Every finding on record at Durango Health and Rehabilitation

Based on record review and interviews, the facility failed to ensure one (#13) of five residents received treatment and care in accordance with professional standards or practice out of 48 sample residents.Specifically, the facility failed to:-Complete a timely assessment after Resident #13 experienced altered mental status; and,-Ensure an antibiotic was started in a timely manner for Resident #13.Findings include:I. Facility policy and procedureThe Change Of Condition Reporting policy, revised October 2020, was provided by the nursing home administrator (NHA) on 7/31/26 at 8:25 a.m. It revealed in pertinent part, Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. Document resident change of condition and response in nursing progress notes, on 24-Hour report or dashboard and update resident care plan, as indicated in clinical meeting. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response.II. Resident #13A. Resident statusResident #13, age [AGE], was admitted on [DATE] and discharged to the hospital on 7/27/26. According to the July 2026 computerized physician orders (CPO), diagnoses included non-alcoholic steatohepatitis (NASH - non-alcohol induced liver failure), hepatic encephalopathy (swelling around the brain), muscle weakness, back pain, osteoarthritis, hypertension, ascites, edema, and chronic kidney disease. The 7/7/26 minimum data set (MDS) assessment revealed Resident #13 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #13 required substantial assistance with bathing, lower body dressing and repositioning. Resident #13 required moderate assistance with toileting, personal hygiene, upper body dressing and transfers. B. Resident's representative interviewResident #13's representative was interviewed on 7/28/26 at 10:21 a.m. The representative said Resident #13 was in the hospital with altered mental status at the time of the interview. The representative said Resident #13's liver was failing and she was hospitalized recently from 7/17/26 to 7/25/26, but had to be hospitalized again on 7/27/26. The representative said she heard Resident #13 was starting to have confusion on the morning of 7/27/26 from a friend visiting Resident #13. She said she went to visit Resident #13 early in the afternoon, at approximately 1:30 p.m., and Resident #13 appeared confused during her visit. The representative said at first Resident #13 was just disoriented, but she felt the resident was getting worse as the afternoon progressed, until Resident #13 could no longer answer questions appropriately and did not understand how to use her call light for help. The representative said Resident #13 was also intermittently calling out and she thought Resident #13 was in pain. Resident #13's representative said the resident's confusion seemed similar to the previous time Resident #13 was hospitalized for encephalopathy (on 7/17/26) and she told the floor nurse. The representative said the floor nurse argued with her when she reported Resident #13 had a change in mental status. The representative said the floor nurse told her the facility could not keep doing this with Resident #13 and their family, referring to hospital transfers. Resident #13's representative said the floor nurse told her this was her normal cognition. The representative said she told the nurse she was going to call for an ambulance if the floor nurse was not willing to do it because she knew this was not Resident #13's normal behavior; however, at this time the floor nurse was willing to call emergency medical services (EMS) per the request of Resident #13's representative. Resident #13's representative said she stayed with Resident #13 until EMS arrived at approximately 6:00 p.m. (on 7/27/26) She said when EMS arrived, the floor nurse re-entered the resident's room and tried to tell one of the emergency medical technicians (EMT) that Resident #13 did not have a change in mental status and this was her normal behavior. Resident #13's representative said one of the EMTs recognized Resident #13 and told the representative that she helped transfer Resident #13 from the hospital back to the facility on 7/25/26. Resident #13's representative said the EMT told her she remembered that Resident #13 was oriented and appeared able to answer questions appropriately during the transfer on 7/25/26 and Resident #13 appeared different on 7/27/26. Resident #13's representative said she was worried that if Resident #13 returned to the facility, the facility would not recognize her change in mental status and Resident #13 would not be able to use her call light for help. The representative said she remembered the physician at the hospital suggested starting an antibiotic for the resident upon her discharge from the hospital, but she did not know of any issues from the facility's pharmacy and was not aware Resident #13 had not received any doses of the antibiotic on 7/26/26 or 7/27/26 (see record review below) before returning to the hospital. Resident #13's representative said if anyone from the facility had let her know there was a problem ordering the antibiotic medication, she could have tried to pick up the medication from a local pharmacy. C. Record reviewReview of Resident #13's July 2026 CPO revealed the following physician's order:Rifaximin (an antibiotic medication) 200 milligram (mg) oral tablet, give three tablets by mouth two times a day for impaired brain function, ordered 7/25/26 at 6:28 p.m.The progress note, dated 7/26/26 at 7:29 a.m., documented Resident #13's rifaximin was held because the medication was pending pharmacy delivery.-The progress note failed to identify if the physician was notified that the antibiotic medication was not available.Review of Resident #13's July 2026 medication administration record (MAR) revealed all doses of rifaximin (from 7/26/26 to 7/27/26) were documented as held and no doses were administered to the resident.The pharmacy alert, dated 7/27/26 at 5:29 p.m., documented Resident #13's rifaximin order was rejected because the medication was out of stock or under manufacturer back order.The admission assessment, dated 7/25/26 at 5:13 p.m., documented Resident #13 was alert and oriented. The admission assessment documented Resident #13 had clear speech and was able to understand directions.The daily nursing evaluation, dated 7/27/26 at 5:25 a.m., documented Resident #13 was confused, disoriented, and had disorganized thinking. The assessment documented this mental status as chronic for Resident #13, despite previous assessments documenting Resident #13 was alert and oriented.The after hours provider notification, dated 7/27/26 at 5:43 p.m. documented Resident #13's representative called the after hours phone service for the gastroenterology outpatient clinic. The notification documented Resident #13's representative reported Resident #13 had altered mental status and extensive unexplained whole body pain which was washing over her. The notification documented the nurse from the facility briefly got on the speaker phone and stated that the resident appeared at baseline, as she was when she returned from the local area hospital two days prior. The notification documented the on-call provider discussed with Resident #13's representative that if she felt the resident had altered mental status and severe pain that was unexplained, presentation to the emergency department was reasonable. The notification documented the provider was unable to relay the recommendation to the nursing staff at the facility as the nurse felt Resident #13 was at her baseline and had left the room. The notification documented the on-call provider discussed with Resident #13's representative how the provider was unable to manage the situation from his office and recommended presentation to the emergency department.The hospital note, dated 7/27/26 at 10:27 p.m., documented Resident #13 presented to the local area emergency department with altered mental status. The hospital note documented Resident #13 was unable to follow directions or recall her own name. The hospital note document Resident #13 only responded with the word 29 when asked any questions during the emergency room assessment. The hospital note documented Resident #13 had an elevated, but not critical, ammonia level and the elevated level was the likely cause for the resident's altered mental status The hospital note documented it was possible Resident #13 had not received her scheduled lactulose (a medication that helps manage liver complications) as ordered. The hospital note documented Resident #13 was admitted inpatient for management of encephalopathy, likely related to NASH.The progress note, dated 7/28/26 at 12:27 a.m. documented Resident #13 was transferred to the local area hospital by LPN #4 on the previous shift at approximately 6:00 p.m. The progress note documented Resident #13 was admitted inpatient to the local area hospital for encephalopathy.-Review of Resident #13's electronic medical record (EMR) revealed no documentation of nursing assessments for a change of condition on 7/27/26, no vital signs assessment at the time Resident #13 was transferred to the local hospital and no documentation of provider notification to the facility's nurse practitioner or medical director when Resident #13 transferred to the hospital on 7/27/26.III. Staff interviewsCertified nurse aide (CNA) #8 was interviewed on 7/28/26 at 11:08 a.m. CNA #8 said she took care of Resident #13 frequently. CNA #8 said Resident #13 had been having intermittent confusion that had been getting worse over the last month. CNA #8 said normally Resident #13 was oriented and able to follow directions, but when she provided care to Resident #13 on 7/27/26, the resident appeared confused again and required more directions when providing care.The pharmacist was interviewed on 7/28/26 at 12:02 p.m. The pharmacist said the medication rifaximin was an antibiotic that had a secondary use in managing liver failure. The pharmacist said rifaximin worked differently compared to the lactulose Resident #13 was already taking. The pharmacist said lactulose helped remove ammonia from the body, whereas rifaximin reduced the amount of ammonia produced by digestion. The pharmacist said rifaximin typically took at least a month to have its intended effect. The pharmacist said the pharmacy provided deliveries to the facility daily, and if they needed to, they could have a local pharmacy fill the prescription for a family member or staff member to pick up. The pharmacist said some facilities carried rifaximin in their emergency medication dispensing system to start the antibiotic immediately, but this facility did not. The pharmacist said she sent communication to the facility regarding Resident #13's rifaximin on 7/27/26 at 11:43 a.m. She said the physician's order was written for 200 mg of rifaximin, but most manufacturers no longer made 200 mg tablets and she requested the facility provide a new physician's order for 550 mg tablets. The pharmacist said her system did not show a new physician's order from the provider at the time of the interview. The pharmacist said Resident #13 missing approximately four doses of the medication was not ideal, but the missed doses were probably not the reason Resident #13 was rehospitalized because it took awhile for the medication to build up enough to have the intended effect for liver failure. The medical director was interviewed on 7/28/26 at 2:09 p.m. The medical director said he was not aware Resident #13 was transferred to the hospital on 7/27/26. He said the nurse practitioner (NP) was assigned to take calls from the facility that day, so it would make sense that he did not receive the notification. The NP was interviewed on 7/28/26 at 2:46 p.m. The NP said she was the provider taking calls for the facility on 7/27/26. The NP said she was not aware Resident #13 was transferred to the local area emergency room at the time of the interview. The NP said she had been visiting residents at the facility earlier in the day, but was not at the facility when Resident #13 was transferred to the local area hospital. The NP said she found a notification from the facility regarding the physician's order change request for the rifaximin in her notes, and the notification had a reply that the medical director sent a new order this morning (7/28/26). The NP said she did not remember receiving a call about Resident #13 having a change in condition or requesting transfer to the hospital. The NP said she could not find a missed call or notification from the facility around 6:00 p.m., the approximate time Resident #13 transferred to the hospital on 7/27/26. The NP said she managed hundreds of residents across multiple facilities and it was common for her to receive multiple notifications from the facility at once; so she may have forgotten if she was notified some other way.Registered nurse (RN) #3 was interviewed on 7/28/26 at 3:27 p.m. RN #3 said she had worked at the facility for a year and a half, mostly as a licensed practical nurse (LPN), but she had recently obtained her RN license. RN #3 said she was Resident #13's nurse on the morning shift of 7/27/26. RN #3 said when Resident #13 was first admitted to the facility, she was alert and oriented, but Resident #13 started having episodes of confusion and disorientation as her liver failure progressed. RN #3 said when she assessed Resident #13 in the morning on 7/27/26, Resident #13 was confused, but able to follow directions and was able to take the two doses of lactulose scheduled during her shift along with her other medications. RN #3 said she held the scheduled rifaximin because she heard in report a previous nurse checked the emergency medication dispensing system and none were stocked, and the pharmacy said the medication was on back order. RN #3 said because of Resident #13's recent hospitalization, she charted the confusion and disorientation as chronic because she thought they were her new baseline after returning from the hospital. RN #3 said she was not aware Resident #13 was assessed to be alert and oriented upon readmission to the facility on 7/25/26. RN #3 said if the resident or family reported a change in condition, a LPN should obtain vital signs and then notify the charge nurse or nurse manager to complete a formal assessment while contacting the provider. The medical director was interviewed again on 7/29/26 at 2:30 p.m. The medical director said he was not aware Resident #13 had not received any doses of the ordered rifaximin prior to her hospitalization, but he did not think that the missing doses caused the hospitalization because rifaximin did not work that quickly in helping manage liver failure. The medical director said the primary intervention for managing Resident #13's liver failure was the scheduled lactulose, which was being given as ordered, but was less effective as the liver failure worsened. The medical director said Resident #13's liver failure had been progressing to the end stage over the last month, evidenced by the previous hospitalization, but the resident and the family were not ready to transition to hospice care services during the last care conference. The medical director said if he was the provider the facility was supposed to call on 7/27/26, he would have sent Resident #13 to the hospital. The medical director said other than failing to meet the regulatory requirement of notifying the provider in a timely manner, he had no issues with the care provided or the nurses decision to transfer Resident #13 to the local area hospital.The director of nursing (DON) and the NHA were interviewed together on 7/30/26 at 11:27 a.m. Both the DON and the NHA remembered when Resident #13 transferred back to the hospital on 7/27/26. The DON and the NHA both said they thought the floor nurse on duty contacted the NP. The DON said after reviewing Resident #13's EMR, she could not find any documentation of a change in condition assessment or provider notification. The DON said she was able to find documentation of an oxygen saturation assessment around 12:00 p.m. that day (7/27/26), but could not find any documentation of vital signs taken at the time of the resident's transfer to the hospital. The NHA said normally the nurses did not miss documentation like this. The NHA said the facility used a whiteboard to track transfers, falls, and other incidents. The NHA said normally the DON or the NHA reviewed the residents' EMRs to ensure the event was documented correctly, as well as contacting the nurse for more information about the incident, but they had not been able to review the white board during the survey.

Based on record review, observations and interviews, the facility failed to ensure residents were kept free from abuse for one (#3) of six residents reviewed for abuse out of six sample residents.Specifically, the facility failed to protect Resident #3 and Resident #4 from physical abuse toward each other. Findings include:I. Facility policy and procedure The Abuse Prevention and Reporting Guidelines policy, revised June 2025, was provided by the interim nursing home administrator (NHA) on 3/31/26 at 5:07 p.m. The policy read in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect, and exploitation. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff or other agencies serving the residents, family members or legal guardians, friends, or other individuals. Any staff member who has reasonable cause to believe or reason to suspect any situation that may be considered abuse will immediately report to the charge nurse. The staff member will intervene and ensure that the resident is safe. Make sure that all residents are kept safe during the investigation. If a resident was the assailant, make sure that they are kept out of the reach of other residents and increase monitoring.II. Incident of resident-to-resident physical abuse between Resident #3 and Resident #4 on 11/26/25A. Facility investigation The 11/26/25 facility investigation was provided by the interim NHA on 3/31/26 at 10:30 a.m. The investigation revealed Resident #3 and Resident #4 resided in the memory care unit. The investigation documented the residents were observed to be frustrated and agitated with each other, as evidenced by their body language, per staff. Resident #3 had sustained a superficial scratch above his left eyebrow. The investigation determined Resident #4 might have made contact with Resident #3, causing the scratch. The staff member present was redirecting another resident to his room at the time of the incident and overheard the residents' elevated voices and defensive body language. The investigation documented the staff member observed the residents moving their arms as if they were going to hit each other, but the staff member did not see contact made. The investigation documented the residents were unable to provide information regarding the incident due to their cognitive status. The investigation documented psychosocial checks were completed for both residents for 72 hours. The residents' physicians and responsible parties were notified. The investigation documented the facility substantiated the physical abuse. B. Observations On 3/30/26 at 9:30 a.m. Resident #3 was walking around the unit, going in and out of other residents' rooms. Resident #3 walked up to Resident #4, who sat in a chair, and then Resident #3 turned around and walked away. The staff redirected Resident #3 when he was too close to Resident #4.C. Resident #3 (victim)1. Resident status Resident #3, age [AGE], was readmitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnosis included Alzheimer's disease and schizophrenia. The 3/23/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. He required maximum assistance with activities of daily living (ADL). 2. Record review Resident #3's care plan, updated 8/25/25, revealed the resident was at risk for resident-to-resident altercations related to individuals invading his space. The care plan documented he was at risk for re-traumatization, his anxiety was triggered by male caregivers, or those he perceived to be male. Pertinent interventions included providing an opportunity for positive interaction, attention and stopping and talking with the resident while passing by. The skin assessment, dated 11/26/25, revealed Resident #3 had a left eyebrow scratch. D. Resident #4 (assailant) 1. Resident statusResident #4, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included Lewy body dementia, hypertension and depression.The 2/7/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of 0 out of 15. He required maximum assistance with ADLs. The MDS assessment indicated the resident did not have behaviors directed towards others. 2. Record review Resident #4's behavior care plan, dated 1/14/25, revealed the resident was at risk for the potential to demonstrate verbally abusive behaviors. The care plan documented he had the potential for psychosocial issues due to an incident of receiving unprovoked agitation with physical abuse from another resident. Pertinent interventions included monitoring the resident for signs and symptoms of aggression as well as signs and symptoms of fear or psychosocial trauma, documenting behavior and attempted interventions and reporting physical contact from another resident. Resident #4's antipsychotic medication care plan, dated 7/2/25, revealed the resident was at risk for aggressive behaviors. Pertinent interventions included monitoring for aggressive behaviors, such as throwing medications, cursing at others, and non-redirectable agitation and if agitation was observed, intervening immediately to prevent an increase in behaviors.III. Staff interviews Registered nurse (RN) #1 was interviewed on 3/30/26 9:10 a.m. RN #1 said there was one staff member on the unit for seven residents. She said at times it was hard, as she tried to complete personal care with the residents and keep an eye on them too. She said she had seen residents get into each other's space and fights did occur. Certified nurse aide (CNA) #1 was interviewed on 3/31/26 at 9:15 a.m. CNA #1 said she was the only staff member who worked on the unit for seven residents. She said it was very hard at times, especially when the residents had moods,' which was pretty often. She said when the residents' behaviors increased, it was harder. She said the cares were easy to complete, except for Resident #3, who urinated all over the place. CNA #1 said she followed him around all day with the mop bucket. She said she left him alone often and let him do his thing because he was known to hit staff and get aggressive. She said he was not aggressive toward other residents, but he did get in their space often. She said Resident #4 did not like it when others got in his space. She said she had seen Resident #3 and Resident #4 get into a fist fight on 11/26/25. The director of nursing (DON) was interviewed on 3/31/26 at 12:45 p.m. The DON said she was involved with abuse investigations. She said the incident between Resident #3 and Resident #4 on 11/26/25 was substantiated because of the injury for Resident #3. She said the facility monitored and redirected residents away from each other as part of the interventions for safety.

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 an elopement for Resident #1 on 9/16/25.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 12/8/25, resulting in the deficiency being cited as past noncompliance with a corrective action date of 10/1/25.I. Elopement incident on 9/16/25Resident #1 who was at risk for elopement, required distractions from wandering and structured activities.On 9/16/25 at 12:45 p.m. Resident #1 was observed at the nurses' station. At approximately 1:00 p.m. a certified nurse aide (CNA) noticed Resident #1 had received a room tray for lunch but the CNA was unable to locate the resident in his bedroom. At approximately 1:13 p.m. the nurse manager notified the interdisciplinary team (IDT) of a potential missing resident. At 1:15 p.m. an overhead page was made regarding the potential elopement of Resident #1. A search was initiated of the building, which included the common areas, rooms, closets, bathrooms, locked areas, the basement, outside areas, storage units, sheds and nearby vicinity around the facility.At approximately 2:25 p.m. the police department was notified of the missing resident. Resident #1 was located on 9/18/25 at approximately 2:00 p.m. He was found within a mile of the facility and had been missing for 49 hours. He was sent to the hospital, where it was noted he had abrasions and needed intravenous (IV) fluids.II. Facility's plan of correctionThe corrective action plan implemented by the facility in response to Resident #1's elopement on 9/16/25 was provided by the nursing home administrator (NHA) on 12/8/25 at 12:00 p.m. It revealed in pertinent part:A. Action to correct the deficient practice for Resident #1On 9/16/25, a full house audit of all elopement assessments was reviewed to ensure accuracy and to identify any other high-risk residents who needed additional interventions for safety. The nurse clinical resource educated the IDT on the following: -Completing documentation and ensuring that a resolution was clear and documented in the resident's electronic medical record (EMR); -How to pull progress note reports to be reviewed during the facility's morning meeting to address any concerns with resolution, and care plans were updated at the time of review that were resident-specific, which included triggers to identify behaviors before it escalated; -Non-pharmalogical interventions for the residents; -How to review new admission elopement/wander assessments to ensure assessments were completed correctly and that high risk residents had a care plan that was resident-specific;-New admission elopement/wander assessments were to be completed upon admission, quarterly and with a change of condition; and,-Care plans were reviewed and updated if there was a change to the elopement/wander score. All staff education on the elopement policy and procedure was initiated. A contract for a new wander guard system to be installed at the facility on 10/1/25. Once Resident #1 was located and returned to the facility he was going to be placed in the secured unit. B. Identify others at riskThe facility reviewed all other residents at risk for elopement and identified any resident with a high-risk score who was at risk for the alleged deficient practice. C. Systemic changesThe facility completed staff education on 9/19/25 in preventing resident elopement, emergency procedures for a missing resident and wandering and elopement policies and procedures.The staff development coordinator (SDC)/designee educated all staff on the presence of the door alarms, using the alarms and needing to check or investigate the doors and surrounding area outside if the door alarm sounds. An elopement drill was conducted on 9/19/25 for staff on all shifts and education was provided with any identified concerns.D. Ongoing monitoringThe NHA/designee was to monitor all admissions for elopement risk via reviewing their elopement wander user defined assessment during the daily clinical meetings Monday through Fridays, as well as the resident's care plan to ensure the resident-specific interventions were in place. The audits were documented via a spreadsheet and conducted for 12 weeks or until substantial compliance was achieved. The NHA/designee interviewed five staff members a week to identify residents that were at high risk for elopement or wandering. Any identified residents had their care plans reviewed to ensure resident-specific interventions were in place. Audits were documented via a spreadsheet and conducted for 12 weeks or until substantial compliance was achieved. The IDT reviewed daily progress notes for instances of exit-seeking and ensured appropriate interventions were put in place. Audits were documented via a spreadsheet and conducted for 12 weeks or until substantial compliance was achieved. All audits were reviewed in the facility's monthly quality assurance and improvement process (QAPI) meetings until substantial compliance was achieved. III. Facility policy and procedureThe Elopement policy and assessment, revised October 2024, was provided by the NHA on 12/8/25 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to provide a safe environment for all residents. The facility will properly assess residents and plan their care to prevent accidents related to wandering behaviors or elopement. Wandering is defined as movement about the area without a fixed goal and elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff. When an alarm is activated, and it is determined a resident is missing, the following will occur:-Alert the unit nurse and all shift personnel to search the facility. If the resident is not located, institute a grounds search;-If the resident is unaccounted for after a thorough search of the building and grounds, the following will be immediately notified: administrator, director of nursing (DON), family or legal representative, attending physician and police; and,-A complete description of the resident will be given to the police along with a current photo of the resident. When the resident is located, the following procedures will be followed:-An assessment of the resident will be completed to determine if medical attention is required;-After assessment is completed, the attending physician will be notified and results of assessment reported. The physician's plan of care will be documented in the resident's record;-The resident's family/legal representative shall be notified of the resident's condition;-The resident's condition will be monitored every shift for forty-eight (48) hours; -A detailed incident report will be completed and submitted to administration;-The incident will be logged in the Elopement Incident Log. Incidents for the month shall be reviewed at the monthly Safety Committee Meeting and again at each quarter with the Quality Assurance Committee;-The facility will notify the appropriate State Agency;-Notification of the appropriate State Agency will be made in twenty-four (24) hours; and, -All staff will be educated on proper identification, assessment and treatment of residents identified as an exit-seeking risk. This education will occur during orientation and annually thereafter.IV. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease (abnormal memory), severe dementia (abnormal memory), cognitive communication deficit and the need for assistance with personal care.The 10/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. The MDS assessment identified the resident had wandering behaviors almost daily. B. Record reviewResident #1's care plan, initiated 5/27/25, revealed the resident was at risk for elopement and wandering. Pertinent interventions included documenting wandering behavior and attempted diversional interventions and providing structured activities such as toileting, walking inside and outside and reorientation strategies including signs, pictures and memory boxes.V. Staff interviewsThe NHA was interviewed on 12/9/25 at 10:20 a.m. The NHA said Resident #1 was not a typical dementia patient. She said he wandered aimlessly and asked repetitive questions. She said his representative wanted Resident #1 to stay in the general population as long as possible. The NHA said the facility attempted to place Resident #1 on the secured unit before he eloped and it triggered him to become involved in a physical altercation. She said Resident #1 was missing for 49 hours when he eloped on 9/16/25, but when he was found, he only had a couple of abrasions and needed IV fluids. She said they found Resident #1 within a mile of the facility at a little camp with a bunch of bottles of Ensure (nutritional drink) that he drank while he was missing. The NHA said when the facility acquired the building in September 2024 the agreement was that the wanderguard system would be updated by the former managing company but it did not happen until Resident #1 went missing.

