain assessment will be determined by the resident's verbalization and/or outward signs of altered comfort level ...Specific attention will be made to requests for medication, with the evaluation of current orders to control pain. Whenever appropriate, the numeric pain scale of 0-10 will be used as an evaluation tool. "...Not all residents will tell you that they are having pain. Staff will ask and observe for signs and symptoms of non-verbalized pain ..." B. Resident Failures 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/6/13 Minimum data set (MDS) noted the resident was cognitively intact with a BIMS score of 12 on a 0-15 scale. a. Documentation of Pain The 10/6/13 Minimum Data Set (MDS) noted resident #32 had an indwelling Foley catheter and pressure ulcer on lower back. The MDS further revealed the resident had pain in the last five days that made it difficult to sleep at night, and limited her day to day activities. The numeric scale was blank and the verbal descriptor noted moderate pain with hand written notes of "varies mild to severe" and "back, bottom, legs and feet." The section for staff assessment for pain was marked as not conducted and the section for staff assessment for pain was left blank. The Skilled Daily nursing note (SDNN) dated 10/14/13 noted pain in the resident's back and legs, rated at an intensity of 8+. The comment section revealed "[MEDICATION NAME] given one time, tylenol given one time for pain management with positive results...a telephone call was made to the physician about blood sugar, leg spasms and pain medication. No return call at this time." b. Pain Management Plan The 10/13/13 care plan noted a problem of unexpressed pain related to cognitive impairment, communication deficit related to [DIAGNOSES REDACTED]." The care plan additionally noted the facility would monitor facial expressions of grimaces, winces, furrowed brow, clenched teeth and protective body movements of guarding, rubbing or massaging body parts. Medications included (per October Medication Administration Record/MAR) the following "as needed" PRN orders. There were no orders for routine pain medication. -A 9/24/13 physician order [REDACTED]. -A 9/24/13 order for [MEDICATION NAME] two mg by mouth three times a day by mouth for anxiety and palliative care. -A 9/27/13 physician order [REDACTED]. -A 10/15/13 physician order [REDACTED]. c. Observations, Resident Interview and Record Review - failure to ensure resident's pain was assessed, monitored, and addressed (1) 10/16/13 On 10/16/13 at 2:27 p.m., resident #32 was observed lying in bed. The resident stated her pain was a 12 on the zero to ten pain scale, and requested the interview continue as a distraction to the pain. The resident was short of breath, pale and sweaty. The resident stated her pain was in her shoulder, hips and legs. The resident stated none of the medications had worked well for that day. Review of the resident's MAR for 10/16/13 revealed that on 10/16/13, the resident had received Tylenol at 6:00 a.m., and [MEDICATION NAME] 5 mg at 9:15 a.m. She had received [MEDICATION NAME] at 7:00 a.m. pain charted as an 8 - response was "fair relief;" and 1:00 p.m. for pain all over - response was "fair relief." Although the resident rated her pain above ten (most excruciating), there was no documentation the resident received any of the other medications ordered for pain and palliative care ([MEDICATION NAME]). Review of the SDNN for 10/16/13, and the interdisciplinary progress notes (IPN) for 10/15/13 and 10/16/13, revealed no documentation of a return call from the physician (see 10/14/13 SDNN above) and no medication changes. On 10/16/13 at 2:40 p.m., the Registered Nurse (RN) assigned to the hallway was notified of the resident's pain level of 12. -The RN stated "sometimes her pain is odd" and did not go to the resident's room. No staff was observed entering the resident's room from 2:25 p.m. to 3:00 p.m. -The RN further stated residents are assessed for pain each time pain medications are given and the documentation is placed on the back of the MAR. The RN stated pain was not documented every shift for the resident. (2) 10/17/13 and 10/23/13 On 10/17/13 at approximately 2:00 p.m., resident #32 rated her pain as a four on the zero to ten pain scale. She stated as long as she didn't move four was a tolerable level of pain. On 10/23/13 at approximately 9:30 a.m., the LPN assigned to the 200 Hallway stated the resident was unable to use a numeric pain scale and that was why the nurse's used the words "effective" "helped some" "positive" and "fair relief", rather than a pain rating to show the medication's effect. However, see resident interviews above with the resident rating her