Based on record review and interviews, the facility failed to inform the resident or consult with the residents representative regarding a change in the resident's treatment for one (#1) of three residents reviewed out of five sample residents. Specifically, the facility failed to notify Resident #1's medical durable power of attorney (MDPOA) of a medication change. Findings include: I. Facility policy and procedure The Notification of Physician or Responsible Party policy, revised October 2021, was provided by the nursing home administrator (NHA) on 2/5/25 at 10:35 a.m. It read in pertinent part, It is the policy of this facility to notify the resident, his/her attending physician and/or family/responsible party of changes in the resident's condition and/or status. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's family/responsible party when: The resident is involved in any accident or incident which results in an injury including injuries of an unknown source; There is a significant change in the resident's physical, mental or psychosocial status; There is a need to alter the resident's treatment significantly; There is a change in the resident's room assignment; A decision has been made to discharge the resident from the facility; and/or, It is necessary to transfer the resident to a hospital. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's condition or status. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and passed away on 12/31/24. According to the December 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease (neurological disorder) without dyskinesia (involuntary movements) and neurocognitive disorder with Lewy Bodies (neurological disorder/type of dementia). The 11/20/24 minimum data set (MDS) assessment revealed Resident #1 had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. B. MDPOA interview Resident #1's MDPOA was interviewed on 2/5/25 at 12:19 p.m. He said Resident #1 was admitted to the facility with her primary diagnosis being Parkinson's disease followed by Lewy bodies dementia. He said the facility failed to notify him that Resident #1's Carbidopa-Levodopa (Parkinson's medication) was being discontinued. The MDPOA said the medication helped Resident #1 be able to complete some activities of daily living (ADLs) and have a little bit of independence. He said when the medication was discontinued, Resident #1 seemed to have a rapid decline and then she passed away. He said the medication was discontinued on 12/2/24 and he was not informed until he asked the nurse to show him Resident #1's medical record a couple weeks after the medication was stopped. The MDPOA said the physician told him it was discontinued because she was not sure Resident #1 had Parkinson's disease. He said this was confusing because Parkinson's was her admitting diagnosis and the family had been dealing with Parkinson's disease for about four years prior to the resident admitting to the facility. C. Record review Carbidopa-Levodopa 25-100 mg tablet twice a day, was ordered on 4/11/24 and discontinued on 12/2/24. The 11/21/24 physician's note documented the physician questioned if Resident #1 needed to continue the Carbidopa-Levodopa. The physician recommended a trial to discontinue the medication since the medication was not at a therapeutic level. The 12/29/24 physician's note documented the physician had a care conference with Resident #1's MDPOA and family. The physician documented the family was informed the Carbidopa-Levodopa was discontinued on 12/2/24 per best practice guidelines. -However, the facility failed to notify the MDPOA of medication changes for 27 days. IV. Staff interviews Nurse practitioner (NP) #1 was interviewed on 2/4/25 at 11:19 a.m. NP #1 said the Carbidopa-Levodopa was discontinued based on the recommendation from the facility's medical director. NP #1 said she was not positive Resident #1 had Parkinson's disease and wanted to do imagining to confirm. She said the resident declined and the local hospital did not offer the imaging needed. She said she spoke to the family over the phone on 12/29/24 after the medication was discontinued She said the nursing department was responsible for notifying the family or the resident of medication changes. The director of nursing (DON) was interviewed on 2/4/25 at 11:45 a.m. The DON said the nursing staff notified residents or their MDPOAs of medication changes only when the medication being changed was a psychotropic medication. The DON said she did not notify Resident #1's family because the medication was not a psychotropic medication. The DON said she was not aware that the MDPOA needed to be notified of changes in the resident's care.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to ensure food items served were consistent with the posted daily menu. Findings include: I. Facility policy and procedure The Menus policy, revised October 2022, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:30 p.m. It read in pertinent part, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures: Menu cycles will include standardized recipes,menus will be served as written, unless a substitution is provided in a response to preference, unavailability of an item or a special meal. Menu substitution log will be maintained on file. II. Resident interviews Resident #58 and Resident #40 were interviewed together on 6/24/24 at 3:04 p.m. Resident #58 said the facility menus offered a decent selection but the food items did not always match the posted menus. Resident #58 said the menu items were not always available and if they were out of something, the kitchen would just put something else on the plate without informing the residents or asking if it was okay to substitute a listed food item. Resident #40 agreed with the information provided by Resident #58. III. Meal observations and resident interviews The 6/24/24 dinner menu revealed residents were to be served shrimp scampi, spaghetti noodles, sauteed asparagus cuts, Italian herbed dinner roll and chilled peach parfait. Alternative options were cheese pizza and sauteed green beans. During a continuous observation on 6/24/24, beginning at 5:30 p.m. and ending at 7:00 p.m., the dinner being served was plain spaghetti noodles topped with a thick white sauce with cooked shrimp on top of the sauce and snow peas. -The sauteed asparagus or sauteed green beans were not available as the menu indicated, and the shrimp scampi had the addition of the cream, which was not indicated as an ingredient on the recipe (see below). The 6/25/24 lunch menu revealed residents were to be served homestyle meatloaf with ketchup topping, duchess mashed potatoes, broccoli florets, poppy seed dinner roll and cherry cheesecake for dessert. During a continuous observation on 6/25/24, beginning at 12:00 p.m. and ending at 12:45 p.m., the lunch being served did not include broccoli florets and had green beans instead. Resident #37 was interviewed on 6/25/24 at 1:00 p.m. Resident #37 said he did not ask for green beans instead of broccoli florets for lunch. Resident #64 was interviewed on 6/25/24 at 1:10 p.m. Resident #64 said he did not ask for green beans instead of broccoli florets for lunch. Resident #27 was interviewed on 6/25/24 at 1:15 p.m. Resident #27 said she informed the staff member taking her lunch order earlier that she did not want the meatloaf or mashed potatoes but had received it anyway. Resident #27 said she told staff she would make herself a tuna fish sandwich from the personal food items. Resident #27 said she had asked for tuna fish sandwiches from the facility kitchen in the past and was told it was not currently available as a menu item. IV. Shrimp scampi recipe The facility's shrimp scampi recipe was provided by the dietary manager (DM) on 6/27/24 at 4:15 p.m. The recipe revealed the following ingredients: -Hot water; -Chicken soup base; -White wine; -Vegetable oil; -Oregano and black pepper; -Garlic (minced and chopped); -Peeled and deveined shrimp; and, -Fresh lemon. -The shrimp scampi recipe did not indicate to use heavy cream. V. Staff interviews The DM and the dietary consultant (DC) were interviewed on 6/27/24 at 4:14 p.m. The DM said she followed the recipe for shrimp scampi and added cream which was not listed on the recipe. The DM said she was instructed by the previous kitchen manager to do so. The DM said the residents and the staff were not informed there was the addition of cream to the shrimp scampi recipe. The DM said she did not consider complications for the residents who did not prefer or could not have dairy products. The DM and the DC said they were responsible for authorizing menu changes. The DM said the kitchen had started making more soups from scratch which was using more of the ingredients. The DM said the cooks needed to communicate better to ensure there were enough vegetables and other ingredients. The DC said a poll was recently conducted with the residents regarding what food items should be included on the always available menu. The DM said the poll revealed tuna fish sandwiches were included in the poll but did not get enough votes to be an always available item. The DM said she would speak with Resident #27 regarding her food preference with having tuna fish sandwiches for lunch.

Based on record review and interviews, the facility failed to inform three (#23, #81 and #82) of three residents reviewed for beneficiary notices out of 45 sample residents in a timely manner of changes to their services covered by Medicare. Specifically, the facility failed to: -Ensure Resident #23's Notice of Medicare Non-Coverage (NOMNC) included the last covered day and the appeal information; and, -Ensure Resident #81 and Resident #82 were provided a NOMNC letter upon changes to their Medicare coverage. Findings include: I. Resident #23 A. Resident status Resident #23, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included hemiplegia (condition that causes partial or complete paralysis on one side of the body, usually due to brain damage) and hemiparesis (symptom of the brain or nerve condition that causes partial weakness or an inability to move one side of the body) following cerebral infarction disrupted blood flow to the brain due to problems with the blood vessels) affecting the left non-dominant side. The 4/25/24 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 substantial to maximal assistance with toileting, showering and lower body dressing and partial to moderate assistance with upper body dressing, sitting to lying, sitting to standing and transfers. B. Record review The undated Notice of Medicare Non-Coverage letter documented Resident #23's name. -The date indicating when coverage would end was left blank. -The appeal agency name and phone number was left blank. -The notice was signed by Resident #23 on 12/1/23. II. Resident #81 A. Resident status Resident #81, age 72, was admitted on [DATE] and discharged on [DATE]. According to the January 2024 CPO, diagnoses included displaced intertrochanteric fracture of the left femur. The 1/28/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent or required supervision with all activities of daily living (ADL). B. Record review The 1/27/24 discharge summary documented the resident discharged home with home health due to meeting her goals. A review of the resident's electronic medical record (EMR) did not reveal documentation that the resident had been issued a NOMNC letter to indicate her last covered day of Medicare A services or that the resident was provided with the appeal information if she did not agree with the Medicare A services decision. III. Resident #82 A. Resident status Resident #82, age 73, was admitted on [DATE] and discharged on [DATE]. According to the November 2023 CPO, diagnoses included lumbar spondylolisthesis (vertebra in the lower back slips out of place). The 11/8/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 13 out of 15. She required supervision with ambulation and partial to moderate assistance with transfers. B. Record review The 11/22/23 discharge summary documented the resident was discharged from the facility home with her family. It indicated she received her medications and took all belongings. A review of the resident's EMR did not reveal documentation that the resident had been issued a NOMNC letter to indicate her last covered day of Medicare A services or that the resident was provided with the appeal information if she did not agree with the Medicare A services decision. IV. Staff interviews The social services assistant (SSA) and social services director (SSD) were interviewed on 6/27/24 at 6:33 p.m. The SSD said NOMNC letters should be provided three days prior to the last covered day of Medicare A services. She said the letter should include the last covered day of services and the appeal information. The SSD confirmed the last covered day and appeal information was not included in the NOMNC notice for Resident #23. She said the resident would not have been able to appeal if he chose to without that information. The SSD said Resident #81 discharged five days after she was admitted . She said she was unable to locate a NOMNC notice for the resident. She said she did not issue a NOMNC notice to Resident #81. The SSD said Resident #82 was admitted to the facility before she worked there. She said she was unable to locate a NOMNC notice. She said it did not appear that the resident was issued a NOMNC notice. The NHA was interviewed on 6/27/24 at 7:10 p.m. The NHA said a NOMNC notice should be provided to the resident and/or responsible party 72 hours prior to Medicare A services being discontinued. He said the prior social services department did not issue the NOMNC notices appropriately. The NHA said Resident #23's notice did not have the proper elements, including the last covered day and appeal information. He said he was unable to locate a NOMNC notice for Resident #81 and Resident #82.

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 10.34%, or three errors out of 29 opportunities for error. Finding include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 7/9/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure The Medication Administration policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. The policy read in pertinent part, Resident medications are administered in an accurate, safe, timely and sanitary manner. Medication is to be given in compliance with the physician orders and or manufacturer's recommendations. Verify the medication label against the medication administration record for accuracy of drug frequency, duration, strength and route. Never administer medications from an unmarked container. III. Manufacturer's Guidelines According to the manufacturer's guidelines for insulin lispro (Humalog), retrieved on 7/9/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020563s172,205747s008lbl.pdf, Humalog is a rapid acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus. Administer Humalog by subcutaneous (under the skin) injection within 15 minutes before a meal or immediately after a meal. According to the manufacturer's guidelines for Humulin R insulin, retrieved on 7/9/24 from https://pi.lilly.com/us/humulin-r-pi.pdf, Humulin R is a short acting human insulin indicated to improve glycemic control in adults with diabetes mellitus. Inject subcutaneously 30 minutes before a meal. According to the manufacturer's guidelines for Lactaid, retrieved on 7/9/24 from https://www.drugs.com/cdi/lactaid-lactase-tablets.html, Lactaid is used to help break down dairy products. Use Lactaid as ordered by your doctor. Take Lactaid with the first bite or drink of a dairy product. According to the manufacturer's guidelines for levothyroxine, retrieved on 7/9/24 from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=a8db0f7d-8863-9309-e053-2995a90a284a&type=display, Administer once daily, preferably on an empty stomach, one half to one hour before breakfast. IV. Observations On 6/25/24 at 4:41 p.m. assistant director of nursing (ADON) #2 was observed preparing and administering medications to Resident #67. The physician's order was for insulin lispro (Humalog) 100 units/milliliter (ml) pen, inject as per sliding scale. If blood sugar is: 0 - 199 = 0 units; 200 - 249 = 1 unit; 250 - 299 = 2 units; 300 - 349 = 3 units; 350 - 399 = 4 units; 400 - 449 = 5 units; 450 - 499 = 6 units; 500 - 600 = 8 units, subcutaneously every 4 (four) hours for diabetes mellitus. Notify the physician for blood sugar less than 60 milligrams/deciliter (mg/dl) after carbohydrate supplement or greater than 400. mg/dl. The order date of the medication was 2/2/24. ADON #2 obtained a blood sugar reading of high on the glucometer. ADON #2 said that meant the resident's blood sugar was over 600 mg/dl and she would need to give eight units of insulin. ADON #2 took a vial of insulin from the resident's insulin storage box. The insulin vial read Humulin R and there was not a pharmacy label on the vial. She drew up eight units in an insulin syringe and administered it to Resident #67. -ADON #2 administered the incorrect insulin to Resident #67. Cross-reference F760 for failure to ensure residents were free of significant medication errors. On 6/26/24 at 8:59 a.m. registered nurse (RN) #1 was observed preparing and administering medications to Resident #26, who was lactose intolerant (a condition that prevents the body from digesting lactose, a sugar found in dairy products). The physician's order was for Lactaid 3000 units one tablet by mouth. RN #1 was unable to find the medication in her medication cart. She proceeded to administer Resident #26's other medications mixed in yogurt, which contained dairy. RN #1 gave Resident #26 the remainder of the container of yogurt to eat with his breakfast. She said she would go look for the correct dose of Lactaid in the other medication storage areas. On 6/26/24 at 9:05 a.m. ADON #1 was observed preparing and administering medication to Resident #29. The physician's order was for levothyroxine 275 micrograms (mcg) by mouth in the morning. -The medication was scheduled to be administered at 7:30 a.m., however, ADON #1 administered the medication at 9:05 a.m., which was 90 minutes after it was scheduled and after the resident had already eaten breakfast. V. Additional interviews ADON #2 was interviewed on 6/25/24 at 6:48 p.m. regarding the insulin she had administered to Resident #67. She reviewed the physician's order that was for the insulin lispro pen. ADON #2 said the resident's insurance would not cover the insulin pens so the facility had to use the Humulin R insulin from the vial. She said the physician should have been notified to change the order and she said she would take care of it. RN #1 was interviewed on 6/26/24 at 10:34 a.m. She said she had not found the correct dose of Lactaid (the facility only had the 9000 unit dose available) but had one more place to look. She said she felt bad for giving Resident #26 the yogurt without his Lactaid. On 6/26/24 at 10:45 a.m,.RN #1 said she contacted Resident #26's physician and got his Lactaid order changed to 9000 units. She said she was able to administer the new dose of Lactaid to Resident #26. -However, Resident #26 did not receive the medication timely or per the manufacturer's guidelines (see above). The director of nursing (DON) was interviewed on 6/27/24 at 6:45 pm. The DON said the wrong insulin was administered to Resident #67. The DON said the Lactaid order should have been changed and it had not been administered to Resident #26 at the correct time . She said Resident #26 should not have been given a dairy product when his Lactaid had not been administered. The DON said Resident #29's levothyroxine was administered after breakfast was not given timely. The consulting pharmacist (CP) was interviewed on 6/27/24 at 1:59 p.m. The CP said taking levothyroxine could be affected by specific foods if taken after eating them. He said it was recommended to take the medication on an empty stomach. The CP said the insulin lispro and Humulin R (humalog) were two different insulins. He said the insulin lispro was a rapid acting insulin (was effective in about 15 minutes) and Humulin R was short-acting insulin (was effective in about 30 minutes and lasted longer). He said giving Resident #67 Humulin R insulin instead of the insulin lispro was a medication error.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for four (#7, #27, #11 and #22) of five residents out of 45 sample residents. Specifically, the facility failed to: -Ensure neurological checks were completed appropriately for Resident #7 following an unwitnessed fall; -Ensure Resident #7's fall care plan was reviewed and new interventions were added following an unwitnessed fall; -Ensure Resident #27 was appropriately assessed for self-administration of a wart removal medication and eye drops; -Ensure a safety assessments was completed for Resident #27 to determine if she was safe to use a hot tea kettle with a heating element in her room; -Ensure a safety assessment was completed for Resident #11 to determine if he was safe to use a space heater in his room; and, -Ensure a safety assessment was completed for Resident #22 to determine if he was safe to use a coffee maker with a heating element in his room. Findings include: I. Resident #7 A. Facility policy The Fall Management policy was provided by the nursing home administrator (NHA) on 6/26/24 at 11:40 a.m. It documented in pertinent part, A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Research has shown that a structured fall reduction program can substantially reduce the rate of falls and related injuries in nursing facilities. Identifying risk factors, followed by timely and appropriate interventions, is the key to a successful program. Each resident will be re-evaluated quarterly, annually and when a significant change occurs. Assess the environment and make appropriate changes, for example, bed in lowest position, placement of furniture, lighting, personal items within reach, non-slip footwear, night light, walker, wheelchair within reach if applicable. The call light and fluids should be within reach of the resident. If a resident experiences a fall with head injury, the fall is unwitnessed, or the resident self-reports a fall, neurological checks will be initiated. B. Resident status Resident #7, under the age of 65, was admitted on [DATE]. According to the June 2024 computerized physician order (CPO), diagnoses included unspecified diabetes, unspecified disorder of psychological development and muscle wasting with atrophy (gradual decline in function due to underuse or neglect). According to the 6/12/24 minimum data set (MDS) assessment, Resident #7 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required moderate assistance with bathing, supervision assistance with dressing, set-up assistance with personal hygiene, and was independent with all other cares. C. Observations On 6/24/24 at 10:52 a.m., Resident #7's room was observed. The bathroom call light cord was tightly wrapped around a bathroom grab bar next to the call light. The black connector attaching the call light cord to the wall appeared crooked and scratched. The call light cord did not function correctly (see interview below). D. Resident interview Resident #7 was interviewed on 6/24/24 at 10:52 a.m. Resident #7 said she had fallen in her bathroom earlier this month (June 2024), and could not call for help. Resident #7 said her call light cord did not work correctly. Resident #7 said she could activate her call light by taking her shoe off and hitting the black connector where the call light cord was affixed to the wall. Resident #7 said she could not pull on her bathroom call light cord because it did not work that way. Resident #7 said her call light cord had been wrapped around the grab bar in the bathroom for more than a year. Resident #7 said after her fall she was told to call for help when she needed, but taking her shoe off to hit the call light also made her feel like she might fall in her attempt to call for help. E. Record review A progress notes dated 6/14/24 at 11:15 a.m. documented Resident #7 had an unwitnessed fall at 11:15 a.m. The progress note documented neurological assessments and vital signs were obtained beginning at 11:15 a.m. The progress note documented the resident's call light was activated when nursing staff entered the room. A progress notes dated 6/14/24 at 11:26 a.m. documented Resident #7 underestimated the distance to her chair and sat back on the floor, missing the chair while self-transferring off the toilet. The progress note documented the resident did not call for staff assistance. -However, the 11:15 a.m. progress note documented the resident's call light was activated when nursing staff entered the room (see progress note above). Resident #7's neurological record documentation, dated 6/14/24, was reviewed in the electronic medical record (EMR). The neurological record documented a full set of neurological assessments required a 72-hour period of time to complete appropriately. The neurological record documented the facility protocol was to document neurological checks every 30 minutes for four assessments, then every one hour for four assessments, then every four hours for six assessments and then every eight hours for the remainder of the 72-hour post-fall period. Resident #7's neurological record documented the resident received a neurological assessment on 6/14/24 at 11:15 a.m., 11:45 a.m., 12:15 p.m., 12:45 p.m. and 1:45 p.m. -However, the neurological assessment documented that at the time for the hourly 2:45 p.m. and 3:45 p.m. neurological assessments, the resident was out of the facility on a pass with the activities department. An activity progress notes dated 6/14/24 documented the activity staff took Resident #7 out for a shopping outing between 2:00 p.m. and 4:30 p.m. -The facility failed to complete neurological checks in accordance with facility protocol. -The facility failed to document neurological checks on 6/17/24. An interdisciplinary team (IDT) post-fall review, dated 6/19/23, was reviewed in the EMR. The post fall-review documented Resident #7 could demonstrate use of her bathroom call light. The post-fall review recommended the resident use a reacher or call for assistance to get objects from the floor, to ensure the resident was aware of safe wheelchair positioning and to provide the resident with education not to have a pillow in her wheelchair. The post-fall review documented a recommendation to revise Resident #7's care plan. -The post fall review failed to identify Resident #7's call light cord could not be appropriately used. Review of Resident #7's care plan, revised 8/22/23, identified the resident as being a high risk for falls. Interventions included ensuring the resident's call light was within reach, encouraging the resident to use a reacher to pick up objects from the floor, ensuring Resident #7 was wearing appropriate footwear, providing education on appropriate wheelchair use, checking the resident's room for wet floors frequently and reviewing information on past falls to determine the root cause of the falls. -The facility failed to update Resident #7's care plan with new interventions following the resident's unwitnessed fall on 6/14/24. II. Staff interviews Registered nurse (RN) #1 was interviewed on 6/27/24 at 4:02 p.m. RN #1 said neurological assessments were a strict protocol and should be followed in accordance with the neurological record. RN #1 said she would never allow a resident who had experienced an unwitnessed fall to leave the facility until all 72-hours of post-fall neurological assessments had been completed. RN #1 said delayed brain bleeds or other important neurological changes could be missed if residents were not assessed appropriately after an unwitnessed fall. Licensed practical nurse (LPN) #1 was interviewed on 6/27/24 at 4:06 p.m. LPN #1 said residents with an unwitnessed fall should receive neurological assessments in accordance with the facility protocol printed on the neurological record. LPN #1 said if a resident was alert and oriented it would be acceptable to allow the resident to leave the facility on pass during the 72-hour post-fall assessment period because the resident could tell him whether or not they hit their head. The director of nursing (DON) was interviewed on 6/27/24 at 4:56 p.m. The DON said bathroom call light cords should not be wrapped up in a grab bar but should instead be readily available for a resident to use. The DON said neurological assessments should be completed in accordance with the facility protocol printed on the neurological record. The DON said nursing staff should not allow a resident who was within the 72-hour time frame following an unwitnessed fall to leave the facility without receiving their neurological assessments. The DON said it was important for nursing staff to assess residents who had an unwitnessed fall because staff did not know exactly what happened during the unwitnessed fall and the facility should remain cautious to ensure residents were kept safe. The DON said if nursing staff did not complete neurological assessments they could miss important neurological changes in the resident. 38185 III. Resident #27 A. Resident status Resident #27, age 81, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included nonrheumatic aortic valve disorders (inflammation of the heart's chambers and valves). The 4/16/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with activities of daily living (ADL). B. Resident observation and interview On 6/24/24 at 9:37 a.m. Resident #27's had a jar of Freeze Wart Removal sitting on the bedside table in her room. Resident #27 said she had a wart on her finger that bothered her. Resident #27's middle finger on her left hand was observed to have a wart-like lesion on the digit close to the fingernail. Resident #27 said she had tried to peel off the wart and it bled and bled and bled, so she started putting wart remover on it. During the interview, a box of Refresh Eye Drops and a hot water tea kettle with a heat source were observed on Resident #27's night stand. C. Record review The visual function care plan, initiated on 5/3/23 and revised on 8/14/23, documented Resident #27 had impaired visual function and required glasses. The interventions included providing the resident with glasses as required, ensuring the appropriate visual aids were available to support the resident's participation in activities and reminding the resident to wear her glasses. -A review of Resident #27's electronic medical record (EMR) did not reveal a physician's order for Refresh eye drops or wart remover. -Resident #27's EMR did not document an assessment to determine if the resident was able to self-administer eye drops or wart removal. Additionally, there was no assessment to determine the resident's safety level for the hot tea kettle kept in the resident's room. IV. Resident #11 A. Resident status Resident #11, age 74, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included a transverse fracture of the right humerus shaft (fracture of the upper arm). The 6/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required partial assistance with ADLs. B. Resident observation and interview On 6/24/24 at 2:12 p.m. a space heater was observed in Resident #11's room. The space heater was turned on and operational. Resident #11 said he was often cold in his room. He said a family member brought him a space heater for his room. He said he used it almost every day. C. Record review -A review of Resident #11's EMR did not reveal documentation that an assessment had been completed to determine the resident's safety level to operate a space heater independently. V. Resident #22 A. Resident status Resident #22, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, the diagnoses included dementia, heart failure and hypertension (high blood pressure). The 5/3/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was independent with ADLs. B. Resident observation and interview On 6/24/24 at 9:51 a.m. a coffee maker with a heating element was observed in Resident #22's room. Resident #22 said he used it almost every day to make himself coffee. C. Record review Resident #22's behavioral care plan, initiated 2/23/23 and revised 5/20/24, documented the resident had a behavioral problem related to a decline in health and a diagnosis of dementia. It documented that the resident had morning irritation, irritation when he needed to smoke or when having a bad day, verbal outbursts, making inappropriate vulgar statements, striking out at staff or making verbal threats. The interventions included providing the resident an opportunity for positive interactions and attention, explaining all procedures to the resident before starting and allowing the resident time to adjust to the changes, explaining why the resident's behavior is inappropriate, intervening as necessary to protect the rights and safety of others and providing a program of activities of interest. -A review of Resident #22's EMR did not reveal documentation that an assessment had been completed to determine the resident's safety level to operate a coffee pot alone and without supervision. VI. Staff interviews LPN #3 was interviewed on 6/27/24 at 2:50 p.m. LPN #3 said medications should not be left at the residents' bedside unless the resident had been assessed to be competent with administering their own medications. He said any medications in the residents' room should be kept in a secure location. LPN #3 said each resident should be assessed for self-administration of any medication, even over the counter medications. He said the self-administration assessment should be kept in the resident's EMR. LPN #3 said he was not aware Resident #27 had medications at the bedside. He said Resident #27's EMR did not have a physician's order for the resident to self-administer medications or a self-administration assessment completed. LPN #3 said a safety assessment should be completed for Resident #27's use of the tea kettle in her room. He said he was unable to locate a safety assessment for Resident #27. RN #2 was interviewed on 6/27/24 at 3:05 p.m. RN #2 said a safety assessment should be completed for Resident #22's use of the coffee pot in his room. She said she did not know anything about safety assessments or where to locate them. RN #2 said the facility's management team should know where the safety assessments were and she was not part of conducting any safety assessments. LPN #1 was interviewed on 6/27/24 at 3:15 p.m. LPN #1 said he was aware Resident #11 had a space heater in his room. He said he had seen the resident use it. LPN #1 said a safety assessment should have been completed for the resident's use of the space heater. He said he would not know where to find a safety assessment or who was responsible for completing the assessment. The DON was interviewed on 6/27/24 at 3:58 p.m. The DON said medications should not be left at the residents' bedside. She said for any resident to self-administer medications, an assessment should be completed along with obtaining a physician's order for self administration of medications. The DON said a safety assessment should be completed for any resident who wished to have a device with a heating element in their room. She said the nurse was responsible for completing the assessments. The DON said a safety assessment was not completed for Resident #27, Resident #22 or Resident #11 and a self-administration assessment was not completed for Resident #27.

Based on interviews and observations, the facility failed to consistently serve food that was palatable, attractive and at a safe and appetizing temperature. Specifically, the facility failed to ensure resident food was served at palatable temperatures. Findings include: I. Facility policy and procedure The Food: Quality and Palatability policy, revised February 2023, was received by the nursing home administrator (NHA) on 6/27/24 at 7:30 p.m. It read in pertinent part, Food will be prepared by methods that can serve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Proper (safe and appetizing) temperature: food should be at the appropriate temperature as determined by the type of food to ensure residents satisfaction and minimize the risk for scalding and burns. II. Resident group interview Six alert and oriented Resident's (#27, #37, #63, #32, #64 and #15), who were identified as alert and oriented per the facility and assessment, were interviewed in a group meeting on 6/26/24 at 10:00 a.m. Resident #27 and Resident #37 said the food was cold regardless of eating in either the dining room or being served a room tray. The remaining residents (#63, #32, #64 and #15) all agreed with this information. III. Observation On 4/25/24 at 7:20 p.m. a test tray for a regular diet, which was served immediately after the last resident had been served their room tray, was evaluated by the dietary manager (DM) for serving temperatures. The test tray was plated in the kitchen at 6:10 p.m. and the last tray on the unit was delivered at 7:20 p.m. The test tray meal consisted of shrimp scampi, spaghetti noodles and snow peas for dinner and peach parfait for dessert. Temperatures of the test tray were taken at the delivery cart and were as follows: -The spaghetti noodles were 123 degrees fahrenheit (F). -The snow peas were 109 degrees F. -The shrimp scampi was 112 degrees F. -The temperatures were all below the palatable temperature of 135 degrees F for hot foods. IV. Staff interview The DM was interviewed on 4/25/24 at 7:20 p.m. The DM said the food carts used for passing room trays were not heated and a plate warmer was used in the kitchen to keep food at a palatable temperature throughout meals services. The DM said a palatable food temperature was at or above 135 degrees F. The DM said the heated plates were not successful with keeping food at the desired temperature.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate; -Ensure housekeeping staff properly sanitized resident rooms; -Dispose of contaminated medication pass water cups; -Offer hand hygiene to residents before meals; and, -Implement an effective water management plan. Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 7/9/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Observations On 6/26/24 at 9:32 a.m. housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER]. HSKP #1 donned (put on) a pair of gloves and began spraying disinfectant in the bathroom. HSKP #1 then emptied the trash can in the bathroom. Without changing gloves, HSKP #1 began to clean the resident room, the sink and the mirror. After cleaning the resident's room, HSKP #1 changed her cleaning cloth and began cleaning the resident's bathroom. HSKP #1 moved the resident's commode to the opposite side of the bathroom to clean the toilet. When HSKP #1 finished cleaning the resident's bathroom, she removed her gloves for the first time and performed hand hygiene. -The call light cord in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. -HSKP #1 failed to sanitize the room properly by moving from clean to dirty surfaces. -HSKP #1 failed to change her gloves and perform hand hygiene after touching potentially contaminated surfaces and items including the resident's trash can. -HSKP #1 failed to sanitize the resident's commode. On 6/11/24 at 9:14 a.m. HSKP #2 was observed cleaning room [ROOM NUMBER]. -HSKP #2 was sanitizing and cleaning the bathroom before she began to clean the resident's room. -HSKP #2 failed to sanitize the room properly by moving from clean to dirty surfaces. -The call light cord in the resident's room and resident's bathroom were not cleaned by HSKP #2 during the room cleaning process. C. Facility documentation Housekeeping in-service documentation, not dated, was obtained from the corporate consultant (CC) on 6/26/24 at 10:42 a.m. It documented the five step daily patient room cleaning procedure included emptying trash, disinfecting horizontal surfaces, spot clean walls, dust mop the floor, and then damp mop the floor. It documented the seven-step washroom cleaning process included checking supplies, emptying trash, dust mop the floor, clean and sanitize the sink and tub, clean and sanitize the commode, spot clean walls and/or partitions, and damp mop the floor. -The documentation failed to identify when housekeepers should perform hand hygiene or change gloves. D. Staff interviews HSKP #1 was interviewed on 6/26/24 at 9:53 a.m. HSKP #1 said she did not need to clean the resident's commode because the resident did not use the commode. HSKP #1 said she cleaned the residents' call lights sometimes but not all the time. HSKP #1 said she needed to put gloves on to clean a room, but did not have to change her gloves between cleaning tasks. HSKP #1 said she was given two days of orientation when she began her housekeeping role. HSKP #1 said she had not received education or training in the last few months. HSKP #2 was interviewed on 6/27/24 at 9:31 a.m. HSKP #2 said housekeepers did not clean resident call lights every day, but only cleaned them on deep clean days that occurred once or twice a week. HSKP #2 said her orientation was very short upon hire. HSKP #2 said she had not received training or education in the last few months. The infection preventionist (IP) and the CC were interviewed together on 6/27/24 at 3:23 p.m. The IP said she had not provided the housekeeping staff with education. The CC said housekeeping staff were contracted outside of the facility. The CC said the facility administration needed to audit the housekeeping company to ensure proper sanitation practices were upheld. II. Failure to offer hand hygiene to residents before meals A. Facility policy and procedure The Hand Hygiene policy, undated, was obtained from the nursing home administrator (NHA) on 6/25/24 at 4:12 p.m. It documented in pertinent part, Hand hygiene will be performed before and after eating. B. Observations During a continuous observation on 6/24/24, beginning at 11:31 a.m. and ending at 12:28 p.m., the following was observed in the main dining room: -At 11:48 a.m. Resident #33 was observed self-propelling himself in a wheelchair to a table. He was not offered hand hygiene before or after his meal. -At 11:58 a.m. Resident #16 was observed self-propelling himself in a wheelchair to a table. He was not offered hand hygiene before or after his meal. -At 12:11 p.m. an unidentified resident wearing a green shirt and red sweatpants, was observed self-propelling himself in a wheelchair. The resident was not offered hand hygiene before or after his meal. The resident was observed eating a sandwich with his hands. During a continuous observation on 6/25/24, beginning at 5:22 p.m. and ending at 6:36 p.m., the following was observed in the main dining room: -At 5:46 p.m. the NHA was offering residents drinks. She did not offer the residents hand hygiene. -At 5:57 p.m. Resident #16 self-propelled himself in a wheelchair to a dining room table. He was not offered hand hygiene before or after his meal. He used his hands to eat two breaded chicken breasts. -At 6:04 p.m. Resident #33 self-propelled himself in a wheelchair to a dining table. He was not offered hand hygiene before or after his meal. He used his hands to eat a sandwich. B. Resident interview Resident #16, who was cognitively intact, was interviewed on 6/24/24 at 10:17 a.m. Resident #16 said the facility did not offer hand hygiene before or after meals in the main dining hall. C. Staff interviews The IP was interviewed on 6/27/24 at 3:23 p.m. The IP said hand hygiene was one of the key components of infection prevention. The IP said residents should be offered hand hygiene before and after every meal. III. Failure to dispose of contaminated medication pass water cups A. Observations On 6/26/24 at 3:30 p.m. registered nurse (RN) # 2 was observed by the medication cart. Several medication cups fell off of the cart onto the floor. RN #2 picked up the cups and placed them on top of the medication cart. B. Staff interviews RN #2 was interviewed on 6/26/24 at 3:45 p.m. RN #2 said she should have thrown the cups away that had been on the floor. RN #2 said she would not use the cups and would instead throw them away. -RN #2 disposed of the cups, but did not sanitize the medication cart where the contaminated cups had been placed. The DON was interviewed on 6/27/24 at 3:23 p.m. The DON said the nurses should dispose of medication cups if they fell on the floor. IV. Failure to have an effective water plan A. Professional reference According to The CDC's Legionella (Legionnaires Disease and Pontiac fever), (3/25/21), retrieved on 7/10/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team -Describe the building water systems using text and flow diagrams -Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them -Establish ways to intervene when control limits are not met -Make sure the program is running as designed (verification) and is effective (validation) -Document and communicate all the activities. Principles: In general, the principles of effective water management include: -Maintaining water temperatures outside the ideal range for Legionella growth - Preventing water stagnation -Ensuring adequate disinfection -Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. According to the CDC's Controlling Legionella in Potable Water Systems, (2/3/21), retrieved on 7/10/24 from https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-Potable-Water.pdf, Store hot water at temperatures above 140 degrees fahrenheit (F) and ensure hot water in circulation does not fall below 120 degrees F. Recirculate hot water continuously, if possible. Store and circulate cold water at temperatures below the favorable range for Legionella (77 degrees F to 113 degrees F). Legionella may grow at temperatures as low as 68 degrees F. B. Record review The facility's water management plan was obtained from the NHA on 6/27/24 at 3:28 p.m. It documented the water management plan was initiated on 6/27/24. The document was signed by the NHA and the DON The facility's water management plan, dated 2021, was obtained from the NHA on 6/27/24 at 3:49 p.m. It documented the facility tested for Legionella to ensure the water management plan worked effectively. However, the facility failed to test the water for Legionella as stated in the water management plan. (see interview below) -Additionally, the facility's water management plan was not updated annually. C. Staff interviews The NHA was interviewed on 6/27/24 at 3:49 p.m. The NHA said the facility initiated a new water management plan on 6/27/24 (during the survey). The NHA said the facility previously had an effective water management plan. He said the water management plan had not been updated since 2021 and he implemented a new program on 6/27/24 (during the survey). The NHA said he would need to find the testing information for legionella. -The NHA was interviewed again on 6/27/24 at 4:38 p.m. The NHA said he did not have documentation that the facility had been testing for Legionella after 2021.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of training per year. Specifically, the facility failed to: -Ensure a system was in place to track CNA training to ensure they met the requirements; and, -Ensure CNA #9 and CNA #10 received the required 12 hours of training per year. Findings include: I. Record review A review of the CNA training records was completed on 6/27/24 at 2:00 p.m. -CNA #9's training records documented CNA #9 received seven hours of training in the previous calendar year. -CNA #10's training records documented CNA #10 received eight hours of training in the previous calendar year. II. Staff interviews The staff development coordinator (SDC) was interviewed on 6/27/24 at 4:04 p.m. The SDC said she did not have a system in place to monitor the CNAs yearly training. She said the CNAs were required to receive 12 hours of training per year. She said CNA #9 received seven hours of training in the calendar year and CNA #10 received eight hours of training in the calendar year, which did not meet the 12 hours of annual training requirement.

Based on record review and interviews, the facility failed to ensure the resident's right to be informed of, and participate in his or her treatment for four (#4, #53, #70 and #41) of four residents out of 45 sample residents reviewed for the right to be informed and make treatment decisions. Specifically, the facility failed to inform Resident #4, Resident #53, Resident #70 and Resident #41 and/or their legal representative of the length of time the residents would be in isolation for COVID-19 and when they would be able to leave their rooms. Findings include: I. Facility policy and procedure The Changes In Resident Condition policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. It read in pertinent part, Purpose: the resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. Changes of condition are communicated from shift to shift through the 24 hour report management system. Changes in resident status that affect the problem/goal or approach on his/her plan of care are documented as revisions and communicated to the IDT team. II. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and COVID-19. According to the 6/27/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. B. Resident interview Resident #4 was interviewed on 6/25/24 at 11:18 a.m. Resident #4 was in isolation for COVID-19. He said it would be nice to know when he would be out of isolation. C. Record review The 6/18/24 nursing progress note indicated the resident was moved to another room for cohorting (placing residents with other residents with the same symptoms) due to testing positive for COVID-19. -There was no documentation in Resident #4's electronic medical record (EMR) to indicate that the resident or the resident's legal representative was notified of the room change or gave consent for the room change. -There was no documentation in the resident's EMR to indicate the resident or the resident's legal representative was notified how long the resident would be in isolation and when the resident would be able to leave his room III. Resident #53 A. Resident status: Resident #53, age 70, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction (stroke) due to thrombosis of unspecified middle cerebral artery (a blood clot blocking blood flow to the brain) and COVID-19. The 6/12/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. B. Resident interviews and observations Resident # 53 was interviewed on 6/25/24 at 11:17 a.m. Resident #53 said he did not know when he would be getting out of isolation. He said the facility told him he would be in isolation for 10 days but he did not know when the 10th day was. Resident #53 was interviewed again on 6/26/24 at 11:03 a.m. Resident #53 said he might be out of isolation in a few days but he was not sure. A sign was posted on the wall above the resident's bed which documented the date the resident would be out of isolation. The sign was behind the resident when he was sitting up and was not easily seen by him. On 6/26/24 at 1:47 p.m. Resident #53 was observed asking certified nurse aide (CNA) #3 how long he had to be in isolation. CNA #3 told the resident he had to be in isolation for at least 10 days or until he had a negative COVID-19 test. C. Record review: The comprehensive care plan documented Resident #53 had a diagnosis of COVID-19, initiated 6/17/24. Interventions included to educate/encourage him to stay in his room. A nursing progress note dated 6/18/24 at 4:00 a.m. documented the resident continued in isolation in a semi-private room with a roommate who was also positive for COVID-19. The resident was alert and calling frequently with repeated concerns about when he could get out of isolation so he could play bingo. A nursing progress note dated 6/18/24 at 10:44 p.m. documented the resident was afebrile (no fever), became very agitated during the shift and was refusing to remain in isolation. The resident demanded to go to the dining room for dinner. -There was no documentation in Resident #53's EMR to indicate the resident or his legal representative was notified of how long the resident would be in isolation. IV. Resident #70 A. Resident status: Resident #70, age 74, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included chronic respiratory failure with hypoxia (inadequate levels of oxygen), emphysema, hypertensive heart disease without heart failure, bipolar disorder, anxiety disorder and post-traumatic stress disorder. The 4/22/24 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 15 out of 15. B. Resident interview Resident #70 was interviewed on 6/24/24 at 3:00 p.m. Resident #70 said his only concern was that he wanted to get out of isolation. He said he did not know when that would be. Resident #70 was interviewed again on 6/25/24 at 3:04 p.m. Resident #70 said he was out of isolation and was very happy about that. He said he had already left his room today (6/25/24). C. Record review A nursing progress note dated 6/15/2024 at 10:54 a.m documented Resident #70 tested positive for COVID-19 on 6/14/24. -There was no documentation in Resident #70's EMR to indicate the resident had been notified how long he would be in isolation. V. Staff interview Assistant director of nursing (ADON) #2 was interviewed on 6/25/24 at 3:10 p.m. ADON #2 said the residents were notified of the length of isolation verbally when they tested positive for COVID-19 and they were told isolation was for 10 days. She said Resident #53 had been told many times when he could come out of isolation. She said a sign was posted in his room to help the resident remember when his isolation would end. 50314 VI. Resident #41 A. Resident status Resident #41, age greater than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included generalized muscle weakness, chronic kidney disease, and cerebral infarction (stroke). According to the 6/3/24 MDS assessment, Resident #41 had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required moderate assistance with bathing, set-up assistance with eating, and was independent with all other cares. B. Resident observations and interviews Resident #41 was interviewed on 6/24/24 at 11:25 a.m. Resident #41 said he was supposed to stay in his room and could not leave. Resident #41 said he did not know why he had to stay in his room. Resident #41 said no one had informed him of why he was supposed to stay in his room which made him feel very upset. Resident #41 said he felt like he was in prison. -There was no posted notification regarding the reason for isolation or information detailing when the resident was allowed to leave his room observed in Resident #41's room during the interview. Resident #41 was interviewed again on 6/27/24 at 10:04 a.m. Resident #41 said the facility had not informed him why he must remain in his room. Resident #41 said the facility had not informed him when he could leave his room. Resident #41 said the facility had not provided him any documentation or had a discussion with him about the need for his isolation. -There was no posted notification regarding the reason for isolation or information detailing when the resident was allowed to leave his room observed in Resident #41's room during the interview. C. Staff interviews The activity assistant (AA) was interviewed on 6/27/24 at 11:58 a.m. The AA said that residents in isolation should have activities offered to them. The AA said he was unsure if residents in isolation had been told when they could leave their rooms. The AA said since Resident #41 could be forgetful at times it could be helpful to give him a memory aid to help him remember what was happening. The AA said he was unsure if the facility could provide that for Resident #41. Licensed practical nurse (LPN) #1 was interviewed on 6/27/24 at 4:06 p.m. LPN #1 said residents should know when they were allowed to leave their room for COVID-19 isolation. LPN #1 said the facility did not document when they educated residents about their COVID-19 infections. The director of nursing (DON) was interviewed on 6/27/24 at 4:56 p.m. The DON said residents requiring room isolation should know when they could leave their rooms. The DON said Resident #41 was forgetful and the facility could provide a memory aid to help him remember both the reason for isolation and when he could leave his room safely. The DON said the facility had not provided a memory aid to Resident #41. The DON said the facility could do more to help residents with cognitive impairment remember and understand required isolation.

Based on observations, record review and interviews, the facility failed to ensure one (#57) of five residents reviewed for pressure injuries out of 45 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Specifically the facility failed to implement timely interventions to prevent Resident #57 from developing a Stage 2 pressure injury to her right lateral ankle on 5/25/24 and to prevent the potential for further pressure injuries to occur. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from https://www.internationalguideline.com/guideline on 7/1/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy The Pressure Injury policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. It read in pertinent part, Purpose: To assess and implement interventions as appropriate to reduce the likelihood of development of pressure injuries. Protecting against the effects of pressure, friction and shear: -Reduce pressure over bony prominences by offloading and positioning; -Develop turning and repositioning plans for residents in bed or chair; -Provide special attention to suspending heels; -Maintain good hydration; and, -Evaluate the need for a pressure-reducing mattress. Encourage optimal nutrition and fluid intake: -Conduct nutritional consultation with registered dietician; -Identify clinical signs of malnutrition (unintended weight loss); -Offer snacks and fluids between meals; -Consider administration of supplements (vitamins, mineral, calories, protein, fluids); and, -Report and document any concerns in the nutritional plan of care. III. Resident status Resident #57, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included non-ischemic myocardial injury (non-traumatic injury to the heart)), acute on chronic diastolic (congestive) heart failure, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and type 2 diabetes mellitus with diabetic chronic kidney disease. According to the 5/27/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. She needed substantial to maximal assistance with bed mobility, transfers and personal hygiene, but only required set-up assistance with eating. She used a wheelchair for mobility. The assessment did not identify the resident as being at risk of developing pressure ulcers. The assessment documented the resident had one unstageable pressure injury which was not present on admission. The assessment documented the resident had a pressure reducing device for her chair, a pressure reducing device for her bed and received pressure injury care. IV. Observations On 6/25/24 Resident #57 was observed during a continuous observation, beginning at 2:21 p.m. and ending at 4:01 p.m. At 2:21 p.m., the resident was in bed lying on her right side. The resident had an alternating pressure mattress on her bed. -There were no pressure reducing boots on the resident's feet. At 3:48 p.m. Resident #57 continued lying in bed on her right side. A certified nurse aide (CNA) entered the room. -The CNA did not provide any care to the resident or attempt to place pressure reducing boots on the resident's feet. At 4:01 p.m. the resident was sitting on the side of the bed. There were no pressure reducing boots on her feet or observed in the room. On 6/26/24 at 10:39 a.m. the resident was lying in bed on her right side with her feet hanging off the side of the bed. -One pressure reducing boot was observed on the bed, however, it was not on either of the resident's feet. -On 6/26/24 at 1:05 p.m. the resident was lying in bed with no pressure reducing boots on her feet. On 6/26/24 at 1:05 p.m. the nurse corporate consultant (CC) and assistant director of nursing (ADON) #2 obtained permission from Resident #57 to perform her wound care. The CC removed the dressing on the lateral right ankle and there was minimal drainage on the dressing. The wound bed was pink with no slough and the skin was dry around the wound bed. After the wound care was completed, the CC offered the pressure reducing boot for the right foot and the resident accepted it. -The CC did not put a pressure reducing boot on the resident's left foot and there was not a second pressure reducing boot observed in the room. -However, according to the resident's June 2024 CPO, she was to have pillows or heel protectors to offload the pressure to both of her feet and ankles while she was in bed (see physician's orders below). On 6/26/24 at 2:41 p.m. Resident #57 was lying on her right side in bed and her feet were dangling off of the side of the bed. -There were no pressure reducing boots on either of the resident's feet. One boot was observed on the floor and a second boot was not observed in the room. V. Record review The pressure injury care plan, updated 6/18/24, revealed Resident #4 was at risk for pressure injuries. Pertinent interventions included providing a pressure relieving device to bed and wheelchair, keeping skin clean and dry, using lotion on dry skin, administering treatments as ordered and observing for effectiveness, providing heel protector boots or floating heels on pillows for pressure relief (often declined to wear boots), assisting the resident to reposition and or turn at frequent intervals to provide pressure relief, and encouraging good nutrition and hydration to promote healthy skin. -The care plan did not include any nutritional interventions such as supplements for pressure injury prevention or healing. The nutrition care plan, revised 5/31/24, documented Resident #57 had an unstageable pressure injury to the right ankle. -On 6/25/24, during the survey, a new intervention was added that documented the resident declined the use of nutritional supplements. A readmission assessment was completed on 5/21/24 when Resident #4 readmitted to the facility following a hospital stay. The admitting nurse documented that Resident #57's skin was warm, normal in color, there was no edema and there were no skin issues present. A pressure ulcer was not identified. A review of Resident #57's June 2024 CPO revealed the following physician's orders: Cleanse wound to the lateral right ankle with normal saline. Apply MediHoney to the wound bed only and cover with Optifoam. Change every other day and as needed for loose, soiled, or excessive drainage, monitor and report abnormalities, ordered 5/25/24. Provide house nutritional supplement between meals. Document amount consumed two times a day, ordered 5/30/24. -The nutritional supplement was not implemented until five days after the right lateral ankle pressure wound was identified on 5/25/24. Apply pressure reducing boots while lying in bed every shift, ordered 5/30/24. -The intervention was not implemented until five days after the right lateral ankle pressure wound was identified on 5/25/24. Use pillows or heel protectors to off load pressure to feet and ankles while in bed, every shift, ordered 6/8/24. -The intervention was not implemented until 14 days after the right lateral ankle pressure wound was identified on 5/25/24. Alternating pressure mattress to the bed. Set at level 30 firmness and check the mattress every shift for proper setting and function, ordered 6/17/24. -The intervention was not implemented until 23 days after the right lateral ankle pressure wound was identified on 5/25/24. A review of Resident #57's electronic medical record (EMR) revealed the following progress notes: The 5/23/24 physician note documented the resident's skin was pale/sallow (gray in color), warm and dry. -The progress note did not identify a pressure injury. The 5/24/24 skilled nursing note documented the resident's skin had multiple bruises related to multiple attempts at drawing blood. -The progress note did not identify a pressure injury. The 5/25/24 nursing wound note documented Resident #57 had a stage 2 pressure injury to the right lateral ankle measuring 4 centimeters (cm) by 1.5 cm. injury. The wound bed contained 100 percent (%) slough (soft yellow or white tissue covering the wound bed). The 5/30/24 wound note documented the right lateral ankle measurements were 3.8 cm by 0.9 cm. The wound was unstageable due to 100% slough present in the wound bed. The 6/6/24 wound note documented the superior (upper) area of the right lateral ankle wound measured 0.2 cm by 1.0 cm and the inferior (lower) area measured 1.4 cm by 0.7 cm and the wound had macerated (moist or soggy) edges. The 6/13/24 wound note documented the superior area of the right lateral ankle wound measured 1.0 cm by 0.3 cm and the inferior area measured 1.2 cm by 0.7 cm and there was no slough in the wound bed. The wound had macerated edges. The 6/13/24 registered dietitian (RD) assessment did not identify that Resident #57 had a pressure injury. The 6/20/24 wound note documented the superior area of the right lateral ankle wound measured 1.5 cm by 0.3 cm and the inferior area measured 1.5 cm by 0.8 cm. The wound bed was 75% slough and 25% granulated (new, pink) tissue with macerated edges. The 6/27/24 wound note documented the superior area of the right lateral ankle wound measured 0.1 cm by 1.0 cm and the inferior area measured 1.1 cm by 0.5 cm. The CC said there was no slough present in the wound bed. V. Staff interviews ADON #2 was interviewed on 6/27/24 at 11:10 a.m. ADON #2 said upon Resident #57's readmission to the facility on [DATE], the admitting nurse documented the resident had bandages on the right foot, however, the nurse did not remove them to look at her skin. ADON #2 said she discovered the right lateral ankle wound two days later (per the medical record, it was actually identified four days after admission). ADON #2 said the wound was a facility acquired pressure injury because it had not been identified upon the resident's readmission to the facility The director of nursing (DON) was interviewed on 6/27/24 4. The DON said a house supplement was attempted, however, she said Resident #57 would not drink it. The DON said she did not know if any other supplements were tried with the resident. She said she did not know what other supplement options the facility had available.