pain. And, when interviewed again on 10/23/13 at approximately 9:50 a.m., resident #32 rated her pain as a five on the zero to ten scale. She said the nursing staff had not asked her a pain score today. d. Record Review - additional facility failures in resident #32's pain management (1) Review of the resident's entire record revealed no comprehensive assessment of the resident's pain since admission. The 9/24/13 Admission Assessment for resident #32 was incomplete. The assessment noted a location of right shoulder pain with the responses for type of medication used at home left blank, the intensity of pain on a zero to ten scale left blank, and the acceptable level of pain score was left blank. See MDS above; the section for staff assessment for pain was marked as not conducted and the section for staff assessment for pain was left blank. (2) Review of the resident's MAR for October 2013 revealed no indication from the MAR indicated [REDACTED].' According to the October MAR: The resident received Tylenol 650 mg every four hours as needed for pain as follows: -10/11/13, the resident received three doses out of six possible doses -10/12/13 the resident received two doses out of six possible doses -10/13/13 the resident received two doses out of six possible doses -10/14/13 the resident received two doses out of six possible doses -10/15/13 the resident received three doses out of six possible doses -10/16/13 the resident received three doses out of six possible doses. The resident received [MEDICATION NAME] 5/500 mg: -10/15/13 at 5:00 p.m., the resident received her first dose; -10/16/13 (see above) the resident received three doses; one at 7:00 a.m. pain charted as an 8 - response was "fair relief"; one at 1:00 p.m., for pain all over (no pain rating) - response was "fair relief"; and one at 8:00 p.m. for pain all over - response was sleeping. -10/17/13 at 2:00 a.m., the resident received a dose for leg pain (no pain rating). Response at 2:30 a.m. was sleeping. The resident received [MEDICATION NAME] 5-10 milligrams (available every three hours as needed) ten times in the month of October 2013. -10/11/13- no administrations -10/12/13- one administration of 10 mg at 7:10 p.m. (no pain rating) -10/13/13 - three doses of 10 milligrams at 10:30 a.m. (no pain rating), 3:35 p.m. (no pain rating) and 7:30 p.m. (no pain rating) -10/14/13- one dose of 10 mg at 8:15 a.m. -10/15/13- two doses of 10 mg at 7:30 a.m. and 9:15 a.m. (one and three-quarters hours apart. No pain rating) -10/16/13- no administrations The resident had not received [MEDICATION NAME] (for anxiety and palliative care) since admission. e. Interviews On 10/23/13 at approximately 10:00 a.m., the Assistant Director of Nursing (ADON) stated residents are asked about their pain level upon admission and the Admission assessment form serves as the pain assessment. The ADON stated the facility expectation was that all admission forms would be completed for pain. The ADON confirmed the resident's admission form was blank for pain medications used at home and what level of intensity was the resident currently experiencing and what would be an acceptable pain level. The ADON was not familiar with another section of the chart where the information could be located. On 10/23/13 at 9:30 a.m., the 200 Hallway licensed practical nurse (LPN) stated resident #32 was not able to give an acceptable pain level to the nurse upon admission. The nurse stated the admission form was still blank as the resident was sometimes unable to give a pain number. The LPN further stated she was not aware of the facility policy to document pain using a numerical scale of zero through ten. She stated most nurses used the charting that they were the most comfortable using. The LPN stated the facility uses non-verbal pain assessment cues such as grimacing, groaning and increased anxiety. On 10/23/13 at 9:48 a.m., the DON stated that all residents on skilled charting (SDNN) are assessed every shift. -The DON stated the facility expectation was that pain would be assessed using a numerical scale and all nurses would be inserviced on the pain policy. -The DON further stated the facility did not assess residents for pain that did not receive pain medications. 