Based on record review and interviews, the facility failed to ensure three (#42, #52 and #68) of five residents reviewed for abuse out of 45 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #42 from physical abuse by Resident #25; and, -Protect Resident #52 and Resident #68 from physical abuse by Resident #24. Findings include: I. Facility policy and procedure The Abuse Policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:30 p.m. It read in pertinent part, Community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including other residents. Residents have the right to be free from abuse. This includes physical abuse. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Resident abuse is defined as the willful Infliction of injury of a resident resulting in physical harm or pain and mental anguish. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching and kicking. Willful means the individual must have acted deliberately, not that he or she must have intended to inflict injury or harm. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or risk thereof. If a resident experiences a behavior change resulting in aggression towards other residents, the community will implement interventions for protection of alleged assailants and other residents. The residents care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate interventions, up to and including hospitalization s, can be implemented. II. Facility investigation of physical abuse involving Resident #25 and Resident #42 on 6/6/24. The abuse investigation, dated 6/6/24, revealed Resident #25, who had a diagnosis of dementia with behavioral disturbances pushed Resident #42, who had a diagnosis of Parkinson's disease (degenerative brain condition), resulting in Resident #42 falling. Both residents resided in the memory care unit of the facility. Certified nurse aide (CNA) #5 witnessed the event and reported being in the dining room and seeing Resident #42 walking down the hallway with her walker. Resident #25 exited her room and pushed Resident #42, who fell to the floor. After pushing Resident #42, Resident #25 returned to her room and shut the door. CNA #5 informed licensed practical nurse (LPN) #2 who assessed Resident #42 for injuries. On 6/6/24 the director of nursing (DON) interviewed Resident #25, Resident #42 and staff who were working in the memory care unit. The interview with Resident #25 revealed the resident was unable to recall events, had no injuries and was free from psychosocial distress. The interview with Resident #42 revealed the resident was unable to recall events, had no injuries and was irritable at the time of interview. The interview with CNA #5 revealed the incident between Resident #25 and Resident #42 was believed to be unprovoked as both residents had been free of agitation prior to the incident. On 6/11/24 the facility concluded the investigation and physical abuse was substantiated. III. Resident #25 (assailant) A. Resident status Resident #25, age 78, was admitted on [DATE]. According to the June 2024 computerized physicians orders (CPO), diagnoses included dementia with behavioral disturbances and anxiety. The 4/15/24 minimum data assessment (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. She required set up assistance with activities of daily living (ADL) and was independent with mobility without the use of assistive devices. The assessment revealed Resident #25 displayed behavioral symptoms directed at others daily to include hitting, kicking, pushing, scratching and grabbing and behavioral symptoms not directed at others to include physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. B. Record review The 5/23/24 psychotropic pharmacological management review indicated a gradual dose reduction (GDR) was occurring for Resident #25 with her Buspirone (anti-anxiety medication). The 6/6/24 psychotropic pharmacological management review indicated Buspirone was restarted for Resident #25 related to increased behaviors, including aggression towards other residents. The behavioral care plan, initiated on 4/8/22 and revised on 6/6/24, revealed Resident #25 had anxiety related to her diagnosis of dementia with behavioral disturbances as evidenced by pacing, repetitive and unrealistic concerns, tearfulness, agitation and aggressive behaviors of striking out during care. Resident #25 had a history of a fixed hallucination of a man who she believed to be her companion. The care plan indicated the resident would have fewer episodes through the review date. Pertinent interventions included administering anti-anxiety medications and monitoring for unexpected side effects of mania, hostility, rage, aggressive or impulsive behaviors and hallucinations. IV. Resident #42 (victim) A. Resident status Resident #42, age 80, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included Parkinson's disease and psychotic disorder with hallucinations and delusions. The 5/17/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required maximum assistance with ADLs and needed supervision when walking short distances and maximum assistance with mobility when using a wheelchair. The assessment revealed Resident #42 displayed behavioral symptoms not directed towards others such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. B. Record review The wander risk care plan, initiated on 2/10/24 and revised on 5/21/24, revealed Resident #42 had a history of wandering aimlessly. It indicated the resident would remain safe through the review date. Pertinent interventions included identifying if wandering was purposeful, aimless or escapist or if the resident was looking for something and wandering indicated the need for exercise and distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. A review of Resident #42's electronic medical record (EMR) and facility investigation revealed no skin issues were identified, nor was pain or mental distress identified verbally or nonverbally, following the incident by Resident #25 on 6/6/24. V. Facility investigation of physical abuse involving Resident #24 and Resident #52 on 6/13/24. The abuse investigation, dated 6/13/24, revealed Resident #24, who had a diagnosis of dementia with behavioral disturbances was exhibiting agitation with exit seeking behaviors to include pushing her walker into Resident #52, who also had a diagnosis of dementia with behavioral disturbances, while Resident #52 was standing up in front of her wheelchair. Both residents resided in the memory care unit of the facility. CNA #4 witnessed the event and reported she separated the residents and provided information to registered nurse (RN) #2 who notified the director of nursing (DON). The DON proceeded with the investigation. On 6/13/24 the DON interviewed Resident #24, Resident #52 and staff working in the memory care unit. The interview with Resident #24 revealed the resident was agitated, stating she wanted to go home and wanted out of the facility while moving personal belongings around her room. The investigation revealed Resident #24 was placed on one to one observations. The investigation revealed Resident #52 was confused and only recalled being pushed by Resident #24. The investigation revealed Resident #52 was assessed by the DON and was free of psychosocial distress and had no new injuries as a result of the event and Resident #52 received one to one staff supervision for the duration of the investigation. The investigation revealed CNA #4 witnessed the event and provided the following information to the DON. CNA #4 reported Resident #24 was having increased agitation with staff, pacing the hallway of the memory care unit in an attempt to leave. CNA #4 reported Resident #24 was slamming doors, throwing objects and shoving her walker into staff who were attempting to redirect her. CNA #4 reported Resident #24 attempted to invite another male resident into her room. CNA #4 reported attempting to redirect Resident #24 with a supervised walk throughout the building, however, Resident #24 declined, entered another resident's room and began undressing. CNA #4 reported attempting to assist Resident #24 with dressing but Resident #24 declined and walked into the hallway where she approached Resident #52 standing in front of her wheelchair. Resident #24 pushed her walker into Resident #52 causing Resident #52 to fall back into a seated position in her wheelchair. The investigation summary indicated staff believed Resident #24 was having increased behaviors as a result of a gradual dose reduction (GDR) with her current psychotropic medications. On 6/19/24 the facility concluded the investigation and physical abuse was substantiated. A review of the Resident #52's EMR and the facility investigation revealed no skin issues were identified, nor was pain or mental distress identified verbally or nonverbally, following the incident by Resident #24 on 6/13/24. VI. Resident #24 (assailant) A. Resident status Resident #24, age 88, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia with behavioral disturbances. The 6/4/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required supervision to partial assistance with ADLs and was independent with mobility with the use of a four wheeled walker. The MDS assessment revealed Resident #24 displayed physical and verbal behavioral symptoms directed towards others on one to three days during the assessment period, such as, hitting, kicking, pushing, scratching or grabbing, threatening or screaming and cursing at others. B. Record review The 5/30/24 psychotropic pharmacological management review revealed there was a GDR in progress for Resident #24 and she was being titrated off of Seroquel (an antipsychotic medication) and Risperdal (an antipsychotic medication) would be ordered in place of the Seroquel. The 6/13/24 change of condition (COC) evaluation revealed the GDR of Seroquel had failed and Resident #24 was noted to have worsening behavioral symptoms. The dementia care plan, initied on 8/22/17 and revised on 6/1/24, revealed Resident #24 was taking an antipsychotic medication for a diagnosis of dementia with behavioral disturbances. It indicated the resident would remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date. Pertinent interventions included administering antipsychotic medications as ordered and observing for side effects. The behavior care plan, initiated on 2/5/21 and revised on 5/7/24, revealed Resident #24 had behaviors which included pacing to the point of exhaustion, yelling out, cursing, hitting, throwing items, slamming fists on table, making repetitive statements towards staff, inability to focus and becoming hypervigilant resulting in restlessness. It indicated the resident's behaviors would not disturb others. Pertinent interventions included assisting the resident to contact her son as a means of distraction, engaging the resident in activities of enjoyment such as folding laundry or entertaining herself with a balloon or bouncing and trying to keep it in the air, watching movies, participating in crafts, and walking outside or sitting and talking with the resident if she presented with anger. VII. Resident #52 (victim) A. Resident status Resident #52, age greater than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia with behavioral disturbances. The 4/25/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She was independent with ADLs and mobility with a wheelchair. The MDS assessment revealed Resident #52 displayed physical and verbal behavioral symptoms directed towards others on four to six days during the assessment period such as, hitting, kicking, pushing, scratching or grabbing, threatening or screaming and cursing at others. B. Record review The fall risk care plan, initiated on 11/1/23, revealed Resident #52 was a moderate fall risk related to confusion, balance problems and was legally blind. It indicated the resident would be free from falls through the review date. Pertinent interventions included increased monitoring to anticipate the resident's needs. VIII. Facility investigation of physical altercation involving Resident #24 and Resident #68 on 6/15/24. The physical abuse investigation dated, 6/15/24, revealed Resident #24, who had a diagnosis of dementia with behavioral disturbances and Resident #68, who had a diagnosis of dementia with behavioral disturbances, both residing in the memory care facility, were observed by staff engaging in a physical altercation. The investigation revealed Resident #24 was walking out to the courtyard of the memory care unit with a baby doll set on top of the seat of her walker and Resident #68 reached out and took the baby doll off the walker of Resident #24. The investigation revealed Resident #24 slapped the hand of Resident #68 in response to the baby doll being taken and Resident #68 slapped Resident #24 in the chest, at which point, staff intervened. The investigation indicated no injuries or distress were noted for Resident #24 or Resident #68 and Resident #24 received one to one supervision for the duration of investigation. The DON proceeded with investigation. On 6/16/24 the DON interviewed Resident #24, Resident #68 and staff working in the memory care unit. The interview with Resident #24 revealed the resident continued to be agitated and irritable without aggression following the interaction. Resident #68 was unable to recall events. CNA #6 was interviewed by the DON and reported Resident #24 began displaying unprovoked agitation during the evening and was pacing the unit, pushing her walker into doors attempting to open the doors and exit the memory care unit. CNA #6 reported attempts at redirection and de-escalation with Resident #24 were unsuccessful and the resident eventually stopped pacing the unit and joined the other residents in the courtyard for dinner for a short period of time before standing and walking back through the doorway to reenter the unit. CNA #6 reported it was when Resident #24 was walking through the doorway back into the unit with a baby doll on her walker that Resident #68 reached out and tried taking the baby doll resulting in Resident #24 slapping the hand of Resident #68 and Resident #68 slapping the chest of Resident #24. CNA #6 intervened and separated the two residents. CNA #6 reported Resident #24 was continuing to display agitation and an unidentified CNA walked for approximately 30 minutes with Resident #24 throughout the facility Upon returning to the memory care unit, Resident #24 was escorted by the unknown CNA to her room where she stayed for the remainder of the evening without issue. CNA #6 reported the unknown CNA provided one to one oversight to Resident #24 while the resident had a snack, took her medication, ate dinner and was assisted to bed. The investigation summary indicated staff believed Resident #24 was having increased behaviors as a result of a gradual dose reduction (GDR) with her current psychotropic medications. On 6/21/24 the facility concluded the investigation and physical abuse was substantiated. A review of Resident #68's EMR and the facility investigation revealed no skin issues were identified, nor was pain or mental distress identified verbally or nonverbally, following the incident by Resident #24 on 6/15/24. IX. Resident #68 (victim) A. Resident status Resident #68, age 83, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia and anxiety. The 4/19/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. She required set up for eating and substantial assistance with all other ADLs and was independent with mobility. The MDS assessment revealed Resident #68 displayed physical and verbal behavioral symptoms directed towards others on one to three days during the assessment period, such as, hitting, kicking, pushing, scratching or grabbing, threatening or screaming and cursing at others. X. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 6/27/24 at 1:08 p.m. CNA #7 said she was aware of the resident to resident altercation between Resident #25 and Resident #42 on 6/6/24 but had not witnessed the event. CNA #7 said she had not noticed any changes in behaviors regarding Resident #25 or Resident #42 individually or separately. CNA #7 said she had not witnessed any provoking interaction between the two residents prior to the altercation. CNA #7 said she was made aware of the resident to resident altercation between Resident #24 and Resident #52 on 6/13/24 and the altercation between Resident #24 and Resident #68 on 6/15/24. CNA #7 said she had not personally witnessed either event. CNA #5 was interviewed on 6/27/24 at 1:10 p.m. CNA #5 said she witnessed the resident to resident altercation between Resident #25 and Resident #42 on 6/6/24. CNA #5 she had not noticed any changes in behaviors regarding Resident #25 or Resident #42 individually or separately. CNA #5 said she had not witnessed any provoking interaction between the two residents prior to the altercation. The director of nursing (DON) was interviewed on 6/27/24 at 5:00 p.m. The DON said it was determined the GDR for Resident #24's anti-anxiety medication would be considered a failed trial as the altercation between the resident and Resident #25 was unprovoked and the facility determined the GDR to be a contributing factor. The DON said Resident #24 was in the process of a GDR of her antipsychotic medication at the time of the resident to resident altercations with Resident #52 and Resident #68. The DON said Resident #24 had been stable on the medication and it was determined the GDR was a contributing factor to the altercations and the GDR was considered a failed trial. The DON said increased monitoring was implemented in the memory care unit during the GDR for Resident #24 and there was to be one staff member with eyes on the residents at all times. The DON said there was now the addition of a full time activities assistant dedicated to the memory care unit and the addition of a memory care unit manager to provide more staff to try to prevent further incidents of abuse.

Based on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for three (#67, #26 and #29) of nine residents reviewed out of 45 sample residents. Specifically, the facility failed to: -Ensure medications and insulin supplies, including sharps, were not left at the bedside; -Ensure medications were not dispensed and stored in medication cups in a nurse's pocket; and, -Ensure medications were not contaminated by placing dispensed medication back into the original bottle. Findings include: I. Facility policy and procedure The Medication Administration policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. It read in pertinent part, Resident medications are administered in an accurate, safe, timely and sanitary manner. Do not leave medications with the resident. Follow the medication/pharmacy guidelines for storage. II. Resident #67 A. Resident status Resident #67, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included unspecified severe protein-calorie malnutrition, type 1 diabetes mellitus with other specified complications, alcohol abuse and functional quadriplegia (complete immobility due to severe physical disability or frailty). The 5/14/24 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. B. Observations On 6/25/24 assistant director of nursing (ADON) #2 was preparing to administer insulin to a resident. After checking the resident's blood sugar, ADON #2 left the room to obtain an insulin syringe from the medication cart. -ADON #2 left the insulin supply box at the bedside, which contained insulin and sharps for the glucometer. III. Resident #26 A. Resident status Resident #26, age less than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease (decreased blood flow to the brain) affecting the right dominant side, unspecified psychosis not due to a substance or known physiological condition, type 2 diabetes mellitus without complications and acute respiratory failure with hypoxia (inadequate oxygen supply). The 6/11/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. B. Observations On 6/26/24 at 8:59 a.m., registered nurse (RN) #1 was preparing medication for Resident #26. She cut an olanzapine tablet (antipsychotic medication) in half with a pill cutter. She placed the half that was not going to be administered in a medication cup and put the cup containing the medication into her pocket. RN #2 said she would take it to the drug buster (a container used to destroy medications) for disposal later . IV. Resident # 29 A. Resident status Resident #29, age 76, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder (break down of discs between the vertebrae in the back, causing pain), chronic respiratory failure with hypoxia and type 2 diabetes mellitus without complications. The 4/24/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. B. Observations On 6/27/24 at 8:59 a.m., ADON #1 was preparing medication for Resident #29. She poured two tablets of famotidine 10 milligrams (mg) (medication to treat heartburn) into a medication cup with other medications. She then realized there were 20 mg tablets in the medication cart and that she should administer one 20 mg tablet instead of two 10 mg tablets. -ADON #1 took the two 10 milligram tablets out of the medication cup with a spoon and returned them to the original bottle. The bottle was a stock medication bottle and was utilized for more than one resident. V. Staff interviews ADON #2 was interviewed on 6/27/24 at 4:30 p.m. ADON #2 said there were not drug buster containers in every medication cart so nurses had to take medications for disposal to another area when passing medications. The director of nursing (DON) was interviewed on 6/27/24 at 5:20 p.m. The DON said insulin supplies should not be left in a resident's room unattended. She said pills should not be put back into stock containers after dispensing them into a medication cup with other medications.

Based on observations, interviews and record review, the facility failed to ensure one (#57) of six residents reviewed for activities out of 45 sample residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Specifically, Resident #57 was not provided with meaningful activities or one-to-one activity staff visits per her individualized plan of care. Findings include: I. Resident #57 A. Resident status Resident #57, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included non-ischemic myocardial injury (non-traumatic injury to the heart), acute on chronic diastolic (congestive) heart failure, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side and type 2 diabetes mellitus with diabetic chronic kidney disease. The 5/27/24 minimum data set (MDS) assessment revealed the resident was unable to answer any of the questions on the brief interview for mental status (BIMS) which resulted in a BIMS score of zero out of 15. The assessment indicated her activity preferences included animals, going outside, books, magazines, music and keeping up with the news. The assessment documented she had adequate hearing and was sometimes able to make herself understood. II. Observations On 6/25/24 at 11:19 a.m. Resident #57 was lying in bed on her right side in a fetal position. She was in isolation for COVID-19. On 6/25/24 Resident #57 was observed during a continuous observation, beginning at 2:21 p.m. and ending at 4:01 p.m. At 2:21 p.m. the resident was lying in bed on her right side. There was no television on or music playing in her room. At 3:20 p.m. the resident continued lying in bed on her right side. No staff had entered her room and the resident was not engaged in any individual activities. There was no television on and there was no music playing in her room. At 3:48 p.m. a certified nurse aide (CNA) entered the room briefly and exited with a trash bag. At 4:01 p.m. Resident #57 was sitting on the side of the bed. There was no television on or music playing in the room and she was not engaged in any individual activities. On 6/26/24 at 10:39 a.m. the resident was lying in bed on her right side with her feet hanging off the side of the bed. There was no television on or music playing in the room and she was not engaged in any individual activities. The resident had been taken off of isolation for COVID-19. On 6/26/24 at 1:05 p.m. Resident #57 was lying in bed on her right side. Assistant director of nursing (ADON) #2 and the corporate consultant (CC) were providing wound care to the resident. The resident did not have the television on or music playing. ADON #2 and the CC did not offer any type of activity to the resident when they left the resident's room. On 6/26/24 at 2:41 p.m. the resident was lying in bed on her right side with her feet dangling off of the bed. There was no television on or music playing in the room and she was not engaged in any individual activities. III. Resident interview Resident #57 was interviewed on 6/25/24 at 2:19 p.m. Resident #57 was lying in bed. She said she did not have any activities to do in her room and she was always bored. She said she liked to read but hadn't been reading because she had been sick. The resident was able to answer questions and was understood during the interview. IV. Record review Resident #57's activities care plan, initiated 5/2/24, identified the resident had little or no involvement in activities due to disinterest and physical limitations. The goal was to have one to one visits one time per week from activities staff. -Review of Resident #57's progress notes for May 2024 and June 2024 did not reveal any one to one activity visit documentation. V. Staff Interview The activity director (AD) was interviewed on 6/27/24 at 4:50 p.m. The AD said she had been the activity director for four months. She said when a resident had one to one activity visits, the visits were documented in the progress notes. She said if a resident refused a one to one visit that would also be documented in the progress notes. The AD said Resident #57 had been refusing one to one visits since her decline in condition a couple of months ago. -The AD was unable to provide documentation for Resident #57 which documented weekly one to one visits or refusals. The AD said before her decline in condition, Resident #57 was still socializing with people in the hallways. She said the resident liked to talk about her husband who was in the military. The AD said she recently started auditing the activity documentation because the documentation was lacking. She said she had recently started training her staff on documentation expectations.

Based on record review and interviews, the facility failed to ensure two (#58 and #67) of two sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of 45 sample residents. Specifically, the facility failed to: -Notify the physician for high blood sugar readings for Resident #58; and, -Consistently monitor blood sugars according to the physician's order for Resident #67. Findings include: I. Facility policy and procedure The Diabetic Management policy, dated 3/19/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. It read in pertinent part, Diabetic management involves both preventative measures and treatment of complications. The interdisciplinary team evaluates the diabetic resident and implements a plan of care: to ensure orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow in communicating with the physician. If the resident has high blood sugar, follow physician ordered parameters. If the blood sugar is above 'high' parameter, the physician must be contacted for further instructions. For acute complications, documentation should include at least the following information: resident's signs and symptoms, results of blood testing, notification of physician and any new orders, interventions initiated, resident's response to treatment and notification of responsible party if applicable. II. Resident #58 A. Resident status Resident #58, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus. According to the 5/7/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was independent with most activities of daily living (ADL) but needed supervision with bathing. B. Record review The June 2024 CPO revealed the following orders for diabetic management: Lantus subcutaneous solution 100 units per milliliter (insulin glargine), inject 20 units subcutaneously in the morning for type 2 diabetes mellitus without complications, ordered on 4/8/23. Insulin glargine subcutaneous solution (insulin glargine), inject 10 units subcutaneously in the evening for type 2 diabetes mellitus without complications, ordered on 7/31/23. Fingerstick blood sugar once per day for type 2 diabetes mellitus management, ordered on 11/23/23 and revised on 3/22/24. Hyperglycemia (high blood sugar) protocol, use as needed for hyperglycemia, a blood sugar over 400 milligrams/deciliter (mg/dl), notify the physician, follow the physician's orders and continue to recheck the blood sugar every hour and provide interventions as needed or specified by the provider, ordered on 12/18/2023. -The January 2024 diabetic record revealed missing documentation of physician notification for high blood sugars on 1/26/24 at 7:59 a.m. for a blood sugar of 418 mg/dl and on 1/28/24 at 7:53 a.m. for a blood sugar of 409 mg/dl. -The February 2024 diabetic record revealed missing documentation of physician notification for a high blood sugar on 2/20/24 at 7:59 a.m. for a blood sugar of 420 mg/dl. -The May 2024 diabetic record revealed missing documentation of physician notification for high blood sugars on 5/2/24 at 10:00 a.m. for a blood sugar of 486 mg/dl and on 5/11/24 at 7:04 a.m. for a blood sugar of 599 mg/dl. 50853 III. Resident #67 A. Resident status Resident #67, age less than 65 was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included type 1 diabetes mellitus with other specified complications, unspecified severe protein-calorie malnutrition, alcohol abuse and functional quadriplegia (complete immobility due to severe disability or frailty, not due to a spinal cord injury). The 5/14/24 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. The assessment indicated the resident received insulin injections seven out of seven days during the assessment reference period. B. Record review The 2/22/24 physician ' s order for insulin lispro (Humalog) 100 units/milliliter (ml) pen, inject as per sliding scale. If blood sugar is: 0 - 199 = 0 units; 200 - 249 = 1 unit; 250 - 299 = 2 units; 300 - 349 = 3 units; 350 - 399 = 4 units; 400 - 449 = 5 units; 450 - 499 = 6 units; 500 - 600 = 8 units, subcutaneously every 4 (four) hours for diabetes mellitus. Notify the physician for blood sugar less than 60 milligrams/deciliter (mg/dl) after carbohydrate supplement or greater than 400. mg/dl. The order date of the medication was 2/2/24. The 1/12/24 physician ' s order indicated for hyperglycemia (high blood sugar) protocol as needed for blood sugar greater than 400 mg/dl. Step one notify the physician, step two follow physician orders and step three continue to recheck blood sugar every one hour and provide interventions as needed or specified by the provider. According to the June 2024 medication administration record (MAR) the resident had high blood sugars, over 400 mg/dl, on the below listed dates. -On 6/1/24 at 9:05 p.m. the resident ' s blood sugar was 600 mg/dl. The staff did not recheck the blood sugar until 6/2/24 at 2:29 a.m. -On 6/3/24 at 1:58 a.m. the resident ' s blood sugar was 417 mg/dl. The staff did not recheck the blood sugar until 5:13 a.m. -On 6/4/24 at 4:55 p.m. the resident ' s blood sugar was 464 mg/dl. The staff did not recheck the blood sugar until 8:02 p.m. -On 6/5/24 at 3:36 p.m. the resident ' s blood sugar was 586 mg/dl. The staff did not recheck the blood sugar until 7:51 p.m. -On 6/5/24 at 7:51 p.m. the resident ' s blood sugar was 600 mg/dl. The staff did not recheck the blood sugar until 6/6/24 at 1:33 a.m. -On 6/8/24 at 4:52 p.m. the resident ' s blood sugar was 600 mg/dl. The staff did not recheck the blood sugar until 7:40 p.m. -On 6/8/24 at 7:40 p.m. the resident ' s blood sugar was 518 mg/dl. The staff did not recheck the blood sugar until 11:54 p.m. -On 6/11/24 at 4:55 p.m. the resident ' s blood sugar was 466 mg/dl. The staff did not recheck the blood sugar until 8:19 p.m. -On 6/12/24 at 8:16 p.m. the resident ' s blood sugar was 407 mg/dl. The staff did not recheck the blood sugar until 6/13/24 at 5:03 a.m. -On 6/13/2024 at 8:56 p.m. the resident ' s blood sugar was 584 mg/dl. The staff did not recheck the blood sugar until 6/14/24 at 12:13 a.m. -On 6/14/24 at 6:00 a.m. the resident ' s blood sugar was 478 mg/dl. The staff did not recheck the blood sugar until 8:38 a.m. -On 6/15/24 at 3:53 a.m. the resident ' s blood sugar was 492 mg/dl. The staff did not recheck the blood sugar until 9:26 a.m. -On 6/16/24 at 9:15 p.m. the resident ' s blood sugar was 461 mg/dl. The staff did not recheck the blood sugar until 6/17/24 at 12:47 a.m. -On 6/22/24 at 5:10 a.m. the resident ' s blood sugar was 407 mg/dl. The staff did not recheck the blood sugar until 9:25 a.m. -On 6/22/24 at 4:16 p.m. the resident ' s blood sugar was 592 mg/dl. The staff did not recheck the blood sugar until 9:14 p.m. -On 6/22/24 at 9:14 p.m. the resident ' s blood sugar was 439 mg/dl. The staff did not recheck the blood sugar until 11:43 p.m. -On 6/23/24 at 11:33 a.m. the resident ' s blood sugar was 519 mg/dl. The staff did not recheck the blood sugar until 4:03 p.m. -On 6/24/24 at 12:18 p.m. the resident ' s blood sugar was 468 mg/dl.The staff did not recheck the blood sugar until 5:35 p.m. -On 6/24/24 at 8:12 p.m. the resident ' s blood sugar was 465 mg/dl. The staff did not recheck the blood sugar until 6/25/24 at 1:12 a.m. -On 6/25/24 at 4:47 p.m. the resident ' s blood sugar reading was greater than 600 mg/dl (high). The staff did not recheck the blood sugar until 8:34 p.m. -On 6/26/24 at 5:27 a.m. the resident ' s blood sugar was 509 mg/dl.The staff did not recheck the blood sugar until 9:03 a.m. -On 6/26/24 at 5:10 p.m. the resident ' s blood sugar was 600 mg/dl. The staff did not recheck the blood sugar until 8:44 p.m. -A review of the resident ' s electronic medical record (EMR) revealed the nursing staff failed to monitor Resident #67 ' s blood sugar every hour following a blood sugar reading above 400 mg/dl per the protocol in June 2024 (see above). -A review of the June 2024 (6/1/24 to 6/26/24) MAR revealed no documentation indicating the hyperglycemia protocol was followed. IV. Staff interviews Assistant director of nursing (ADON) #2 was interviewed on 6/27/24 at 11:08 a.m. ADON #2 said the hyperglycemia protocol specific to Resident #67 was to give insulin per the sliding scale physician ' s order, notify the physician and follow any new orders that were received. She said she was unsure if the resident ' s blood sugar needed to be rechecked within a certain time frame. The director of nursing (DON) was interviewed on 6/27/24 at 5:20 p.m. The DON said the hyperglycemia protocol needed to be followed if the blood sugar was out of the range of the sliding scale. She said the nurse should notify the provider, recheck the blood sugar within 15 minutes and as often as needed until the resident was stable. She said if the protocol was written in the physician's orders, the nurse should follow the physician ' s ordered protocol. The DON said the licensed nurses were not checking Resident #58's blood sugars hourly for four hours because the physician's order did not prompt the nurses to do so. She said she was unable to find documentation indicating the nurses had followed up on Resident #58's high blood sugars. The DON said the nurses knew they should follow up on the high blood sugar readings. The DON said the nurses should enter a progress note into the resident's EMR and obtain and document the follow-up blood sugars. She said the nurses did not check blood sugars hourly for four hours on Resident #67 as they should have when the resident ' s blood sugars were high in June 2024. She said the nurses may have checked the blood sugars hourly, however, she said because it was not documented, there was no indication that the blood sugars were taken.

Based on record review and interviews, the facility failed to ensure one (#45) of two residents with limited range of motion received appropriate treatment and services out of 45 sample residents. Specifically, the facility failed to offer restorative nursing services as recommended by physical therapy to prevent decline in physical function for Resident #45. Findings include: I. Professional Reference According to the American Association of Post-Acute Nursing (AAPACN) Guidelines for Restorative Nursing Programs, retrieved on 7/1/24 from aapacn.org/restorative-programs-guide/, The risk for functional decline in long term care residents is a serious issue that often leads to falls, pressure ulcers/injuries, weight loss, depression, and other negative outcomes. To ensure quality outcomes and to comply with federal regulation, nursing facilities must have a comprehensive and effective restorative therapy program that encourages each resident's highest level of function. II. Resident #45 A. Resident status Resident #45, age greater than 65, was admitted to the facility on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia, Parkinson's disease and anemia. The 3/25/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision or touching assistance with bathing and set up or clean-up assistance with personal hygiene. B. Resident interview Resident #45 was interviewed on 6/24/24 at 3:14 p.m. Resident #45 said she had not received restorative nursing services for a few weeks. Resident #45 said she felt like she was becoming more stiff and could not move as easily as she used to when getting out of bed. Resident #45 said when she was in physical therapy she could walk longer distances, but felt that it had become more difficult for her to walk since physical therapy services ended in May 2024. Resident #45 said she thought her fall earlier this month (June 2024) could have been because she had become weaker. Resident #45 said she was worried she might fall more in the future if she did not keep her strength up with restorative nursing services. C. Record review A physical therapy discharge summary dated 5/10/24 documented that physical therapy services ended because Resident #45 completed all physical therapy goals. The discharge summary documented the following regarding Resident #45: -She could walk 100 feet four times per physical therapy session; -She required minimum assistance with transfers in bed and required stand-by assistance to transfer with a four wheel walker; -She had a significant increase in endurance with skilled physical therapy; and, -She had an increase in ambulation ability with skilled physical therapy. The discharge summary recommended a restorative nursing program to include restorative ambulation and a restorative range of motion. The discharge summary documented a good prognosis to maintain current level of function with consistent staff follow-through. -A review of the June 2024 CPO revealed the resident did not have an order for restorative nursing services. A restorative nursing program referral form, dated 5/10/24, was obtained from the director of rehabilitation (DOR) on 6/27/24 at 10:06 a.m. The referral form documented a physical therapy recommendation for Resident #45 to receive restorative nursing services four to five times per week. The referral form documented the restorative goal was to maintain or improve Resident #45's movement and strength in her lower limbs and to enable the resident to continue to transfer and walk. The referral form documented the resident required further services in the areas of active range of motion, transfers, and walking. The referral form documented the resident was able to walk 80 to100 feet three to four times per physical therapy session. A restorative aide progress note dated 5/28/24 documented Resident #45 was on a restorative program including active range of motion for the resident's legs, ambulation with a four wheel walker and for transfers. A restorative aide progress note dated 5/31/24 documented Resident #45 was participating well in the restorative nursing program and was able to ambulate 300 feet per session. A restorative aide progress note dated 6/9/24 documented Resident #45 was participating well in the restorative nursing program and was able to ambulate 30 feet per session. A restorative aide progress note dated 6/14/24 documented Resident #45 was participating well in the restorative nursing program and was able to ambulate 140 feet per session. A restorative aide progress note dated 6/21/24 documented Resident #45 was participating with the restorative nursing program two times per week. The progress note documented the restorative nursing program was on hold because the resident was COVID-19 positive and was not feeling well. A restorative aide progress note dated 6/23/24 documented the resident's restorative nursing program was on hold because the resident was COVID-19 positive. -The progress note failed to document if restorative nursing services were offered to the resident in her room. A review of the certified nurse aide (CNA) task response history (from 5/25/24 to 6/26/24) revealed Resident #45 received restorative nursing services on 5/30/24, 6/4/24, 6/5/24, 6/8/24, 6/11/24, and 6/13/24. -Resident #45 did not receive restorative nursing services until 5/30/24, 20 days after the resident was referred to a restorative nursing program by physical therapy. -Resident #45 received restorative nursing services six times between 5/30/24 and 6/13/24. -The facility failed to offer restorative nursing services to Resident #45 four to five times per week as recommended by physical therapy (see physical therapy referral form above). -One resident refusal was documented on 6/21/24; however, the facility failed to re-offer restorative nursing services on a different date to Resident #45. III. Staff interviews Registered nurse (RN) #1 was interviewed on 6/26/24 at 4:02 p.m. RN #1 said she worked as needed in the facility and was familiar with all the residents in the building. RN #1 said she had recently noticed Resident #45 had gotten more stiff during transfers and ambulation. RN #1 said she had heard other staff members mention Resident #45 required more assistance with her ADLs (activities of daily living) than she used to. RN #1 said she was not aware what restorative nursing services Resident #45 required because the restorative aides provided restorative services. CNA #3 was interviewed on 6/26/24 at 4:21 p.m. CNA #3 said Resident #45 required the same number of staff for ADLs as before, but needed more assistance from the staff member to assist with transfers. CNA #3 said Resident #45 could walk about 50 feet before she usually got tired and needed a rest. CNA #3 said she knew Resident #45 was receiving restorative nursing services but she was unsure if it was ongoing or discontinued. The MDS coordinator (MDSC) was interviewed on 6/27/24 at 10:19 a.m. The MDSC said she was also the director of restorative nursing services in the facility. The MDSC said restorative nursing services were important to maintain a resident's current level of function. The MDSC said restorative nursing service referrals from physical therapy should always be followed. The MDSC said residents who tested positive for COVID-19 should still have restorative nursing services offered to them in accordance with the physical therapy recommendations. The MDSC said the restorative services department had lost a restorative aide recently and the department had to make some hard decisions about how to continue restorative services for all residents. The MDSC said Resident #45's restorative services were reduced to twice per week because of the loss of the restorative aide. The MDSC said the facility's choice to reduce Resident #45's restorative nursing services to two times per week instead of the four to five times per week recommended by physical therapy could have contributed to her decline in physical function. The director of nursing (DON) was interviewed on 6/27/24 at 4:56 p.m. The DON said restorative nursing services were important to maintain a resident's current level of function. The DON said physical therapy recommendations for restorative nursing services should be followed. The DON said restorative nursing services should be offered to residents who had a COVID-19 infection and those services could be provided in the resident's room if needed. The DON said Resident #45 had not been receiving restorative nursing services as was initially recommended by physical therapy.

Based on observations, record review and interviews, the facility failed to provide necessary respiratory care consistent with professional standards of practice in coordination with the resident plan of care for two (#4 and #3) out of four residents reviewed for respiratory care out of 45 sample residents. Specifically, the facility failed to: -Ensure Resident #4 received supplemental oxygen therapy per the physician's orders; and, -Ensure Resident #3 could safely and appropriately perform her tracheostomy care independently. Findings include: I. Supplemental oxygen failure A. Professional reference According to [NAME], B. B. (2022, November 23). Oxygen saturation, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK525974/ on 7/8/24, Cyanosis (bluish discoloration) may not develop until oxygen saturation reaches about 67%. As such, pulse oximetry is extremely useful because the signs and symptoms of hypoxemia may not be visible on physical examination. There is no set standard of oxygen saturation where hypoxemia occurs. The generally accepted standard is that a normal resting oxygen saturation of less than 95% (percent) is considered abnormal. Therefore, it remains vital to observe patients for the clinical markers of hypoxemia. The brain is the most sensitive organ, and visual, cognitive, and electroencephalographic changes develop when the oxyhemoglobin saturation is less than 80% to 85%. It is unclear whether there are long-term deficits from hypoxemia. B. Facility policy and procedure The Oxygen policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/27/24 at 7:29 p.m. It read in pertinent part, Oxygen is administered and stored to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. C. Resident #4 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and COVID-19. According to the 4/30/24minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. He required substantial to maximal assistance with bed mobility and transfers. He was not receiving supplemental oxygen. 2. Observations On 6/25/24 Resident #4 was observed during a continuous observation, beginning at 2:03 p.m. and ending at 2:51 p.m -At 2:03 p.m. Resident #4 was lying on his back in bed. He did not have an oxygen cannula in his nose. -At 2:10 p.m. Resident #4 was observed in bed lying on his back with no oxygen cannula in his nose. -At 2:51 p.m. Resident #4 was in bed not wearing an oxygen cannula. -No staff entered Resident #4's room to put the resident's oxygen on during the continuous observation. On 6/26/24 at 11:00 a.m. Resident #4 was observed in bed with an oxygen cannula in his nose. On 6/26/24 at 1:00 p.m. Resident #4 was observed in bed without an oxygen cannula in his nose. -A certified nurse aide (CNA) was observed in his room, however, the CNA did not offer to put Resident #4's oxygen on him. On 6/26/24 Resident #4 was observed during a continuous observation, beginning at 1:20 p.m. and ending at 3:36 p.m. At 1:49 p.m. CNA #1 was in Resident #4's room assisting his roommate. CNA #1 asked Resident #4 if he wanted a pain pill and the resident said no. -CNA #1 did not offer Resident #4 his oxygen. At 2:02 p.m. Resident #4 was observed in bed on his left side. The oxygen cannula was not in his nose. At 2:43 p.m. LPN #4 was observed entering Resident #4's room. Resident #4 was lying on his back in bed without his oxygen cannula in his nose. -LPN #4 asked the resident if he wanted her to remove his lunch tray, however, she did not offer the resident his oxygen. At 2:50 p.m. Resident #4 was observed lying in bed on his back. The oxygen cannula was not on his nose. At 3:32 p.m. CNA #1 was asked by the assistant director of nursing (ADON) #2 to check the oxygen saturation level (measure of oxygen in the blood) of Resident #4. CNA #1 reported the resident's oxygen saturation level was 69%. ADON #2 encouraged Resident #4 and he allowed the oxygen cannula to be put in his nose. At 3:36 p.m. Resident #4's oxygen saturation level was 79% with two liters per minute (lpm) of oxygen applied. On 6/26/24 at 4:40 p.m. registered nurse (RN) #2 entered Resident #4's room. RN #2 put the oxygen cannula in Resident #4's nose. The oxygen concentrator was set on 3 lpm. RN #2 checked the resident's oxygen saturation level and it was 83%. His heart rate was 122 beats per minute (BPM). RN #2 listened to Resident #4's lungs and said he had air movement but he had chronic COPD. She said since he was just in bed not moving around, that was why his oxygen saturation level was probably low. -RN #2 did not make any changes to Resident #4's oxygen liter flow. 3. Record review Review of Resident #4's comprehensive care plan, initiated 11/4/23, revealed the care plan did not include the resident's diagnoses of COPD or chronic respiratory failure with hypoxia. -A care plan focus area for COVID-19 was entered on the comprehensive care plan on 6/24/24, however, it did not include the use of oxygen as an intervention. Review of Resident #4's vital signs from 6/2/24 to 6/13/24 revealed the resident's oxygen saturation levels were below 90% on the following days: On 6/2/24 at 12:11 a.m. the resident's oxygen saturation level was 82% on room air. -There was no nurse progress note regarding the low oxygen saturation level. On 6/5/24 at 1:09 a.m. the resident's oxygen saturation level was 82% on room air. -There was no nurse progress note regarding the low oxygen saturation level. On 6/6/24 at 12:14 a.m. the resident's oxygen saturation level was 86% on room air,. -There was no nurse progress note regarding the low oxygen saturation level On 6/7/24 at 2:59 a.m. the resident's oxygen saturation level was 82% on room air. -There was no nurse progress note regarding the low oxygen saturation level. On 6/8/24 at 12:08 a.m. the resident's oxygen saturation level was 88% on room air. -There was no nurse progress note regarding the low oxygen saturation level. On 6/11/24 at 1:12 a.m. the resident's oxygen saturation level was 85% on room air. -There was no nurse progress note regarding the low oxygen saturation level. On 6/12/24 at 1:50 a.m. the resident's oxygen saturation level was 87% on room air. -There was no nurse progress note regarding the low oxygen saturation level. On 6/13/24 at 12:11 a.m. the resident's oxygen saturation level was 88% on room air. -There was no nurse progress note regarding the low oxygen saturation level. A review of Resident #4's June 2024 CPO revealed the following physician's order for oxygen: Oxygen at 2 liters per minute (lpm) via nasal cannula at night and while lying in bed napping, ordered 6/13/24. A nurse progress note dated 6/19/24 at 1:30 a.m. documented the resident's pulse oximetry (oxygen saturation level) on room air was 79% and oxygen was applied via nasal cannula at 2 lpm. The resident's oxygen saturation level came up quickly to 96%. He was to wear the oxygen continuously and continue to be monitored for improvement. A nurse progress note dated 6/20/24 at 4:25 a.m. documented the resident was in isolation for COVID-19 in a semi private room with a roommate who was also COVID-19 positive. The resident complained of fatigue and was irritable with interruptions. Resident #4 was removing his oxygen often and his oxygen saturation level dropped to the 70% range, but once the oxygen was replaced it returned to the 90% range. A nurse progress note dated 6/22/24 at 2:45 a.m. documented the resident's oxygen saturation level was at 89% on room air. Resident #4 was in cohort isolation for COVID-19. He was lethargic and showed no interest in anything. His appetite was poor and he was only taking liquids. His urine output was dark and concentrated. He removed his oxygen frequently. His pulse had been running high, in the 120 bpm range. A nurse progress note dated 6/25/24 documented the resident's oxygen saturation at 1:44 p.m. was 86% on oxygen. A change of condition report was completed and the provider was contacted at 8:22 a.m. due to low oxygen saturation levels and being lethargic. There was no provider response noted in the progress note. A nurse progress note dated 6/26/24 at 3:33 a.m. documented the resident was in cohort isolation for COVID-19. He was more alert and was having more behavioral issues. He yelled at staff and used the call light repetitively with no requests made. He continued to refuse to wear oxygen and his oxygen saturation levels were in the low 70% range. He was only taking sips of liquids and his heart rate was still high at 124 bpm. -There was no progress note indicating the physician had been contacted regarding the resident's condition since the change of condition report on 6/25/24 at 8:22 a.m. A nurse progress note dated 6/26/24 at 4:33 p.m. documented the resident's oxygen saturation level on room air (at 3:32 p.m.) was 69%. The nurse asked the resident if he would allow staff to help him put his oxygen on and the resident reluctantly allowed staff to put his oxygen on. After two minutes of having oxygen on, the resident's oxygen saturation level went up to 79% on 3 lpm. The nurse notified the provider of the resident's low oxygen saturation levels. On 6/26/24 at 4:26 p.m. a physician's order was obtained to monitor for signs and symptoms of respiratory illness/COVID-19 for suspected or confirmed COVID-19 infection or possible COVID-19 exposure and conduct respiratory exam including lung sounds every shift. Staff was to observe for signs or symptoms of respiratory illness: fever greater than100 degrees Fahrenheit (F), shortness of breath, cough, sputum production, sore throat, rhinorrhea, chills, myalgias, fatigue, headache, nausea/diarrhea/vomiting, new loss of taste or smell, and mental status changes. Staff was to document findings in progress notes and notify the provider of changes in condition. 4. Staff Interviews CNA #1 was interviewed on 6/26/24 at 3:30 p.m. CNA#1 said Resident #4 was supposed to be on 2 lpm of oxygen constantly. She said when staff entered his room they should ask him if he wanted the oxygen. She said he would accept the oxygen but then would take it off again. ADON #2 was interviewed on 6/26/24 at 3:31 p.m. ADON #2 said Resident #4 was encouraged to wear his oxygen but he was adamant about not wanting it. She said when staff were in the room, they should offer it and sometimes he would accept it. RN #2 was interviewed on 6/26/24 at 4:11 p.m. RN #2 said staff put Resident #4's oxygen cannula on and he took it back off. She said the resident ran low on his oxygen saturation levels. She said the resident was not doing well since he had gotten COVID-19. The director of nursing (DON) was interviewed on 6/26/24 4:18 p.m. The DON said she was aware of the change of condition completed on 6/25/24 for Resident #4 and the doctor decided not to order anything and just monitor the resident's respiratory status. She said when a resident had COVID-19, staff should be checking vital signs. She said staff should check respirations and temperature every shift and check other vitals once per day. 50314 II. Tracheostomy care failure A. Facility policy and procedure The Tracheostomy Care policy, undated, was obtained from the NHA on 6/26/24 at 4:55 p.m. It documented in pertinent part,Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. B. Resident #3 1. Resident status Resident #3, over the age of 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included heart failure, respiratory failure with hypoxia (low levels of oxygen) and generalized muscle weakness. According to the 5/9/24 MDS assessment, the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. She required touching assistance with shower transfers and was independent with all other cares. The assessment documented the resident had a tracheostomy. 2. Resident interview Resident #3 was interviewed on 6/24/24 at 11:10 a.m. Resident #3 said she always performed her own tracheostomy care independently. Resident #3 said nursing staff did not assist or observe her when she was performing tracheostomy care. Resident #3 said she did not know if the facility had assessed her to safely perform tracheostomy care. 3. Record review The care plan, dated 8/2/22 and revised 5/22/24, documented the resident was independent with her tracheostomy care. The tracheostomy care assessment documentation for Resident #3 was received from the corporate consultant (CC) on 6/26/24 at 3:12 p.m. The tracheostomy care assessment documented the CC and a respiratory therapist (RT) discussed tracheostomy care steps with Resident #3 on 6/26/24 (during the survey). -The tracheostomy care assessment documentation did not include a direct observation or return demonstration of Resident #3 performing tracheostomy care. -The facility failed to assess if Resident #3 could safely perform tracheostomy care between admission on 7/28/22 and 6/26/24. 4. Staff interviews RN #3 was interviewed on 6/25/24 at 3:04 p.m. RN #3 said Resident #3 did all of her own tracheostomy care independently.She said the nursing staff did not assist or observe the resident when she performed her tracheostomy care. RN #3 said she did not know if the facility had assessed Resident #3 to safely perform her own tracheostomy care. RN #3 said she had not observed Resident #3 perform tracheostomy care. RN #3 said she did not know how often Resident #3 was performing tracheostomy care independently. RN #1 was interviewed on 6/26/24 at 10:12 a.m. RN #1 said the nurses and CNAs did not assist Resident #3 with tracheostomy care. RN #1 said she did not know if the facility had assessed if Resident #3 could safely perform tracheostomy care independently. RN #1 said she had not observed Resident #3 perform tracheostomy care. The CC was interviewed on 6/26/24 at 3:12 p.m. The CC said she and the RT assessed Resident #3 regarding completing tracheostomy care independently. The CC said she and the RT discussed tracheostomy care steps with Resident #3. The CC said Resident #3 did not physically demonstrate any of the steps of tracheostomy care to her or the RT during the assessment on 6/26/24 (during the survey). However, the CC said she had confidence that Resident #3 could perform tracheostomy care appropriately and safely after the assessment. The CC said she was not concerned about the resident performing tracheostomy care appropriately and safely even though she had not watched the resident complete the task. The DON was interviewed on 6/27/24 at 4:56 p.m. The DON said Resident #3 should have been identified as needing a tracheostomy self-care assessment. The DON said the facility did not assess Resident #3's ability to safely and appropriately perform tracheostomy care before 6/26/24 (during the survey). The DON said it was important for residents with documented cognitive decline to be assessed so the nursing staff could ensure the resident's safety. The DON said the facility needed to do more to identify residents who must be self-assessed to complete their own cares.

Based on record review and interviews, the facility failed to ensure that the personal funds accounts were managed adequately for two (#2 and #30) of three residents reviewed for personal funds out of 45 sample residents. Specifically, the facility failed to notify Resident #2 and Resident #30, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person. Findings include: I. Record Review A. Resident #2 A review of the facility's current trust account on 6/27/24 revealed Resident #2 had $2,354.81 in her account, which was $354.81 dollars over the allotted $2000.00 eligibility limit for Medicaid funded residents. -There was no documentation to indicate the facility had notified Resident #2 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. B. Resident #30 A review of the facility's current trust account on 6/27/24 revealed Resident #30 had $3683.41in his account, which was $1,683.41 over the allotted $2000.00 eligibility limit for Medicaid funded residents. -There was no documentation to indicate the facility had notified Resident #2 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. II. Staff interviews The business office manager (BOM) was interviewed on 6/2724 at 7:04 p.m. The BOM said she provided letters notifying residents that they were within $200 of the Medicaid eligibility limit, but did not have documentation of these notifications for Resident #2 or Resident #30. The BOM said she was unable to confirm if Resident #2 and Resident #30, or their legal representatives had received the letters she sent. The BOM said the facility did not keep records of the letters that were sent to residents. The BOM said the facility was responsible for assisting residents with spending down their money. The BOM said she personally assisted residents with spending their money appropriately. The BOM said the facility had an Amazon account to assist residents with spending their money. The BOM said the facility had been assisting Resident #2 with spending her money for the last few months, but despite facility efforts, the resident was still over the $2,000 Medicaid limit. The BOM said Resident #30 was over the $2,000 Medicaid limit by a significant amount and the facility should have done more to help him spend down his money appropriately. The social services director (SSD) was interviewed on 6/27/24 at 7:14 p.m. The SSD said she, the BOM and the activities department staff worked together to assist residents with spending down their money. The SSD said the activities staff served as a second check to ensure the facility had two different departments overseeing the resident account spending. The SSD said the facility used approved magazine orders as well as a facility Amazon account to assist residents with spending their money. The SSD said Resident #2 and Resident #30 did not have enough of their personal funds spent and were both over the $2,000 Medicaid eligibility limit. The SSD said the facility could have done more to assist Resident #2 and Resident #30 with appropriately spending their money down so their accounts were not over the eligibility limit.