2. Resident #67, [AGE] year-old female, was admitted to the facility on [DATE]. According to the face sheet, resident #67's [DIAGNOSES REDACTED]. a. Record Review The 7/24/13 significant change of condition Minimum Data Set (MDS) showed the resident did not speak and rarely or never understood others. Her short- and long-term memory were impaired. Her ability to make decisions regarding daily tasks of life was severely impaired. The resident did not display any non-verbal indicators of pain including sounds, facial expressions, or protective body movements. The pain care plan dated 7/3/13 showed the resident had unexpressed pain related to cognitive impairment and communication deficit related to dementia. She had potential pain related to general discomfort, decreased mobility. Staff were to monitor for non-verbal sounds of crying, moaning, whining, or gasping, facial expressions such as grimacing, wincing, furrowed brow, or clenched teeth, and protective body movements such as guarding or rubbing or massaging body parts, etc. Approaches included: --Meds per PRN order: Tylenol 500 mg TID PRN --Use simple language: aching, stiff, sore, dull, burping, uncomfortable --Ask yes/no questions --Assess for pain before/during/after movement --Palpate areas thought to be painful while asking questions --Notify MD if meds are ineffective or side effects develop --Monitor and chart effects of meds and non-drug therapy --Meds per order for constipation --Monitor for s/s (signs/symptoms) of pain: guarding, grimacing, inability to sleep, poor appetite, unwillingness to do ADLs (activities of daily living) and treat per order --Non-drug therapy which includes but is not limited to repositioning, gentle massage, music , TV, family visits, and diversional activities. The nursing readmission assessment dated [DATE] was reviewed and pain was not assessed. The current physician orders [REDACTED]. --Tylenol 500 milligram three times daily as needed. One tab for mild pain, two tabs for moderate pain as of 3/14/12. --Tylenol 650 milligram rectal suppository every six hours as needed for pain or temperature greater than 101 as of 7/18/13. The August 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The September 2013 MAR indicated [REDACTED]. The October 2013 MAR indicated [REDACTED]. The resident's nursing notes were reviewed back to September 2013. No notes about pain or non-verbal expressions of pain were located. The September 2013 nursing monthly summary, dated 9/6/13 showed the resident did not have pain. No non-verbal indicators of pain were listed. The October 2013 nursing monthly summary, dated 10/17/13, showed the resident did not have pain. No non-verbal indicators of pain were listed. b. Resident Observations --On 10/16/13 at 9:29 a.m., the resident was observed in her room. She was seated in her wheelchair which was next to the bed. An attempt was made to interview the resident but she was not verbally responsive to interview questions. The resident's hands were clenched together and one of her hands was rapidly massaging the other hand. The resident's brow was furrowed and she was shaking her upper body. --On 10/17/13 at 11:42 a.m., the resident was observed in the dining room. She was seated in her wheelchair and was at the dining room table. The resident's hands were clenched together in the same manner. Her brow was furrowed and her face grimaced. --On 10/17/13 at 3:13 p.m., the resident was observed in a musical activity. The resident was not engaged and was not participating. Her hands were clenched together, her brow was furrowed, and she was grinding her teeth. --On 10/21/13 at 11:48 a.m., the resident was observed in the dining room. She was seated in her wheelchair and was at the dining room table. Her hands were clenched and moving together. --On 10/22/13 at 9:05 a.m., the resident was observed in her room. Her hands were held together, her brow was furrowed, and her knees were swaying back and forth. --On 10/22/13 at 10:57 a.m., the resident was seated in her wheelchair in her room. The resident was asked if she had any pain and her forehead wrinkled. Her hands were clenched together and she was rubbing one hand against the other. c. Staff Interview --On 10/22/13 at 11:56 a.m., a licensed practical nurse (LPN) familiar with the resident said grimacing, crying, moving, and facial expressions could be non-verbal indicators of pain. She stated the resident was not verbal and her non-verbal actions "could be pain." --On 10/22/13 at 12:03 p.m., a LPN (licensed practical nurse) familiar with the resident stated she did not believe the resident had pain. She said, "Sometimes she just makes faces." --On 10/22/13 at 12:05 p.m., a registered nurse (RN) assigned to work with the resident was asked about the resident's affect. He said, "She's very flat." When asked about her facial grimacing, furrowed brow, and hand holding, the RN said, "That's just her response and how she's always been. I've heard her say about three words and she can't express her pain. She's always wrung her hands and she doesn't speak a lot." The RN said he would assess the resident as being in pain if she moaned or showed signs of discomfort. --On 10/22/13 