Based on record review and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for two (#38,#72) residents of six residents reviewed for falls and accidents out of 34 sample residents. Resident #38 who had severe cognitive deficits and resided on the facility's memory care unit (MCU), resulting in four falls in four months. One of the falls, which occurred on 8/4/21, resulted in harm to the resident. Due to a deep laceration to her right outer hand, Resident #38 required transport to the local emergency room for stitches. The facility also failed to provide supervision, monitoring and education to staff to prevent Resident #38 from eloping from the MCU's secured patio via a gate on 10/4/21, which led to the resident sustaining another fall in the community while away from the facility. The facility failed to thoroughly investigate and document every fall Resident #38 sustained in IDT meetings, including adding new and effective fall interventions to the resident's care plan following every fall. Additionally the facility failed to provide adequate supervision and safe environment to prevent Resident #72, with multiple incidents of exit seeking and dangerous elopement attempts, from eloping from the facility on 9/9/21. The facility failed to develop an effective performance improvement plan (PIP) for resident falls until the recertification survey began on 11/8/21. I. Facility policy The Elopement and Wandering Resident policy, dated 2021, was provided by the nursing home administrator (NHA) on 11/11/21 at 3:45 p.m. The policy read in pertinent part: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systems approach to monitor and manage residents at risk for elopement or unsafe wandering, including identification and risk assessment and evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary According to the policy the interdisciplinary team (IDT) would evaluate the factors contributing to the resident ' s risk in order to develop a person-centered care plan. Interventions would be included in the care plan and communicated with staff to increase staff awareness of the resident ' s risk. The policy guided staff to provide adequate supervision to help prevent accidents or elopements and evaluate the effectiveness of the interventions, modifying as needed. The policy defined elopement when a resident leaves the premise or a safe area without authorization and/or any necessary supervision to do so. The policy defined wandering occurrence as random or repetitive locomotion that may be goal-directed or non goal-directed or aimless. The policy gave the search for an exit as an example of wandering. The Accidents and Supervision policy, revised November 2017, was provided by the NHA on 11/11/21 at 8:05 a.m. The policy read in pertinent part: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: -Identifying hazards and risks; -Evaluating and analyzing hazards and risks; -Implementing interventions to reduce hazards and risks; and, -Monitoring for effectiveness and modifying interventions when necessary. According to the policy the facility should establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. All staff should be involved in the observation and identification of potential hazards in the environment while considering the unique characteristics and abilities of each resident. The policy read the facility should make reasonable efforts to identify hazard and risk factors for each resident and provide various sources of information about the hazards and risks in the residents ' environment. The policy indicated the sources of information could include but not limited to quality assessment and insurance activities (QAPI), environmental rounds, the minimal data set assessment (MDS), a resident ' s medical history, a physical examination, and the facility assessment. II. Resident #38 A. Resident status Resident #38, age 85, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included dementia with behaviors, abnormality of gait and mobility and muscle weakness. Resident #38 resided in the facility's secured memory care unit (MCU). The minimum data set (MDS) assessment dated [DATE] documented the resident had severe cognitive deficits with a brief interview for mental status (BIMS) score of four out of 15. It documented the resident required supervision with set up for bed mobility, transfers, ambulating with her walker and eating. She requires extensive assistance from one for dressing, toileting, personal hygiene and bathing. The MDS documented the resident had physical and verbal behavioral symptoms towards others on a daily basis, as well as behavioral symptoms not directed towards others on a daily basis. It documented the resident rejected care and also wandered on a daily basis. B. Resident observations Resident #38 was initially observed on 11/8/21 at 1:30 p.m. She was seated at a table on the MCU, putting together a large-sized puzzle. She was pleasant, smiling and displayed a calm manner. -At 6:00 p.m., she was eating her dinner at a table in the MCU dining room with another resident and they were socializing together. The resident was observed on 11/9/21 at 9:30 a.m. She was seated at a table in the MCU dining room by herself and she was independently looking at a People magazine. -At 12:01 p.m., the resident was, once again, having a meal with her friend and was eating her meal independently. -At 3:45 p.m., the resident was in her room taking a nap. Resident #38 was observed on 11/10/21 at 8:15 a.m. She was seated alone and finishing her breakfast. Her walker was not observed within reach of the resident or anywhere nearby. -At approximately 10:15 a.m., the resident was engaged in an activity with assistant activity (AA) #1 of making eagle pictures by tracing their hands. Resident #38 was observed on 11/11/21 at 10:33 a.m. She was with AA #1 participating in a Veteran's Day trivia activity. She said she could remember back to WWII and that her family was so happy when the war ended. Her walker was observed to be in another common area of the MCU at this time. -At 12:53 p.m., the resident was observed going through her dresser drawers looking for clothes because she wanted to go and see her mother for a few days. Staff redirected her back to the group of residents in the common area and she readily complied with staff. -At 3:00 p.m., Resident #38 was observed to be engaged with three other resident coloring pictures. She was coloring [NAME]. Her walker was left in another room with a glass of water on it. It was not within reach of the resident at this time. C. Record review The care plan dated 10/17/21 related to falls documented Resident #38 was at risk for falls related to gait/balance problems. Unaware of safety needs, wandering. The goal was to have decreased risk of falls with the staff helping the resident as needed. The general intervention was to anticipate and meet the resident's needs. More specific interventions related to falls included needing a safe environment with even floors free from spills and/or clutter, documenting the resident's falls had been happening the majority of the time in the evening, so the resident would need stand-by assistance when walking at that time, offering the resident a seat if she was pacing and to be outside with her when she was outside in the patio area in case she needed redirection or assistance. Another intervention in this care plan was when the resident's anxiety was increasing, staff should attempt to find the source and alleviate it and attempt to redirect the resident. If the resident was not redirectable, staff should allow her to call her son, as talking with him and being assured she was okay, would usually relieve the resident's level of anxiety. The care plan dated 10/17/21 related to elopement documented Resident #38 was an elopement risk/wanderer related to her history of packing, attempting to leave and arguing for staff to let me go. It documented the resident could be disoriented to place and situation, with impairment to safety awareness, which is why I resident on (MCU). It documented the resident would remain safe in the facility and not exit the building without supervision. It documented the staff should distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. It documented staff should identify the resident's pattern of wandering and intervene as appropriate. It documented if the resident was exit seeking, staff should attempt to redirect the resident by offering to walk with her and engage her in conversation during those walks. It documented staff should observe Resident #38 at regular and frequent intervals and document the wandering behavior and attempted diversional interventions. The Morse fall scale assessment dated [DATE] documented Resident #38 score was 80.0 or a high risk for falling. It documented the resident had fallen prior, used a cane or walker for ambulation, had a weak gait and over-estimated her limits. This was the only Morse fall assessment seen in Resident #38's chart. D. Elopement investigation The suspected abuse investigation form dated 10/8/21 documented Resident #38 was found to be missing from the facility on 10/4/21 at 5:10 p.m. A staff member leaving the facility found the resident at 5:15 p.m., approximately one block from home. The resident had fallen outside while she had been missing. Resident #38 resided on the [MEDICATION(S)] Hall, the facility's MCU. The form documented the resident resided on this unit due to dementia and exit seeking behaviors. It documented Resident #38 had been agitated and exit seeking prior to the incident. It was discovered a staff member entering through the MCU's back gate failed to ensure the gate closed behind them after they came through the gate. Resident #38 then exited through this gate and walked approximately one block where she was found after she had fallen. This form documented there were no injuries, which was incorrect, as the resident sustained bruising to her right knee (See fall investigations below). Following this elopement, the facility added automatically closing gate hinges and a spring to ensure the gate will always close. Education was provided to all staff to ensure the gate to the secured courtyard of the MCU actually closed behind them. The progress note related to this elopement, dated 10/4/21 at 9:41 p.m. documented Resident #38 eloped from the facility at approximately 5:00 p.m. It documented the back gate in the MCU secured patio area had been left open by a staff member using that entrance. It documented Resident #38 had been actively exit seeking all afternoon. The resident was discovered making her way down the sidewalk outside by a passerby on the street, who then apparently let someone in the facility know where she was. The housekeeping supervisor was the first person to discover the resident alone on the sidewalk. Resident #38 had fallen on the sidewalk (See fall investigation #1 below). When the documenting nurse was alerted and reached the scene, there were several staff members already present who had helped Resident #38 stand up and retrieved a wheelchair to escort her back into the building. Resident #38 appeared a bit shaken, but was consolable. She mentioned that her right knee hurt. There were no visible signs of abrasions at this time. Emergency medical services arrived at approximately 5:45 p.m. and transported the resident to the local hospital for evaluation. She returned from the hospital at 9:45 p.m. and was returned to her room on the MCU, where she was assisted to bed. This progress note documented one hour checks, as well as neurological exams due to the unwitnessed fall the resident sustained while she had eloped from the facility's MCU. E. Fall investigations 1. Fall #1 The SBAR form dated 7/29/21 documented Resident #38 sustained an unwitnessed fall on 7/29/21 at 1:45 p.m. as the resident was found outside, lying on the grass, yelling for help. It documented the resident sustained several new abrasions and the fall was related to the resident's agitation and the uneven ground she was walking on. The progress note dated 7/30/21 documented the IDT met with Resident #38 after her fall. It documented the resident had no memory of falling, but the resident sustained abrasions to her arms. It documented a CNA observed the resident had gone outside and saw the resident trying to pick up and throw her walker. It documented the CNA tried to go out to assist the resident and redirect her, but she had already fallen. The IDT post fall review dated 9/2/21, which was completed over a month since the resident's fall occurred, documented Resident #38 sustained abrasions to her forehead, left wrist and her left 3rd and 4th knuckles. IDT recommended that physical therapy reassess the resident's type of walker being utilized for appropriateness. It documented staff would be educated to be out with this resident when she was outside to supervise her more efficiently and provide assistance to the resident in a timely manner. The facility failed to adequately supervise and monitor Resident #38 while she was ambulating outside, per the MDS assessment dated [DATE]. (See above). 2. Fall #2 The SBAR form dated 8/4/21 documented Resident #38 sustained a witnessed fall on 8/4/21 at 8:54 p.m. with the resident falling on her knees, front and face. She rolled onto her back by the time staff got to her. She sustained a small cut on the bridge of her nose and a bruise to her forehead. She also suffered a deep cut to her right outer hand by the little finger, which needed stitches. She sustained a skin tear to her right lower arm, measuring 3 cm X 3 cm. She was sent to the local hospital's emergency room for stitches for the deep cut. The progress note dated 8/5/21 documented the IDT met with Resident #38 after her fall. It documented the resident had no memory of the fall, but did sustain a few injuries. The resident complained of mild pain. Staff state Resident #38 was agitated at the time of fall as evidenced by making statements of wanting to go home, while she was pulling on the back gate outside the MCU. They said the resident fell forward. The resident's care plan was updated and staff was advised to use prn (as needed) [MEDICATION(S)] (an anti-anxiety medication) if the resident became too agitated. The IDT post fall review dated 8/16/21 documented the fall occurred at 5:35 p.m., which was an approximate three hour difference than documented in the SBAR above. It documented the resident required first aid, including stitches. It documented Resident #38 was pulling on a patio gate handle, trying to get it open. She turned to the left and fell on her knees and face. There was a small round pipe by the wall, which probably cut her hand. The resident sustained no loss of consciousness. She was trying to go home. IDT recommended staff notify the MD of possible need for med(ication) review. Anxiety meds were increased as deemed appropriate. PT to evaluate the type of walker for appropriateness. Staff to assist the resident while outside in the courtyard. Neuro(logical checks) done in case she did hit her head. The facility failed to adequately supervise or re-direct Resident #38 while she was actively trying to elope from the facility in order to prevent her falling and sustaining an injury requiring stitches. 3. Fall #3 The SBAR form dated 9/17/21 documented Resident #38 sustained a witnessed fall in the MCU dining room on 9/16/21 at 6:41 p.m. It documented the resident fell after slipping on water, falling to her knees and brushing her forehead against the dining room wall. The progress note dated 10/5/21 documented the IDT met with Resident #38 after her fall. It documented the resident stated she did not remember what occurred, but denied pain or injury. It documented formal education was provided to staff about keeping the residents' environment clear and safe. The IDT post fall review dated 9/21/21 documented the fall occurred at 7:00 p.m. and Resident #38 sustained no injury. It documented another resident pulled a pitcher of water off the counter top and the water spilled on the floor. Resident #38 went over to help catch the pitcher and wipe up the water and ended up slipping on the floor. IDT recommended staff education to keep the MCU environment clean and clear for resident safety and to check the environment frequently. It was documented staff should frequently encourage the resident to use her walker due to her cognitive barriers with dementia. The facility failed to supervise and re-direct Resident #38 away from the spilled water in the MCU dining room, causing Resident #38 to fall. 4. Fall #4 The situation, background, assessment and recommendation (SBAR) communication form and progress note dated 10/4/21 documented Resident #38 sustained an unwitnessed fall on 10/4/21 at 10:25 p.m. It should be noted the fall was documented here as occurring approximately five hour later than was noted in the elopement documentation (See above). It documented Resident #38 had eloped outside the facility and fell on the sidewalk. It documented the resident had been exhibiting new or worsening behavioral symptoms. The assessment was Resident is an active exit seeker. It documented, per the progress note dated 10/5/21 at 9:32 a.m. (See below), the resident had no pain or injury other than bruising of her right knee. The progress note dated 10/5/21 documented the interdisciplinary team (IDT) met with Resident #38 after her fall. She said she fell on the street, but denied having any pain or injury at the time. It documented all staff education was to take place. The IDT post fall review dated 10/6/21 documented the resident hit her right knee on the sidewalk and said it was hurting. She had a history of falls and cognitive deficit. The summary of the interdisciplinary team was the secured back gate was left unlocked and the resident went through the gate. It documented education was to take place related to gate checks, when the gate was to be locked and monitoring of the residents in the area of secured patio gate in the MCU. Maintenance was to inspect the gate and apply a spring for automatic closure and ensure proper latching of the gate. The facility failed to provide adequate supervision and re-direction for Resident #38 to prevent the resident from eloping from the facility and sustaining a fall in the community after she eloped. F. Family interview A family member of Resident #38 was interviewed via telephone on 11/11/21 at 10:40 a.m. He said it had been about two months since he had seen his mother due to COVID-19 restrictions. He said he wished he could see her more often. He said he did not receive a phone call earlier in the day on 10/4/21 prior to his mother eloping from the facility. He said he wished he had received a call and maybe he could have calmed her down so she did not escape and fall, but said he was almost proud of her for trying to get to her family. G. Staff interviews The director of nursing (DON) was interviewed on 11/11/21 at 1:52 p.m. She said Resident #38 was able to escape from the facility because staff had been using the back gate in the secured MCU's patio, the gate did not latch properly and no one noticed this until after the resident eloped. She said Resident #38 had been reported as a missing person on 10/4/21. She said the spring on the gate was replaced and all staff were educated about no longer using that gate to enter and exit the facility. She said normally the doors to the MCU were left open during the summer months and the facility assumed the secured area of the MCU patio was safe for residents. She said it was not until Resident #38 eloped from the facility when they realized there was a safety issue. She acknowledged there was only one staff member working on the MCU at the time of the resident's elopement, but that was usually enough to handle the low census of six residents on the unit. She said MCU staff could ask for help from other halls if needed by means of a walky-talky. She said Resident #38 had been assessed by both physical therapy (PT) and occupational therapy (OT) and that the resident was still receiving OT services. She said staff had been aware the resident had been agitated and exit seeking most of the day on 10/4/21, but staff also felt that cornering the resident agitated her more, so they just allowed Resident #38 to come in and out of the facility, feeling the secured patio was safe for the resident. She said it was not until after Resident #38 eloped, staff realized the resident should not have been left alone outside in the secured courtyard. She said after the elopement, all staff were educated about not leaving this resident outside by herself without supervision. She also said gate checks have been initiated and staff were no longer using that gate to enter or exit the premises. She said all staff training had been completed by 10/6/21. The maintenance manager (MM) was interviewed on 11/11/21 at 2:20 p.m. He said after Resident #38 eloped from the facility, he placed a self-spring on the gate so when someone opened the gate, it would automatically shut itself. He said he made sure the new spring, latch and everything was functioning on the MCU gate, including the magnet. He said no staff should be entering or exiting through that gate and he believed education had been provided to all staff about this. Registered nurse (RN) #2 was interviewed on 11/11/21 at 2:40 p.m. She said when Resident #38 was first admitted to the facility, she was out of her mind and would sit at the front door, threatening and yelling about leaving. She said the resident stabilized with some medication changes, but had begun getting agitated and asking for either her mother or her husband recently. She said Resident #38 was very pleasant, but would also flip on a dime because she needed to leave for some family reason. She said Resident #38 was hard to redirect, especially during the afternoons and early evenings when she was sun-downing. She said when the resident got revved up, staff would try to verbally redirect her. She said, If I was the nurse on duty during the times of her elopements and falls, I would have wanted to have my eyes on her. She said Resident #38 was more of a risk for falling if she was outside by herself. She said she got nervous when any of the MCU residents were outside by themselves. She said she would, at least, stand by the door so she could see the residents outside at all times. She said there was not always enough staff on the MCU when residents were revved up because the resident upset needed one-on-one attention while someone else was monitoring the other residents residing on the unit. She said some falls and the elopement could have been prevented. She said once Resident #38 was observed trying to throw her walker over the fence and if staff had been out there with her at the time, this resident's fall could have been prevented. She also said having the resident speak to her son over the telephone was a good intervention to calm the resident before she really escalated. The nursing home administrator was interviewed on 11/11/21 at 3:50 p.m. She stated Resident #38 was reported to the state portal as a missing person on 10/4/21. She said after the elopement, the facility placed hinges and springs on the gate, causing it to self-latch after the gate had been opened. She said she did not believe staff were outside with the resident when she eloped because they had the doors between the facility and the secured patio open to let fresh air in. She said staff did not feel they needed to be outside with her because of the secured gate. She said the reason staff came through the secured gate earlier that day was because the staff was afraid to enter through the main door to the MCU through the facility because that was the door Resident #38 had been trying to exit seek through most of the day. She said right before Resident #38 eloped, she had calmed down a bit and when staff saw her go outside, they just let her be. She said, Luckily, they went out to check on her about five or six minutes later. The NHA said staff were educated the day following the elopement, on 10/5/21, about any staff using the gate, to ensure the gate was completely shut and the magnet was engaged. She said the facility thought about permanently closing off the gate, but families used that gate to come and visit their loved ones on the MCU. The NHA said, in relation to Resident #38's falls, she did not like to see any of the residents fall. She said there should not have been water on the floor when Resident #38 fell in the water on 9/16/21. She said if Resident #38 needed to use a walker, she should and it should have been within the resident's reach, but most of the time the resident chose not to use the walker. At this time, approximately 4:05 p.m., the vice president of operations (VPO) entered and joined the interview. She said the facility had opportunities for improvement with resident falls and the facility now had a performance improvement plan (PIP) for falls, which they just developed on 11/8/21, the day the recertification survey began. She said education was provided to the IDT earlier that week and the facility's next step was to roll the information in the PIP out to the nursing department. She said, with the facility's recent change in corporate management and confusion related to the reporting process, the facility did not currently have a systemic approach related to falls and they would be working on this. The VPO brought the DON into the interview when discussing why it took so long to review the 8/4/21 fall in IDT, as it was not reviewed until 8/16/21. The same issue was seen in documentation for the 7/29/21 fall being reviewed on 9/2/21. (See fall investigations above). The DON said she knew they did review these falls and did not know what happened when the assessments were locked. The DON checked to see if new interventions were in place after 8/4/21 fall and said she did not see any new interventions in place after that fall. She said she thought the problem was not officially reviewing the falls in a timely manner and closing them out. III. Resident #72 A. Resident status Resident #72, under the age of 65, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included malignant neoplasm of the cervix, [CONDITION(S)] of the liver and anxiety disorder. The 9/7/21 MDS assessment identified the resident's cognition was moderately impaired with a BIMS score of eight out of 15. The resident has a wandering behavior that occurred one to three of the days during the assessment look back period. The MDS revealed Resident #72 ' s wandering placed her at significant risk of getting to a potentially dangerous place, such as stairs or outside of the facility. According to the MDS, Resident #72 required minimal assistance for all of her activities of daily living (ADLs) with supervision of ADLs with set up help only. The MDS did not identify exhibited behaviors physically or verbally or directed at others. B. Record review The 9/9/21 facility investigative report for Resident #72 was provided by the NHA on 11/10/21. The report revealed Resident #72 eloped from the facility on 9/9/21. The resident was reported missing between 3:50 p.m. and 4:20 p.m. Resident #72 was found by staff a few blocks away from the facility without injury. The report identified the resident was under one on one supervision of a certified nursing aide (CNA) prior to the elopement. According to the report, the CNA sat at the nurses station and watched the resident through a slightly ajar door. The CNA could not see the restroom door or the window from her position. The CNA believed the resident entered the restroom in her room at 3:40 p.m. She did not see the resident return from the restroom. A nurse entered the room of Resident #72 and identified the resident was not in her room and the room window was open with the screen removed. The report revealed the resident had attempted elopement several times. The facility determined the elopement attempts were related to agitation and her end-of-life decline. The investigative report for Resident #72 indicated facility policies and procedures were not followed. According to the report the SBAR (situation, background, assessment and recommendation was incomplete, the care plan did not include elopement or wanderguard, and sliding door/window locks were not in place, allowing the window to be opened more than six inches. Resident #72 was a new admission to the facility from the hospital. The hospital medication orders, signed on 9/1/21, read Resident #72 was admitted to hospice with an expected decline. The care plan for behavior initiated on 9/7/21 read Resident #72 had anxiety with agitation related to EOL (end of life). She exhibited pacing and wandering to the point of exhaustion with exit seeking behavior. Interventions included to anticipate and meet the resident ' s needs, encourage her to express her feelings appropriately and staff to provide opportunities for positive interaction and attention by stopping and talking with Resident #72 as they pass by. The care plan for elopement risk/wandering was initiated on 9/10/21. -The care plan was not initiated after the risk was identified on 9/5/21 or on 9/8/21, after continued exit seeking and elopement attempts. According to the care plan, Resident #72 was at risk for elopement and wandering due to a confusion related to malignant cancer. The care plan read the resident had a recent elopement where she jumped out of her bedroom window. The care plan identified the resident was on one-on-one supervision with interventions and needed emotional and psychological support, orientation to environment and re-orientation with validation and redirection as needed. The 9/5/2021 nursing note read Resident #72 observed walking outside in front of the facility door. Staff in the parking lot observed the resident and assisted her back inside the facility. According to the note, the resident was confused, wandering throughout the hallway and needed constant redirection to her room. The note revealed Resident #72 attempted to go out the front door twice prior to this incident. The note indicated a wanderguard was activated after she was found outside and staff would continue to monitor the resident. The note did not identify when the resident attempted to exit through the front door prior to the identified incident. The 9/5/21 phone order written at 3:19 p.m. identified orders to check the wanderguard for placement and function at every shift for wandering. The 9/8/2021 behavior note read Resident #72 was observed by a CNA on the phone behind the nurses station. The resident was crying and wanted to call the police. The CNA informed the resident she could not be behind the nurses station. According to the behavior note, the[TRUNCATED]