at 12:16 p.m., the quality assurance nurse (QAN) was asked how residents were assessed for pain. She said, "We rely on the CNAs (certified nurse aides) and they report if there's an issue." --On 10/22/13 at 12:30 p.m., the staff development coordinator (SDC, RN) was interviewed about the resident's non-verbal indicators of pain. She said, "It's very difficult to assess if she is in pain. She has facial grimacing but that's her normal appearance. She appears comfortable and she sleeps good at night." --On 10/22/13 at 1:29 p.m., the SDC said, "I've asked the staff to try to offer her some Tylenol three times per day. They said they've observed the furrowed brow since she's come in so it's hard to tell. They will offer the Tylenol to see if that changes." The SDC was asked how the facility ruled out the resident's facial grimacing as pain and she, "I guess we probably never really have done that." --On 10/23/13 at 7:31 a.m., a registered nurse (RN) was asked about non-verbal indicators of pain. She said, "If there's moans or groans or grimaces of if their respiratory rate goes up." --On 10/23/13 at approximately 7:45 a.m., a CNA who worked with the resident said the resident usually just, "sits there and doesn't really move." She continued, "Usually when we touch her she can do facial expressions and she grunts and holds her teeth in. I think she's communicating with us. She doesn't like to sit up too much and when she starts moving her hands, it means she wants to go back to bed or she's cold." --On 10/23/13 at 9:35 a.m., the director of nursing (DON) was asked about ruling out the resident's potential non-verbal indictors of pain., "She's had that facial expression ever since she's come through the door. How can we determine if it's pain if she looks like that all the time. We did discuss maybe doing a trial of Tylenol." She said, residents were assessed for pain every shift and if there was pain, nurses do an "on the spot" nurse's note. She said on admission, residents were asked if they were having pain, if they normally have pain, and their acceptable pain level. II. Positioning Resident #33, a [AGE] year-old female, was admitted to the facility on [DATE]. According to the face sheet, resident #33's [DIAGNOSES REDACTED]. a. Record Review The 7/9/13 quarterly Minimum Data Set (MDS) showed the resident had long-term and short-term memory impairment. She required total assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The resident had upper and lower extremity limitations in range of motion. The physical safety device care plan last updated on 4/9/13 showed the resident used a high back wheelchair to be able to self propel with a goal of being able to maintain an upright sitting position to enhance quality of life. Approaches included: --Resident will have improved sitting balance --Will attend meals and activities of choice The resident's nursing progress notes were reviewed back to July 2013. No notes regarding the resident's wheelchair positioning were present. The resident was last seen by physical therapy in March 2013 after falling from bed and sustaining a [MEDICAL CONDITION]. The physical therapy initial evaluation, dated 3/29/13, documented: "...Pt (patient) is resting in bed, had difficult time getting patient to awaken. Did open her eyes very briefly. Did try to attempt some PROM (passive range of motion) with her extremities. Pt resisted that movement and was not following any commands. Therefore at this time I do not feel that patient is a good candidate for therapy due to her decreased mental status. Therefore will not be doing any further therapy with patient at this time." b. Resident Observation --On 10/16/13 at approximately 12:15 p.m., the resident was observed in the dining room. She was seated in a wheelchair at a dining room table. The resident was in a high back wheelchair. Her head was observed to tilt upward so that she was looking at the ceiling. The top of her head rested about two inches from the top of the seat of the chair. Her pelvis tilted forward and she maintained a slouched position. --On 10/17/13 at approximately 12:15 p.m., the resident was observed in the dining room. The resident was in a high back wheelchair. Her head was observed to tilt upward so that she was looking at the ceiling. The top of her head rested about two inches from the top of the seat of the chair. Her pelvis tilted forward and she maintained a slouched position. --On 10/21/13 at 11:48 a.m., the resident was observed in the dining room. She was again in the high back wheelchair. Her head was observed to tilt upward and she was severely slouching with her hips set forward. Her body was angled to the right. She did not have foot rests on