Based on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#52 and #51) of five residents reviewed for pressure ulcers out of 34 sample residents. Resident #52 was admitted to the facility with intact skin, and no pressure ulcers, and developed multiple areas of skin breakdown to her buttocks, perineal area, heels and ankles. The facility failed to consistently and accurately assess and monitor the resident's skin and provide adequate pressure-relieving interventions. As a result, Resident #52 developed multiple pressure areas, some of which had healed. Her skin breakdown as of 11/11/21 included two unstageable pressure ulcers to her heel, irritated and reddened areas to her thigh from the strap that held her catheter tubing in place, irritation to her nose and ears from her oxygen nasal cannula and tubing. Resident #52 said she experienced discomfort, soreness and burning as a result of pressure areas acquired at the facility. Resident #51 was admitted with intact skin and developed skin breakdown described as blisters and open areas to his coccyx. The facility failed to ensure Resident #51 received the standard level of care necessary to prevent development of pressure ulcers. Findings include: I. Professional references According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org (11/16/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. According to Key Points for Pressure Ulcer Staging and Documentation, 11/23/13, MedLeague.com (11/16/21), in pertinent part: Pressure ulcer staging and correct documentation are critical in acute care settings as well as long-term care settings. Pressure ulcers are caused by unrelieved pressure. Any bony prominence is at the highest risk. After a pressure ulcer has been assessed it is essential that the correct stage of pressure ulcer is assigned and documented. Here are a few essential do's and don ' ts of pressure ulcer staging. Pressure ulcers are assessed as Stage 1, 2, 3, 4, Unstageable and Deep Tissue Injury. Documentation must accurately reflect each stage. The higher the stage the more underlying tissue damage there is. Once a pressure ulcer is 'staged' it can progress to a higher stage but can NEVER be 'BACK-STAGED, REVERSE STAGED or DOWN STAGED.' Example: A Stage 3 pressure ulcer can worsen and become a Stage 4 but it NEVER becomes a Stage 2 as it heals. II. Facility policy The Pressure Injury Prevention and Management policy, dated 1/1/2020, provided by the corporate vice president of operations (VPO) on 11/11/21, in pertinent part: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Assessments of pressure injuries will be performed by a licensed nurse and documented in wound rounds or in skin/wound portal in the medical record. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS (minimum data set assessment). Training in the completion of the pressure injury risk assessment, full body skin assessment, and pressure injury assessment will be provided as needed. III. Resident #52 A. Resident status Resident #52, age 74, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 10/21/21 minimum data set (MDS) significant change assessment, Resident #52 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15, with no behavioral symptoms and no rejection of care. She required extensive two-person assistance for activities of daily living (ADLs) including bed mobility, transfers, toilet use, dressing and bathing. Ambulation did not occur. She had an indwelling catheter and was always incontinent of bowel. She had occasional mild pain and weight loss without a physician-prescribed weight loss regimen. She had two stage 2 pressure ulcers, none present upon admission, and moisture associated skin damage. She was not on a turning/repositioning schedule. She had pressure-relieving devices to her bed and chair, pressure ulcer care, nutritional/hydration interventions, and applications of dressings/ointments/medications other than to her feet. According to the 5/19/21 admission MDS assessment, Resident #52 was at risk but had no pressure ulcers upon admission. B. Resident interview/observations Resident #52 was interviewed on 11/9/21 at 9:10 a.m. She was lying on her back in bed, her heels were not floated and one of her padded booties was on the floor. She said her booties did not stay on, and that nursing staff had to come in periodically and make sure her left leg was on the bed. She said her legs and feet jerked uncontrollably at times, and her booties fell off. She said the staff tried to float her heels, reposition her, and remind her to wear booties, but they had to check frequently because of her involuntary movements to her legs and feet. She said she had wounds on both feet because her feet jerked and twitched. She said physical therapy had her doing exercises while she was in bed and she did that so her feet did not get stiff and jerk and twitch. She said she did not take medications to address the jerking and twitching, just pain medications like Tylenol, but she used to have a [MEDICATION(S)] patch. She said she had an open wound on her bottom but it was healed now. Resident #52 said, and observation revealed, she did not have an alternating air mattress, and said, That would be nice. She said she just had a regular hospital bed mattress now. She said the wounds on her feet hurt, especially when her legs moved back and forth and it rubbed her skin. That's why they need to have my boot on and the moisturizer to keep my feet from drying out. She was wearing her right bootie (heel protector) but not her left. She said she had skin breakdown/irritation to her nose and ears from her oxygen nasal cannula and tubing. She said they would not give her any ointment to relieve the discomfort to her nose or padding to protect the sensitive skin around her ears. Her nostrils just above her lip were red and irritated. She said she had just pulled a scab off her thigh that was caused by the Velcro strap that held her catheter tubing in place (cross-reference F690 catheter care). She said she also had skin issues related to moisture, and that nursing staff used moisture barrier and powder to treat those areas. Observations during the survey conducted 11/8 to 11/11/21 revealed the resident was always in her bed lying on her back. She was able to shift her weight and slightly reposition herself using a trapeze bar above her bed and repositioning rails on the upper bilateral sides of her bed. On 11/8/21 from 2:00 to 6:00 p.m. and 11/9/21 from 8:15 a.m. to 5:00 p.m., the resident's heels were not consistently floated with pillows, her soft padded booties were not on her feet, and her heels and/or the sides of her feet frequently rested directly on the mattress. Observations on 11/10/21 and 11/11/21 from 8:15 a.m. to 6:00 p.m. revealed the resident's heels were more consistently floated and her booties were on during frequent observations. During wound care observations on 11/10/21 at 10:33 a.m., licensed practical nurse (LPN) #2 washed her hands and donned gloves. The resident had two scabbed areas to her left heel, which LPN #2 cleaned with wound cleanser and painted with [MEDICATION(S)]. She used a new swab for each wound and replaced the resident's heel protectors afterwards. The resident's left heel had a wound on the medial posterior the size of a dime that was difficult to visualize due to the resident's discomfort when her leg was moved or lifted, but the area was partially covered with a dark red scab. The resident's second heel wound, on the lateral side of her heel, was approximately the size of a pencil eraser and was completely covered with a dark red scab. Her buttocks were intact, and her skin was clear from any excoriation. The site where her strap held her catheter tubing in place appeared excoriated with dryness and a superficial wound with a pink wound bed about the size of a nickel. The strap had been moved to a different part of the resident's leg. C. Record review The resident's pressure ulcer care plan, revised on 10/29/21, identified the potential for and actual pressure ulcer development related to immobility. I have 2 pressure ulcers to the medial and outer aspect of my left heel. The goal was, I will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included: -Assist and encourage me to reposition and or turn at frequent intervals to provide pressure relief. -Complete a full body check weekly and document -Encourage and assist me to change positions for prevention of pressure ulcers. -Encourage small frequent position changes. -Encourage and assist me to reposition in chair frequently for comfort and pressure reduction. -Interdisciplinary team (IDT) referrals as indicated to registered dietitian (RD), physical therapy (PT), occupational therapy (OT) or other. -Observe nutritional status. Serve diet as ordered, observe intake and record. -Observe/document/report as needed (PRN) any changes in skin status: appearance, color. -Provide incontinence care after each incontinence episode, or per established toileting plan. -Use pillows to reposition me off of my pressure areas. -Encourage adequate hydration and nutrition to assist in the healing process of my wounds. -Please ensure that I am wearing my heel protectors at all times while in bed. -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Educate me/family/caregivers of causative factors and measures to prevent skin injury. -Encourage and assist me to reposition frequently. Use pillows to position me off my pressure areas. -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Identify/document potential causative factors and eliminate/resolve where possible. -Keep skin clean and dry. Use lotion on dry skin and apply moisture barrier cream as needed. -Monitor dressing to ensure it is intact and adhering. -Observe site for redness, swelling, increasing drainage, pain. -Observe/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician. -Use a draw sheet or lifting device to move me. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Current pertinent physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate site of securement daily and as needed every day shift, dated 6/12/21. -Observe skin integrity every shift at pressure points from the oxygen delivery device while in use every shift, dated 6/26/21. -Cleanse both wounds to left medial and outer heel with wound cleanser. Paint with [MEDICATION(S)] ensuring not to get on healthy skin. Please reapply heel protectors at all times. Observe for abnormalities to wound bed, surrounding skin, or pain associated with wound. Document + (plus sign) for no abnormalities noted, - (minus sign) for abnormalities, must document abnormalities in nursing notes, every day and evening shift, dated 10/30/21. (On the treatment administration record from 11/1 to 11/11/21, abnormalities were documented on the evening shift on 11/1, 11/2 and 11/3/21. Day shift documented no abnormalities, and did not document on 11/4/21.) The nursing admission assessment on 5/12/21 documented the resident's skin was intact and she had no pressure ulcer risk. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary of plans included skin care. The 5/19/21 Braden scale for predicting pressure sore risk, documented a score of 16, at risk, due to occasionally moist skin, chairfast, slightly limited mobility, probably inadequate nutrition and potential for friction and shear. (The scoring scale was at risk 15-18, moderate risk 13-14, high risk 10-12 and very high risk nine or below.) The 5/20/21 skin assessment documented intact skin. The resident was hospitalized from 5/20/21 through 6/8/21. There were no nurses' notes regarding the resident's skin condition upon her return from the hospital on 6/9/21. The 6/10/21 skin assessment documented an existing pressure ulcer described as two open wounds to sacrum, red and friable; fragile, excoriated perineum, and rash with open sores to her groin and labia. -There were no further nursing notes or evidence of physician notification. The 6/11/21 Braden scale assessed her at risk with a score of 15. The 6/16/21 weekly pressure ulcer record documented a sacrum pressure ulcer, date of onset 6/9/21, documented as a stage 1 and a stage 2 in the same assessment, 3x3 cm, described as a stage 2 to sacrum presents as intact dark purple superficial area with surrounding excoriation. Dark area peeling off on one edge presenting healthy blanchable skin surrounding the purple area. The ulcer was documented as admitted with as the resident had been in the hospital. The IDT team recommended to continue with treatment. Wound team to reassess weekly until healed. The 6/17/21 skin assessment documented excoriation with superficial open areas to buttocks, dark eschar skin to left buttocks. -There was no documentation of a wound assessment of the dark eschar which indicated an unstageable pressure ulcer. The 6/23/21 weekly pressure ulcer record documented a 2x2 cm stage 2 to the sacrum described as very superficial pressure area presenting as dark tissue with surrounding blanchable excoriation, no s/sx (signs/symptoms) of infection noted. The wound bed was described as black. The IDT recommended to continue treatment, wound team to assess weekly, and hospital wound care following as well. -There were no notes in the resident's medical record regarding hospital wound care. The 6/27/21 skin assessment documented no changes to the sacral wound. The 6/30/21 weekly pressure ulcer record documented the sacral wound as a stage 2 measuring 4.0 x 2.6 cm, black/purple tissue to wound bed with surrounding excoriation to skin. Skin sloughing off from surrounding (area), does (complain of) minor discomfort when area is cleansed. The wound had deteriorated, increased in size as well as surrounding skin with excoriation. -There were no changes to treatment, and no documentation of hospital wound care. The 6/17/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident's skin breakdown was not documented. The 7/4/21 skin assessment documented new and existing skin issues, (left) upper thigh healing skin tear (2x2 cm), (left) outer ankle blister (2 x 2 cm with 4mm depth), 3 excoriation areas on (left) buttocks, reddened peri area, (left) sacrum necrotic area, (left/right) buttocks reddened. -There was no evidence in the medical record that the physician was notified. On 7/7/21 the weekly pressure ulcer record documented: (1) The existing sacral pressure ulcer measured 4.8 x 3.0 cm, assessed as stage 2, wound improving in size, black eschar has sloughed off revealing healthy pink tissue to wound bed with surrounding excoriation to skin. A new order was received to cleanse the wound and back, apply [MEDICATION(S)] to healthy tissue and leave wound open to air as it appears foam adhesive may be worsening surrounding excoriation. (2) The new left buttock pressure ulcer measured 2.1 x 1.2 cm, stage 2, new wound to left buttock to the side of previous sacral wound. Area presents with 75% slough with surrounding excoriation/sloughing of skin. The wound bed description was yellow. New orders were received to cleanse wound, apply mixture of A&D ointment and antifungal cream, leaving open to air. The onset date was 7/4/21. (3) The new unstageable pressure ulcer to the left heel measured 2.2 cm length x 2.0 cm width, was described as a new intact blister to left heel with translucent intact skin with darker hard tissue to blister edges, first observed on 7/4/21. New orders were received to paint with [MEDICATION(S)] twice daily. -There were no corresponding nurses' notes and the physician was not notified until 7/7/21, three days after the new pressure ulcers were identified as acquired. The 7/11/21 skin assessment documented existing pressure ulcers described as left upper thigh healing skin tear, left outer ankle blister and three excoriation areas on left buttocks. -The sacral pressure ulcer was not documented. The 7/14/21 weekly pressure ulcer record documented: (1) Sacrum pressure ulcer, 4.0 x 3.5 cm, stage 2, wound continues with 25% slough to wound bed with surrounding excoriation of lower back. (2) Left buttock, 1.0 x 2.3 cm, stage 2, wound continued with slough to 25% of wound with surrounding excoriation. (3) Left heel, 2x2 cm, unstageable, hard intact non fluid filled blister to left outer aspect of heel. Treatment to all wounds continued as ordered. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Summary of plans included skin care. The 7/18/21 skin assessment documented new and existing issues as follows: 3 open wounds on left buttocks with granulation tissue continues, left ankle blister; and existing-left thigh skin tear with scab, abdominal fold with excoriation. Further description of skin issues: gluteal fold reddened, peri area reddened, buttocks reddened on left side. -The sacrum pressure ulcer was not documented. The 7/20/21 Braden scale assessed the resident at high risk with a score of 12, due to very moist skin, bedfast, very limited mobility, probably inadequate intake, and friction and shear problem. The 7/21/21 weekly pressure ulcer record documented: (1) Sacrum 4.1 x 3.5 cm, stage 2, same description as previous assessment. (2) Left buttock 1.2 x 2.5 cm, stage 2, same description. (3) Left heel 2x2 cm, unstageable, hard intact non fluid filled blister to left outer aspect of heel. -The sacrum and left buttock wounds were slightly larger, but the left buttock was the only wound documented as deteriorated. No new orders or treatments were documented. The 7/25/21 skin assessment documented three open wounds on left buttocks with granulation tissue remain, left ankle open area where pustule was, redness under gluteal fold and perineal area. -The sacral wound was not documented. The 7/28/21 weekly pressure ulcer record documented: (1) Sacrum 4.0 x 1.7 cm, stage 2, wound bed with healthy granulation, improved. (2) Left buttock 1x2 cm, stage 1, wound bed beefy red. (3) Left heel 1.8 x 1.6 cm, unstageable, improved in size and appearance, intact, hard, translucent blister continues. -Although the left buttock wound was documented initially as a stage 2, it was downgraded to stage 1 in addition to improved. The 8/1/21 skin assessment documented three open wounds on left buttocks with granulation tissue, and left ankle open area where pustule was. The 8/4/21 weekly pressure ulcer record documented: (1) Sacrum 3.0 x 2.3 cm, 0.9cm depth stage 2, area with beefy red granulation tissue throughout, improved. (2) Left buttock, 1.0 x 1.3 stage 2, with 25% slough, diffuse edges, improved. (3) Left heel 1.0 x 1.3 cm, stage 1, improved, previously black eschar now open superficial area with red healthy tissue. -Although the heel wound previously had black eschar which indicated an unstageable wound, it was downgraded to stage 1. The 8/8/21 skin assessment documented slowly resolving pressure ulcers on buttocks and red groin area. -The sacral and heel wounds were not documented. The 8/11/21 weekly pressure ulcer record documented: (1) Sacrum 3.0 x 2.3 stage 2, pink to beefy red with granulation tissue throughout, no change. (2) Left buttock 1.0 x 1.3 cm stage 2 with 25% slough, diffuse edges, no change. (3) Left heel 1.0 x 1.3 stage 2, open, superficial, red healthy tissue noted, no change. -The left heel wound, previously documented as stage 1, was documented again as stage 2. The 8/15/21 skin assessment simply documented buttocks healing well. -However, the resident had three documented pressure ulcers. The 8/17/21 skin assessment documented a new pressure ulcer described as 2x2 open area to left lateral heel. -The other pressure ulcers were not documented. On 8/17/21 at 9:18 a.m. nursing notes documented pressure from lying on side and not wearing booties. Resident has 2x2 centimeter (cm) open area to her left lateral heel. The resident's representative and primary care clinician were notified. -No further skin issues or details were documented, although the resident continued with three documented wounds. The 8/18/21 weekly pressure ulcer record documented: (1) Sacrum 3.0 x 2.3 cm stage 2, no change. (2) Left buttock 1.0 x 1.3 cm stage 2, no change. (3) Left heel 1.0 x 1.3 stage 2, no change. -There was no documentation of the new left lateral heel wound, documented on the 8/17/21 skin assessment (above). The 8/23/21 skin assessment documented a stage 2 pressure ulcer to the left buttock and an unstageable scabbed abrasion to the front left thigh. The 8/25/21 weekly pressure ulcer record documented: (1) Sacrum 3.0 x 2.3 cm stage 1, no change. (2) Left buttock 1.0 x 1.3 cm stage 1, no change. (3) Left heel 1.0 x 1.3 cm stage 1, wound with only very superficial translucent skin, no change. -Although all the wounds were documented without change, they were downgraded to stage 1. Only one wound was documented to the resident's heel, although the 8/17/21 skin assessment documented a new heel wound. The 8/30/21 skin assessment documented only red buttocks, and no other wounds. On 9/1/21 at 10:53 p.m. a late entry nursing note documented wound care rounds revealed the resident's left buttock wound was healed and two other wounds (location undocumented) continued, which the wound care team would continue following. The 9/1/21 weekly pressure ulcer record documented: (1) Sacrum 2.2 x 1.0 cm stage 1, improved. (2) Left heel 0.8 x 0.8 cm, no stage documented, improved. The 9/6/21 skin assessment documented red buttocks and no other wounds or skin issues. The 9/8/21 weekly pressure ulcer record documented: (1) Sacrum 2.3 x 1.0 cm stage 1, small decrease in size, improved. (2) Left heel 0.5 x 0.5 cm, no stage documented, improved. On 9/12/21 at 6:48 a.m. nursing notes documented a small wound remained on one buttock and no other wounds were documented. The 9/13/21 skin assessment documented red buttocks and no other skin issues. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Summary of plans included skin care. The 9/15/21 weekly pressure ulcer record documented: (1) Sacrum 2.3 x 1.0 cm, no stage documented, no change. (2) Left heel 0.5 x 0.5 cm, no stage documented, no change. The 9/20/21 skin assessment documented red buttocks. The 9/22/21 weekly pressure ulcer record documented: (1) Sacrum 2.1 x 1.0 cm, no stage documented, improved. (2) Left heel 0.5 x 0.5 cm, no stage documented, no change. The 9/27/21 skin assessment documented red buttocks. The 9/29/21 weekly pressure ulcer record documented: (1) Sacrum 2.1 x 1.0 cm, no stage documented, no change. (2) Left heel 0.5 x 0.5, no stage documented, no change. The 10/6/21 weekly pressure ulcer record documented: (1) Sacrum 2.1 x 1.0 cm, no stage, no change. (2) Left heel 0.5 x 0.5 cm, no stage, no change. The 10/11/21 skin assessment documented buttocks are still red and excoriated, treatment in place. On 10/11/21 at 6:00 a.m. a late entry nursing note documented buttocks were still red and excoriated, treatment in place, and no other wounds were documented. The 10/13/21 weekly pressure ulcer record documented: (1) Sacrum 2.1 x 1.0 cm, no stage, no change. (2) Left heel 0.5 x 0.3 cm, no stage, improved. On 10/18/21 at 6:00 p.m. nursing notes documented for previously identified areas, treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The skin assessment on the same date documented the same, with no documentation of the sacrum or left heel. The resident's 10/19/21 Braden scale for predicting pressure ulcer risk revealed she scored 16, at risk, due to slightly limited sensory perception, skin occasionally moist, chairfast, slightly limited mobility, and friction/shear problem. On 10/20/21 a nursing note late entry documented the resident's sacrum was healed, skin clean, dry, intact, problem closed. No other wounds were documented. The 10/20/21 weekly pressure ulcer record documented: (1) Nothing regarding the sacrum. (2) Left heel 0.4 x 0.4 cm stage 2, no change, pressure ulcer to left heel continues. Area free from s/sx of infection. Wound bed red with thin scab covering. On 10/25/21 a nursing note documented the resident's skin was intact. -The 10/25/21 skin assessment documented the same. The 10/27/21 weekly pressure ulcer record documented: (1) Left heel 0.5 x 0.5 cm stage 2, pressure ulcer to left heel continues, no change, stable wound. (2) Left heel 0.4 x 0.4 cm stage 2, new wound to left medial heel, no s/sx of infection, wound bed red and blanchable. The physician was notified on 10/27/21 and treatment was to continue. -Although an additional heel wound had been previously identified in a skin assessment, this was the first time it appeared on the weekly pressure ulcer record. The 11/1/21 skin assessment documented previously identified areas, see below, described as bilateral buttocks with treatment in place. On 11/1/21 at 9:23 p.m., nursing notes documented

Based on interviews, observations and record review, the facility failed to ensure three (#1, #5 and #4) of four out of 10 sample residents who displayed or were diagnosed with [REDACTED]. Specifically, the facility failed to: -Develop a comprehensive plan of care, to include person-centered interventions of dementia care services to address the behaviors for Residents #1, #5 and #4; - The facility failed to provide a person-centered approach to Resident #1's dementia care services to address his physically aggressive behavior in order to prevent physical altercations with other resident's on the secured unit, and -The facility failed to provide person-centered approaches to Resident #4 for therapeutic programming and exhibited behaviors. Resident #9 sustained an injury (bloody lip) that could be managed by facility staff. The injury resulted from the facility failure to develop person-centered interventions to address Resident #1's tendency for resident-to-resident aggression. Resident #9 had previously been the victim of Resident #1's aggression. Findings include: I. Facility policy and procedure The Care of Resident with Dementia policy and procedure, revised October 2017, was provided by the director of nursing (DON) on 3/10/21 at 7:02 p.m. It revealed, in pertinent part, Residents who display symptoms or are diagnosed with [REDACTED]. Providing care and services for residents living with dementia or dementia-like symptoms is an integral part of the person-centered care environment. This environment supports quality of life, meaningful relationships, and positive engagement. The facility provides treatment and services that include, but are not limited to: medical care, diagnosis, and support based on [DIAGNOSES REDACTED]. Necessary person-centered care and services should reflect the resident's goals, choices, and preferences while maximizing their dignity, autonomy, privacy, socialization, independence, choice and safety. Individualized, non-pharmacological approaches to care that are purposeful and meaningful to the resident to enhance their well-being. The facility follows a systematic care process that includes an assessment of the resident's strengths and care needs, and development and implementation of an individualized, holistic care plan that includes input from the resident, the resident's family and/or representative, to the extent possible, and the interdisciplinary team. II. Failure to provide person-centered dementia care for Resident #1's physically aggressive behavior A. Resident #1 status Resident #1, age 90, was admitted on [DATE]. According to the November 2020 computerized physician orders [REDACTED]. The 9/25/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15. He required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene. He required limited assistance of one person with transfers and locomotion on and off the unit. It indicated the resident did not exhibit verbal or physical behaviors during the assessment period. The resident refused care and exhibited wandering one to three days during the assessment period. B. Record review The behavior care plan, initiated 8/21/18, revealed the resident had a psychiatric condition that caused the resident to act in ways that were inappropriate such as physical and verbal aggression toward others. The resident wanted to have inappropriate sexual interactions with females. The interventions included: administer medications as ordered, observe and document side effects and effectiveness of the medication; explain all procedures to the resident before starting and allow the resident time to adjust to the changes; observe behavior episodes, attempt to determine the underlying cause, and document the behavior and potential causes. It did not document any person-centered interventions to address the resident's physical and verbally aggressive behavior. The 9/25/2020 behavior progress note revealed the resident was actively exit seeking, shaking the exit door several times an hour. The 9/29/2020 nursing progress note revealed the resident was observed walking in the hallway on the secured unit, talking loudly, saying (female name), why did you leave me. The 10/9/2020 nursing progress note revealed the resident was observed walking around the secured unit with a walker calling for his sister. The 10/30/2020 medication administration progress note documented the resident was restless and exhibited repetitive movement such as going in and out of rooms, outside and the dining room. The rejection of care from staff care plan, initiated 9/30/2020, revealed the resident had the potential to reject care from staff when required. The interventions included the staff would give the resident time and ask again. It did not document any person-centered interventions. The elopement care plan, initiated 8/17/18, revealed the resident was at risk for elopement related to dementia and resided in the secured unit. The interventions included: provide the resident with structured activities such as walking inside and outside the facility; provide a distraction from wandering such as structured activities, food, conversation, television and a book; offer the resident emotional and psychological support with increased episodes of wandering; orient the resident to the environment as needed; and reorient, validate and redirect the resident as needed. It did not include person-centered interventions. The activity care plan, initiated 9/8/18, revealed the resident was dependent upon staff for meeting his emotional, intellectual, physical and social needs due to the resident ' s cognitive deficits. It documented the resident enjoyed watching movies, reading, trivia, exercise and sitting outside. The interventions included: encouragement of ongoing family involvement; ensure activities the resident attended were compatible with the resident ' s mental capabilities and known interests; introduce him to residents with similar interests; and provide a program of activities that was of interest and empowered the resident allowing the resident a choice, self-expression and responsibility. The facility failed to develop a comprehensive care plan that addressed the resident's behaviors and psychosocial needs to include person-centered approaches. The facility was unable to provide documentation the family had been consulted in the development of the comprehensive care plan to address the resident's behavioral concerns in order to prevent physical altercations with other residents. C. Failure to respond to incidents of physical abuse with person-centered dementia care The 10/31/2020 nursing progress note revealed a CNA (certified nursing aide) was sitting in the hallway next to Resident #1. When another resident (Resident #9) walked passed, Resident #1 stood up and struck the other resident in the chest. The 11/2/2020 physical abuse investigation revealed Resident #9 was walking past Resident #1 on the secured unit. As Resident #9 was walking by, Resident #1 made a fist and punched Resident #9 in the chest. This caused Resident #9 to jerk backwards. Resident #1, during his interview, said he hit Resident #9 because he tried to grab the CNA who was sitting next to him. The facility staff separated both residents and placed them on 15 minute safety checks. It did not reveal documentation to indicate person-centered interventions were implemented to address Resident #1 physically aggressive behavior. The 11/13/2020 situation, background, assessment and recommendation (SBAR) form revealed on 11/13/2020 the resident pushed another resident (Resident #9) with his walker. It indicated Resident #1 hit Resident #9 several times in the face, breaking open Resident #9's lip and caused a small amount of bleeding. It indicated Resident #1 consistently looked for an opportunity to strike Resident #9 and had physically struck this resident prior (10/31/2020). The facility provided separation of the residents, one to one observations and medication administration of [MEDICATION NAME] to Resident #1. It indicated Resident #1 had a history of [REDACTED]. It did not reveal documentation that person-centered approaches were developed or implemented to prevent further physically aggressive behaviors for Resident #1. Cross reference F684: The facility failed to ensure Resident #1 did not receive an excessive dose of [MEDICATION NAME] medication on two occasions which contributed to his functional decline. Cross reference F760: The facility failed to ensure residents were kept free from significant medication errors. The facility failed to address Resident #1's physically aggressive behaviors on 10/31/2020 by putting person-centered interventions in place to prevent another resident to resident altercation. By not addressing Resident #1's physically aggressive behavior, the facility failed to ensure Resident #9 was not victimized again on 11/13/2020 by Resident #1. Cross reference: F600: the facility failed to ensure Resident #9 was kept free from physical abuse by addressing Resident #1's physically aggressive behaviors. III. Failure to develop and implement person-centered dementia care A. Resident #5 1. Resident status Resident #5, age 60, was admitted on [DATE]. According to the March 2021 CPO, the [DIAGNOSES REDACTED]. The 1/27/21 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of six out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident did not exhibit physical or behavioral symptoms toward others during the assessment period. 2. Record review The disorganized thinking care plan, initiated 9/23/2020, revealed the resident had the potential to be distracted while having conversations which led to disorganized thinking. The interventions included: anticipate the resident ' s needs; do not rush the resident and allow time for the resident to respond; face the resident when speaking, make eye contact and turn off the television or radio to reduce environmental noise; encourage the resident to continue stating thoughts even if it is difficult; provide a safe environment; and observe/document physical and nonverbal indicators of discomfort or distress. The 2/18/21 SBAR revealed the resident grabbed her roommate by the shoulders. She let go of her right hand, made a fist and punched her roommate above the left breast. Resident #5 grabbed her roommate's hair and said, I'm going to kill you if you tell anyone. The 2/18/21 physical abuse investigation revealed Resident #10 (Resident #5's roommate) reported to the staff, Resident #5 walked over to her side of the room. She said she was upset because she did not close the door to the room like Resident #5 had requested. She said Resident #5 grabbed her by the shoulders and punched her in the chest. It indicated the facility staff separated the residents, placed both residents on 15 minute safety checks and moved Resident #10 to another room on another unit, per Resident #10's request. Resident #5, during her interview, said she punched her roommate because she would not close the door as she requested. Cross reference F600: the facility failed to implement person-centered approaches to prevent physical abuse. The 3/3/21 nursing progress note documented the resident refused all care that shift, including meals and snacks. The 3/8/21 behavior progress note documented the resident was restless, pacing the room, stating I'm going home. The 3/8/21 nursing progress note revealed the resident refused to take a shower or a bed bath. A review of Resident #5's medical record did not reveal documentation the resident's comprehensive care plan was developed with person-centered approaches to address the resident ' s behavioral concerns demonstrated on 2/18/21. It did not reveal documentation a plan of care with person-centered approaches was developed for the resident's decreased cognition and episodes of refusals of care. The resident's medical record did not provide documentation the resident representative had been contacted to assist in the development of dementia care for the resident. B. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/10/21 at 1:58 p.m. She said she had cared for Resident #1 while he was at the facility. She said the resident was an introvert and liked to be by himself. She said he was able to ambulate throughout the secured unit with a front wheel walker. She said staff would provide the resident supervision while he ambulated throughout the unit. She said Resident #1 would often walk around the unit, walk in and out of the activity room, other resident rooms, and down the hallway. She said sometimes he would bang on the door, attempting to open it. She said Resident #1 could have aggressive behavior toward other residents and staff members. She said he had two incidents two weeks apart with the same resident before he passed away. She said Resident #1 was fixated on that particular male resident (Resident #9). She said Resident #9 would take things from other residents. She said she thought that was why Resident #1 was fixated upon him. She said she was not sure of any person-centered interventions that were successful for Resident #1, other than re-direction. She said Resident #1's family was very supportive, visited often (via video calls) and provided any additional items the resident might need. She said she was not sure if the resident ' s family was involved in developing person-centered approaches to the resident's physically aggressive behaviors. She said from 6:00 a.m. until 2:00 p.m. she was the only staff member assigned to the secured unit. She said she assisted the residents with getting up out of bed, getting dressed, toileting, medication administration, meal set up, etc. She said the program assistant provided activities to the residents. She said the program assistant would come and go throughout the day. She said the program assistant was also a CNA, so she could provide assistance if it was an emergency. She said the facility management did not want the nurse to ask the programs assistant to assist with personal care. She said they wanted the programs assistant to focus on therapeutic activity programs for the residents. She said the staffing had changed since the census on the secured unit was lower. She said, when the unit was full, there was a nurse and CNA at all times on the secured unit. The CNA, now, came into the secured unit at 2:00 p.m. The activity director (AD) was interviewed on 3/10/21 at 5:33 p.m. She said she had worked at the facility for five years as a CNA. She said she began working in the activities department in September 2020. She said an activities assistant was staffed in the secured unit, five days per week. She said the facility mainly provided independent activities for the residents on the secured unit. She said the programming for the secured unit varied based on behaviors. She said she was not familiar with the care for Resident #1. She said she was unaware if Resident #1's family was consulted in the development of a person-centered plan of care. She said she did not have documentation of person-centered activities for the resident. The social services assistant (SSA) was interviewed on 3/10/21 at 4:45 p.m. She said she recently started working at the facility. She said the social services director (SSD) was on medical leave from the facility. She said she was unsure of her role on the secured unit and had not been back on the secured unit. She said the MDS coordinator was assisting in developing the care plans for social services concerns while the SSD was out of the facility. She said she had never developed a care plan before. LPN #1 was interviewed on 3/10/21 at 2:34 p.m. She said she provided care to Resident #5. She said she was not present but heard Resident #5 had punched her roommate. She said the roommate was moved to another room in another unit. She said she had not seen the resident become combative, but Resident #5 did have behaviors. She said Resident #5 did try and do care all by herself. She said Resident #5 would not call for assistance and would often refuse care. She said Resident #5 would get upset if she did not get her way. She said she was unsure of any interventions to address Resident #5's behavior. She said she usually just provided re-direction and education. She said she thought social services was responsible for developing the care plan to address resident behaviors. The nursing home administrator (NHA) was interviewed on 3/10/21 at 6:30 p.m. She said the staffing for the secured unit was based on the census. She said, currently, the nurse was scheduled by themselves from 6:00 a.m. until 2:00 p.m. She said the CNA would arrive at 2:00 p.m. She said the program's assistant was also assigned on the secured unit and was a CNA. She said the program assistant would assist if the nurse asked her. She said the SSD was currently out on medical leave. She said when they were fully staffed, a social worker was assigned to the secured unit and assisted in the development of the comprehensive care plans. She said the SSD had been on medical leave since after the first of the year, 2021. She said each residents' comprehensive care plan should include person-centered interventions and approaches. She said each residents' behavior should be described and interventions included in the comprehensive care plan. She said the comprehensive care plan was part of the dementia care program provided to residents. She said each residents' family or representative should be consulted and involved in the development of the residents comprehensive care plan. She said the comprehensive care plan should be a plan to provide care to all residents and dementia care services. V. Resident #4 A. Resident #4 status Resident #4, age 85, was admitted on [DATE]. According to the March 2021 CPO, the [DIAGNOSES REDACTED]. The 1/14/21 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of 4 out of 15. She required supervised assistance with walking, dressing and bathing. She was independent with bed mobility and transfers. It indicated the resident exhibited verbal behavioral symptoms one to three days and rejected care one to three days during the assessment period. B. Observations On 3/10/21 at 9:42 a.m., Resident #4 was observed sitting at a table in the common room with coloring pages and markers on the secured unit. The resident programs assistant (RPA) was sitting at the same table with the resident making holiday decorations. At 10:05 a.m., Resident #4 fell asleep at the table while coloring. She woke herself up approximately 10 minutes later, and began to color again. At 10:30 a.m., Resident #4 was observed asleep again at the table. At 10:42 a.m., the resident left the table and went to her room. The RPA continued to work on holiday decorations and did not acknowledge the resident or encourage her to return to the table or invite her to participate in making holiday decorations. C. Record Review The activities care plan, initiated 8/24/17 and revised on 12/10/2020, revealed the resident enjoyed listening to music, reading, being outdoors, gardening, shopping, cooking, socializing and bingo. The pertinent interventions included: ensure the activities were compatible with the resident ' s known interests and preferences, establish and record activity involvement by talking with the resident, provide encouragement and reminders to attend and participate in activities, invite the resident to scheduled activities and to provide a program of activities of interest. It did not include person-centered approaches and interventions. The dementia care plan, initiated on 2/5/21, revealed the resident had a [DIAGNOSES REDACTED]. The resident received an anti-anxiety medication. The pertinent interventions included: administer medication as ordered, anticipate and meet needs, assess coping skills, offer as many choices as possible about care and notify the doctor as needed. It did not include person-centered approaches and interventions to address the resident ' s documented behavior concerns. The 1/12/21 behavior progress note revealed Resident #4 was agitated after the lights in the hallway outside of the resident ' s room were turned on. The resident exhibited verbal and physical aggression toward the staff when they attempted to redirect her. It did not reveal interventions used to address the resident ' s behavior other than provide redirection. The 1/15/21 nursing note revealed Resident #4 exhibited exit-seeking behavior. She was agitated when staff attempted to redirect her from exiting the building. The resident had a verbal outburst towards staff, attempted to hit the staff and threw objects. It did not document any person-centered approaches to address the resident ' s verbally and physically aggressive behavior. The 1/24/21 behavior progress note revealed at 2:29 p.m., Resident #4 asked numerous staff members for a car ride into town. The resident was agitated and had verbal outbursts towards staff when they attempted to provide redirection. -At 3:37 p.m. the resident continued to ask staff for a car ride into town. The resident exhibited physical aggression and threw objects. It documented redirection by facility staff was unsuccessful. It did not document person-centered approaches and interventions were used when redirection was not successful. The 1/29/21 behavior note revealed the resident was agitated and exhibited exit-seeking behavior. It revealed staff contacted the resident ' s son to speak with the resident, however the resident ' s son was not available until after 5 p.m. It did not document any additional person-centered interventions or approaches to address the resident ' s behavior. -At 8:56 p.m. the nursing progress note revealed Resident #4 continued to exhibit exit-seeking behaviors. The note indicated staff attempted to talk with the resident about the bad weather outside. The facility staff were not successful redirecting the resident. The resident was upset and angry for over two hours. The nursing progress note did not document any person-centered approaches and interventions. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/10/21 at 11:00 a.m. She said the secured unit was staffed with one nurse and the RPA until 2 p.m. She said a certified nursing aide (CNA) was scheduled at 2 p.m She said if a resident required two person assistance, she had to call another unit for additional staff support. She said Resident #4 had physical and verbal outbursts as evidenced by yelling and throwing objects most days around 2 p.m. She said staff attempted to redirect the resident three times before consulting the doctor. She said she would also offer the resident a snack. She said another resident on the unit would sit with Resident #4 during an outburst. She said the intervention worked occasionally. She said she was not aware of any other person-centered approaches and interventions for Resident #4. She said she did not know if the resident ' s family was consulted in the development of the resident ' s comprehensive plan of care. She said she was not responsible for developing or updating the comprehensive care plan. She said she had not seen a social worker come onto the secured unit in a very long time. She said the social services department was not very involved in the care of the resident ' s on the secured unit. She said the staff did the best they could in caring for the residents on the secured unit. She said her dementia care and de-escalation training took place at a previous place of employment multiple years ago. She said this facility had not provided her dementia care or de-escalation training. The RPA was interviewed on 3/10/21 at 2:13 p.m. She said she was a CNA prior to moving into the programs department in November. She said her training on programming and dementia care came from her experience as a CNA on the secured unit. She said the facility provided training on dementia care that included to offer hydration and snacks to the residents. She said when a resident exhibited a behavioral outburst, redirection was trial and error. She said she offered residents a ball or a doll in an attempt to redirect. She said Resident #4 had behavioral outbursts when staff did not provide her a ride into town. She said Resident #4 was physically and verbally aggressive during outbursts and she provided assistance to the resident to pack her belongings. She said that intervention was sometimes effective, and she was unaware of any other person-centered interventions. She said when a resident had behavioral outbursts, she reported it to the nurse. She said the nurse was responsible for reporting the behaviors to the social worker. She said the social worker was not in the secured unit to address behavioral outbursts and the social services department was not very involved in the care of the residents on the secured unit. The social services assistant (SSA) was interviewed on 3/10/21 at 4:45 p.m. She said the social services director (SSD) was responsible for providing psychosocial support to the residents in the secured unit. She said the SSD was out of the facility for extended leave. She said the other department managers had been providing support as available, but she was the only social services staff in the facility at that time. She said she had never gone into the secured unit to provide support for the residents on the secured unit. The SSD was not available for interview during the time of the survey. The resident programs director (RPD) was interviewed on 3/10/2021 at 5:33 p.m. She said Resident #4 exhibited behavioral outburst regularly. She said interventions to redirect Resident #4 during an outburst included: offering a snack, assisting the resident to a quiet space and talking with the resident. She said that interventions depend on the residents' behavioral expressions that day. She confirmed Resident #4 ' s care plan did not reveal documentation of these interventions. She said each staff member attempted to redirect the resident with their own interventions. She said the residents' psychosocial needs on the secured unit were met mainly through independent programs. She confirmed each resident should have a comprehensive care plan which included person-centered approaches and interventions. The director of nursing (DON) was interviewed on 3/10/21 at 5:45 p.m. She said residents in the secured unit had psychosocial needs met by the activity programs staff. She said staff received dementia care and de-escalation training annually. She was not sure of the topics addressed in the training. She said each resident should have a comprehensive plan of care which addressed each resident ' s behavioral concerns and included person-centered approaches and interventions. She said the SSD was out of the facility on an extended leave and MDS staff assisted the SSA in the development of the comprehensive care plan. She said interviews with facility staff and family members should be included in the development of person-centered approaches and interventions.