her wheelchair and her left ankle was twisted inward. At 11:58 a.m., a certified nurse aide (CNA) said to another CNA, "I think we need to sit (the resident) up in her chair. Will you help me with her? She's like falling out of her chair." Two CNAs then readjusted the resident in her wheelchair. Her head maintained the same tilted position. --On 10/22/13 at 12:30 p.m., the resident was observed in the dining room seated in her wheelchair. The resident was leaning to the left with her ribs pressing on the arm rest. The resident's head was tilted upward. --On 10/23/13 at approximately 9:24 a.m., the resident was observed in her room. She was seated in her wheelchair. Her footrests were not on and her left ankle was twisted inward. Her head was tilted upward. Her hips were thrust forward. c. Staff Interviews --On 10/22/13 at 12:30 p.m., the CNA who was assisting the resident with her meal said she frequently observed the resident in the above position, however, she did not know who in the facility was responsible for assessing wheelchair positioning. --On 10/22/13 at approximately 1:40 p.m., the staff development coordinator (SDC) was asked about the resident's wheelchair positioning. She said wheelchair positioning was usually something the nursing and maintenance department looked at together if a problem was noted. She said physical therapy could be involved if needed. --On 10/22/13 at 2:45 p.m., the SDC stated a therapy evaluation was going to be completed for the resident's positioning. --On 10/22/13 at 4:58 p.m., an occupational therapist (OT) provided a copy of the evaluation. He said, "We are going to get her a cushion to prevent her from doing thrusts. This will minimize her from trying to eject herself from the chair." The OT said he did not think the resident had enough strength in her neck to maintain an upright position, but stated the chair could be tilted back to ensure good head support. The OT's recommendations from the 10/22/13 evaluation included: 1. Foot plates to position bilateral knees to a 90 degree angle. 2. Brake extensions for staff use. 3. Lateral border cushions to ensure appropriate seating posture. 4. Cushion pummel to reduce pelvic thrust. --On 10/23/13 at approximately 7:45 a.m., a CNA who worked with the resident was asked about the resident's wheelchair positioning. She said, "She's kind of hard. She doesn't sit up that good and her hips go forward." --On 10/23/13 at 9:30 a.m., the director of nursing (DON) stated she expected nursing staff to monitor for wheelchair positioning. She added, "When a problem is noted, we use the various things in-house to fix the situation and we ask for a therapy consult so that we can follow their recommendations." The DON said she was aware of the resident's positioning and said, "We need to figure something out for her." III. Skin Concerns A. Facility Policy The facility's skin trauma policy read in pertinent part: "When a skin trauma occurs, the following steps will be implemented in reporting the incident: 1. All staff members will report the incident to the charge nurse as soon as possible. 2. An incident will be filled out and all those witnessing will sign. 3. The nurse will chart the incident in the nurses notes with the following: time, date, nature of the cause, action taken, notification of family. 4. Depending on the severity of the trauma to the skin, a physician will be notified. 5. DON (director of nursing) or administrative staff will be notified and will follow with further investigation as warranted. 6. Each discovered sign of skin trauma; i.e. bruise or skin tear, will be investigated by the DON, administrative staff and/or charge nurse to try and determine nature of origin. 7. If the skin tear and/or trauma occurred while services were being provided by a staff member, the charge nurse, DON, or administrative staff will discuss the incident with the specific individual about how to prevent this from reoccurring in the future. 8. In-services will be held periodically and issues related to skin trauma of the residents will be discussed with emphasis on prevention." B. Resident Failures 1. Resident #2, an [AGE] year-old female, was admitted to the facility on [DATE]. According to the face sheet, resident #2's [DIAGNOSES REDACTED]. a. Record Review The 8/8/13 quarterly Minimum Data Set (MDS) showed the resident's cognition was moderately impaired. She required total assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The resident used diuretic therapies. The altered skin integrity care plan, last reviewed on 8/13/13, showed the resident had the following risk factors for impaired skin integrity: limited mobility with non-ambulation, obesity, incontinence of bowel and bladder, [MEDICAL CONDITIONS], and functional limitations. Approaches included: --Assist position change every 2 hours --Assist to off load when in w/c (wheelchair) --Encourage nutrition and hydration per dietary guidelines --Assess skin during routine cares for s/s of redness, irritation or breakdown --Pressure relieving mattress --Pressure relieving cushion in chair The resident's nursing progress notes were reviewed back to September 2013. No documentation of bruising was present. The 10/8/13 nursing monthly summary showed the resident's skin was intact with good turgor. The resident was not documented to have any bruises. No other skin documentation present. Incident reports for the last three months were requested and no reports about bruising were completed. b. Resident Observations On 10/16/13 at 9:47 a.m., the resident was observed in her room. She was lying in bed and her hands were resting on her chest. A dark, purple bruise approximately half an inch in diameter was noted on the resident's right upper wrist. The resident said she was not sure how she obtained the bruise. On 10/17/13 at 12:15 p.m., the resident was observed in the dining room. The bruise was visible on her right wrist and was still dark purple in color. On 10/22/13 at approximately 12:15 p.m., the resident was observed in the dining room. The bruising on her wrist remained and was purple in color. c. Staff Interview --On 10/22/13 at 11:56 a.m., a licensed practical nurse (LPN) stated if bruising was found, an incident report was to be filled out and a nurse's note was documented. She said, "The CNAs tell us and then we try to find out what happened. We notify the family and the doctor." --On 10/23/13 at 7:31 a.m., a registered nurse (RN) who worked with the resident stated if bruising was noted, "We fill out an incident report and we try and figure out what happened, when it happened, we measure it and then the oncoming shift is notified. We make a nurses note and the doctor and family are notified." The RN said she had not noticed the bruising on the resident's wrist. --On 10/23/13 at 9:30 a.m., the director of nursing (DON) stated, "When bruises happen, they are supposed to be investigated. A nurse's note should be completed." --On 10/23/13 at 10:27 a.m., the DON observed the resident and confirmed presence of bruising on her. 2. Resident #72, an [AGE] year old female, was admitted to the facility on [DATE]. According to the facility admission record, her [DIAGNOSES REDACTED]. The 9/19/13 quarterly Minimum Data Set showed the resident's long- and short-term memory were impaired. She required extensive assistance with bed mobility, transfers, walking, toilet use, and personal hygiene. She was on diuretic medication. a. Observations On 10/16/13 at 9:52 a.m., the resident was observed seated in a recliner in her room. An attempt was made to interview the resident; however, she did not verbally respond to interview questions. The resident was wearing pants which were pulled up to expose her left knee. Six red scratches approximately one to two inches long were observed on her knee. The resident's fingernails were observed and they were clean and neatly trimmed. On 10/23/13 at approximately 1:30 p.m., the resident was observed in her room in a recliner. She had approximately six scabbed over scratches/abrasions to her left knee. The director of nurses (DON) was present during the observation and confirmed the scratches/abrasions. b. Record Review According to the current altered skin integrity care plan, the resident was at risk for skin problems, as evidenced by a Braden score of 15, incontinence, impaired decreased tactile senses, decreased mobility, diuretic use, [MEDICAL CONDITION], and confusion. The approaches included; -Monitor under breast related to history of yeast infections, Braden scale per protocol, promote optimal level of mobility, assist position change every two hours, encourage and assist to offload while in her wheelchair, encourage nutrition and hydration per dietary guidelines, supplements per order, assess skin during routine cares for signs and symptoms of redness, irritation and breakdown, pressure relieving mattress, pressure relieving cushion in wheelchair, podiatrist per order, labs as ordered, do not elevate head of bed or position on side >30 degrees. Review of the nurses' notes and other documents in the record for October 2013 revealed that there were no entries related to the scratches/abrasions on the resident's knee. c. Interviews On 10/23/13 at approximately 1:30 p.m., the DON said she expected that if a resident had a scratch or abrasion, the nurses should complete an incident report, chart on it, and notify the family and or physician.