Based on interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#1) out of 10 sample residents reviewed for unnecessary medications. Resident #1 was administered [MEDICATION NAME] (an antianxiety psychoactive medication) on 11/13/2020. The resident was given 1 ML (milliliters), which was four times the ordered dose. On 11/14/2020, Resident #1, again was administered four times the ordered dose of [MEDICATION NAME] ([MEDICATION NAME]), in [MEDICATION NAME] with [MEDICATION NAME] (liquid opioid) 0.5 ML. Following the initial excess dose of [MEDICATION NAME] on 11/13/2020, Resident #1 suffered a decrease in appetite from an average of 25% to 75% meal intake, to 0% meal intake. Resident #1, who was able to ambulate with supervision prior to the excessive medication administered, was documented as drowsy and in bed from 11/13/2020 to 11/19/2020, when he passed away. The facility failed to ensure Resident #1 was not administered four times the ordered dose of [MEDICATION NAME] on two occasions and contributed to his functional decline, which ultimately led to the resident ' s death. Findings include: I. Resident #1 A. Resident status Resident #1, age 90, was admitted on [DATE]. According to the November 2020 computerized physician orders [REDACTED]. The 9/25/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15. He required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene. He required limited assistance of one person with transfers and locomotion on and off the unit. It indicated the resident did not exhibit verbal or physical behaviors during the assessment period. The resident refused care and exhibited wandering one to three days during the assessment period. B. Failure to respond to Resident #1's behavior prior to 11/13/2020 with person-centered care The behavior care plan, initiated 8/21/18, revealed the resident had a psychiatric condition that caused the resident to act in ways that were inappropriate such as physical and verbal aggression toward others. The resident wanted to have inappropriate sexual interactions with females. The interventions included: administer medications as ordered, observe and document side effects and effectiveness of the medication; explain all procedures to the resident before starting and allow the resident time to adjust to the changes; and observe behavior episodes, attempt to determine the underlying cause, and document the behavior and potential causes. It did not document any person-centered interventions to address the resident ' s physical and verbally aggressive behavior. The rejection of care, care plan, initiated 9/30/2020, revealed the resident had the potential to reject care from staff when required. The interventions included the staff would give the resident time and ask again. It did not document any person-centered interventions. The elopement care plan, initiated 8/17/18, revealed the resident was an elopement risk related to dementia and resided in the secured unit. The interventions included: provide the resident with structured activities such as walking inside and outside the facility; provide a distraction from wandering such as structured activities, food, conversation, television and a book; offer the resident emotional and psychological support with increased episodes of wandering; orient the resident to the environment as needed; and reorient, validate and redirect the resident as needed. It did not include person-centered interventions. The facility failed to develop a comprehensive care plan that addressed the resident ' s behaviors and psychosocial needs to include person-centered approaches. The facility was unable to provide documentation the resident ' s family had been consulted in the development of the comprehensive care plan to address the resident ' s behavioral concerns in order to prevent physical altercations with other residents. Cross-reference F744: the facility failed to provide dementia care services to address the resident ' s behavioral concerns in order to prevent physical altercations with other residents on the secured unit. 1. Failure to respond and address incidents of physical abuse The 10/31/2020 nursing progress note revealed a CNA (certified nursing aide) was sitting in the hallway next to Resident #1. When another resident (Resident #9) walked passed, Resident #1 stood up and struck the other resident in the chest. The 11/2/2020 physical abuse investigation revealed Resident #9 was walking past Resident #1 on the secured unit. As Resident #9 was walking by, Resident #1 made a fist and punched Resident #9 in the chest. This caused Resident #9 to jerk backwards. Resident #1, during his interview, said he hit Resident #9 because he tried to grab the CNA who was sitting next to him. The facility staff separated both residents and placed them on 15 minute safety checks. It did not reveal documentation to indicate person-centered interventions were developed or implemented to address Resident #1 ' s physically aggressive behavior. The 11/13/2020 situation, background, assessment and recommendation (SBAR) form revealed on 11/13/2020 the resident pushed another resident (Resident #9) with his walker. It indicated Resident #1 hit Resident #9 several times in the face, breaking open Resident #9's lip and caused a small amount of bleeding. It indicated Resident #1 consistently looked for an opportunity to strike Resident #9 and had physically struck this resident prior (10/31/2020). The facility provided separation of the residents, one to one observations and medication administration of [MEDICATION NAME] to Resident #1. It indicated Resident #1 had a history of [REDACTED]. 2. Resident #1's aggression was treated pharmacologically The controlled substance administration record documented the resident was administered [MEDICATION NAME] 1 ML at 4:30 p.m., four times the physician ordered dose. The facility failed to address Resident #1's physically aggressive behaviors on 10/31/2020 by putting person-centered interventions in place to prevent another resident to resident altercation. By not addressing Resident #1's physically aggressive behavior, the facility failed to ensure Resident #9 was not victimized again on 11/13/2020 by Resident #1. Cross-reference F600: the facility failed to ensure Resident #9 was kept free from physical abuse by addressing Resident #1 ' s physically aggressive behaviors. Cross-reference F744: the facility failed to provide dementia care services to address the resident ' s behavioral concerns in order to prevent physical altercations with other residents on the secured unit. C. Failure to identify the significant medication error on 11/13/2020 and 11/14/2020 The November 2020 CPOs revealed the following physician orders: - [MEDICATION NAME] ([MEDICATION NAME]) 2 MG/ML: give 0.25 ML sublingually every two hours as needed for anxiety related to dementia with behavioral disturbance for hospice protocol for restlessness aeb (as evidenced by) repetitive movements and shortness of breath (SOB) related to end of life - ordered 10/21/2020. - [MEDICATION NAME] ([MEDICATION NAME]) 2 MG/ML: give 0.5 ML sublingually every two hours as needed for anxiety related to dementia with behavioral disturbance for hospice protocol for restlessness aeb repetitive movements and SOB related to end of life - ordered 10/21/2020. - [MEDICATION NAME] Solution 100 MG/ML: give 0.25 ML by mouth every 2 hours as needed for mild pain or SOB (1-4/10 pain level) - ordered 9/17/2020. - [MEDICATION NAME] Solution 100 MG/ML: give 0.5 ML by mouth every 2 hours as needed for moderate pain (5-6/10 pain level) or SOB - ordered 9/17/2020. The November 2020 controlled drug administration record revealed the following: - On 11/13/2020 the resident was administered [MEDICATION NAME] 1 ML at 4:30 p.m. (the same day as the incident of physical aggression between Resident #1 and Resident #9) The resident was administered 1 ML of [MEDICATION NAME], two to four times the ordered dose by the physician, and was a significant medication error. - One 11/14/2020 the resident was administered [MEDICATION NAME] 1 ML (more than the ordered dose) at 1:00 a.m. At 1:30 a.m. the resident was administered [MEDICATION NAME] Solution 0.5 ML at 1:30 a.m. One day later, Resident #1, again, was administered 1 ML of [MEDICATION NAME], two to four times the ordered dose by the physician, and was a significant medication error. The facility was unable to provide documentation that significant medication errors for 11/13/2020 and 11/14/2020 were identified and an investigation was conducted prior to the survey process (see staff interviews). Cross-reference F760: the facility failed to ensure residents were free from significant medications errors. Cross-reference F758: the facility failed to ensure Resident #1 was free from unnecessary medications D. Resident #1 functional decline 1. Review of Resident #1 ' s functional status prior to 11/13/2020 The ADL care plan, initiated 8/20/18, revealed the resident had a self-care performance deficit related to confusion and dementia. It indicated the resident was independent with bed mobility and transfers. The 9/23/2020 care conference progress note revealed the interdisciplinary team (IDT) met with the resident ' s representative via telephone. The resident transitioned to hospice care that week due to intermittent episodes of [MEDICAL CONDITION]. It indicated a functional decline in the resident ' s abilities was not identified for the resident. The 9/25/2020 behavior progress note revealed the resident was actively exit seeking, shaking the exit door several times an hour. The 9/29/2020 nursing progress note revealed the resident was observed walking in the hallway on the secured unit, talking loudly, saying (Female name), why did you leave me? The 10/9/2020 nursing progress note revealed the resident was observed walking around the secured unit with a walker calling for his sister. The 10/30/2020 medication administration progress note documented the resident was restless and exhibited repetitive movement such as going in and out of rooms, outside and the dining room. 2. Resident #1 functional decline following significant medication error on 11/13/2020. The 11/15/2020 SBAR revealed the resident winced when he was turned to the right side and complained of pain to the right shoulder and right hip. The RN (registered nurse) documented the resident had an episode of aggressive behavior on 11/13/2020 and was administered a dose of [MEDICATION NAME]. The resident had been drowsy since he was administered the dose of [MEDICATION NAME] on 11/13/2020. It documented the nurse notified hospice of the resident ' s functional decline. The 10/1/2020 - 11/12/2020 ADL task sheet for meal intake for Resident #1, prior to the two instances of excessive amounts of [MEDICATION NAME] administered to the resident, indicated Resident #1 consumed the following: -0% - 25% on 36 occasions; 26% - 50% on 44 occasions; 51% - 75% on 27 occasions; 76% - 100% on 12 occasions; Refused on 7 occasions; and No documentation on 10 occasions. The 11/13/2020 - 11/19/2020 ADL task sheet for meal intake revealed Resident #1 consumed the following: On 11/13/2020 (prior to the excessive dose of [MEDICATION NAME]): consumed 26% - 50% for breakfast and 0%-25% for lunch; and (after the excessive dose of [MEDICATION NAME]) the resident was documented as unavailable for dinner. On 11/14/2020: resident refused breakfast (after given the excessive dose of [MEDICATION NAME] and 0.5 ML of [MEDICATION NAME]), lunch and dinner. On 11/15/2020: resident was documented as unavailable for breakfast, and consumed 0% - 25% for lunch and dinner. On 11/16/2020: resident refusal was documented for breakfast, lunch and dinner. On 11/17/2020: resident unavailable was documented for breakfast and lunch, and 0%-25% for dinner. On 11/18/2020: no documentation for breakfast, resident refusal was documented for lunch, and 0%-25% for dinner. On 11/19/2020 (day the resident passed away): no documentation for breakfast and lunch. The 11/13/2020 15 minute safety checks revealed the resident was in his bedroom sleeping, beginning at 4:15 p.m. until 11/14/2020 at 10:15 a.m. The 11/15/2020 15 minute safety checks indicated the resident remained in bed the entire day. The 11/16/2020 nursing progress note revealed the resident remained in bed throughout the day and was unable to sip through a straw. The facility staff provided re-positioning for the resident. The 11/17/2020 15 minute safety checks documented the resident stayed in bed all day. It documented the resident had breakfast from 8:30 a.m. to 9:00 a.m. It did not document where the resident had breakfast. The 11/17/2020 functional assessment staging tool revealed the resident had a higher score from the previous assessment, which indicated the resident had an increase in functional impairment. It documented the resident was under hospice care with a noted functional decline. The resident had been drowsy since he was administered the dose of [MEDICATION NAME] on 11/13/2020. The facility failed to identify the significant medication errors made on 11/13/2020 and 11/14/2020, which contributed to the resident ' s overall functional decline. II. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/10/21 at 1:58 p.m. She said she had cared for Resident #1 while he was at the facility. She said the resident was an introvert and liked to be by himself. She said he was able to ambulate throughout the secured unit with a front wheel walker. She said staff would provide the resident supervision while he ambulated throughout the unit. She said Resident #1 would often walk around the unit, walk in and out of the activity room, other resident rooms, and down the hallway. She said sometimes he would bang on the door, attempting to open it. She said Resident #1 could have aggressive behavior toward other residents and staff members. She said he had two incidents two weeks apart with the same resident before he passed away. She said Resident #1 was fixated on that particular male resident (Resident #9). She said Resident #9 would take things from other residents. She said she thought that was why Resident #1 was fixated upon him. She said the facility staff administered [MEDICATION NAME] to Resident #1 when he would have physically or verbally aggressive behavior. She said the staff attempted to provide re-direction before administering psychoactive medication. She said she was not sure of any person-centered interventions that were successful for Resident #1, other than re-direction. Cross-reference F744: the facility failed to provide person-centered dementia care services for residents. She said she was not working when Resident #1 started his functional decline. She said it was a rapid decline. She said the resident ' s functional decline had been very sudden and fast. She said Resident #1 had suddenly stopped wanting to eat and was in bed all of the time. She said, in the resident ' s final days, he was moved off the secured unit and into a hospice care room. She said she did not believe the resident was supposed to receive more than 0.25 ML of [MEDICATION NAME] at one time. She said 1 ML of [MEDICATION NAME] administered would be considered a significant dose. She said each bottle of medication came with a syringe that had markings to indicate 0.25 ML, 0.5 ML, 0.75 ML and 1 ML. She said giving Resident #1 that excessive of a dose could be detrimental to his health. She said 1 ML of [MEDICATION NAME] could cause sedation and could have contributed to Resident #1 functional decline. She said administering 1 ML of [MEDICATION NAME] would be considered a significant medication error due to the seriousness and type of the medication. The pharmacy consultant was unavailable for an interview during the survey process. The director of nursing (DON) was interviewed on 3/10/21 at 5:42 p.m. She said each nurse was responsible to ensure they were administering the physician ordered dose of medication prior to administering the medication to the resident. She said Resident #1 had experienced a sudden functional decline. She said prior to the resident ' s decline, he was able to ambulate throughout the secured unit. She said the resident could be physically and verbally aggressive at times and had two physically aggressive encounters with another resident (Resident #9) prior to his functional decline. She said one day, Resident #1 just stopped eating. She said he started to have difficulty swallowing and drinking. She confirmed Resident #1 was administered 1 ML of [MEDICATION NAME] on 11/13/2020 and 11/14/2020. She said the resident was administered four times the physician ordered dose of [MEDICATION NAME]. She said she was unaware, until it was brought to her attention during the survey process, Resident #1 was administered an excessive dose of [MEDICATION NAME] on two occasions. She said the unit managers were responsible to review the controlled substance administration records every month. She said if a medication error was observed, then a medication error investigation would be conducted. She said she did not have documentation a medication error investigation occurred regarding Resident #1. She said, based on the documentation, it appeared the resident experienced a decline in eating beginning at the dinner meal on 11/13/2020. She said administering a 1ML dose of [MEDICATION NAME] could cause respiratory distress, lethargy and contribute to an overall decline. She said it appeared from the documentation, Resident #1 was over sedated beginning on 11/13/2020 after 4:30 p.m. (when he was administered the excessive dose of [MEDICATION NAME]) and that contributed to the start of the resident ' s functional decline. She confirmed the documentation indicated the resident was drowsy and remained in bed following the administration of [MEDICATION NAME] on 11/13/2020 and 11/14/2020.

Based on record review and interviews, the facility failed to ensure three (#1, #8 and #7) out of 10 sample residents were free of significant medication errors. Specifically, the facility failed to: -Ensure Resident #1 was not administered two to four times the physician ordered dose of a psychoactive medication on two occasions; and -Ensure the medication administration record (MAR) and controlled substance administration record matched when a controlled substance was administered to Resident #8 and #7. Following the initial excessive dose of [MEDICATION NAME] on 11/13/2020, Resident #1 suffered a decrease in appetite from an average of 25% to 75% meal intake, to 0% meal intake. Resident #1, who was able to ambulate with supervision prior to the excessive medication administered, was documented as drowsy and in bed from 11/13/2020 to 11/19/2020, when he passed away. Cross-reference F684, Quality of Care Findings include: I. Facility policy and procedure The Medication Related Errors policy and procedure, revised May 2010, was provided by the director of nursing (DON) on 3/10/21 at 7:02 p.m. It revealed, in pertinent part, If a medication reached a resident in error, the facility should notify the physician/prescriber and obtain further instructions and/or orders. Facility staff should monitor the resident in accordance with physician/prescriber ' s instructions. Dosage form error: dispensing to the resident of a medication in a different form than that ordered by the physician/prescriber. II. Failed to ensure Resident #1 was not administered two excessive doses of a psychoactive medication A. Resident #1 status Resident #1, age 90, was admitted on [DATE]. According to the November 2020 computerized physician orders [REDACTED]. The 9/25/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15. He required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene. He required limited assistance of one person with transfers and locomotion on and off the unit. B. Record review The 11/13/2020 situation, background, assessment and recommendation (SBAR) form revealed on 11/13/2020 the resident pushed another resident (Resident #9) with his walker. It indicated Resident #1 hit Resident #9 several times in the face, breaking open Resident #9 ' s lip and caused a small amount of bleeding. It indicated Resident #1 consistently looked for an opportunity to strike this other resident and had hit this resident prior. The facility provided separation of the residents, one to one observations and medication administration. It indicated Resident #1 had a history of [REDACTED]. Cross reference: F600: the facility failed to ensure Resident #9 was kept free from physical abuse by addressing Resident #1 ' s physically aggressive behaviors. The November 2020 CPOs revealed the following physician orders: - [MEDICATION NAME] ([MEDICATION NAME]) 2 MG/ML: give 0.25 ML sublingually every two hours as needed for anxiety related to dementia with behavioral disturbance for hospice protocol for restlessness aeb (as evidenced by) repetitive movements and shortness of breath (SOB) related to end of life - ordered 10/21/2020. - [MEDICATION NAME] ([MEDICATION NAME]) 2 MG/ML: give 0.5 ML sublingually every two hours as needed for anxiety related to dementia with behavioral disturbance for hospice protocol for restlessness AEB repetitive movements and SOB related to end of life - ordered 10/21/2020. - [MEDICATION NAME] Solution 100 MG/ML: give 0.25 ML by mouth every 2 hours as needed for mild pain or SOB (1-4/10 pain level) - ordered 9/17/2020. - [MEDICATION NAME] Solution 100 MG/ML: give 0.5 ML by mouth every 2 hours as needed for moderate pain (5-6/10 pain level) or SOB - ordered 9/17/2020. The November 2020 controlled drug administration record revealed the following: On 11/13/2020 the resident was administered [MEDICATION NAME] 1 ML at 4:30 p.m. (the same day as the incident of physical aggression between Resident #1 and Resident #9) The resident was administered 1 ML of [MEDICATION NAME], two to four times the ordered dose by the physician, and was a significant medication error. On 11/14/2020, the resident was administered [MEDICATION NAME] 1 ML at 1:00 a.m. (more than the prescribed amount). At 1:30 a.m., the resident was administered [MEDICATION NAME] Solution 0.5 ML. One day later, Resident #1, again, was administered 1 ML of [MEDICATION NAME], two to four times the ordered dose by the physician, and was a significant medication error. A review of Resident #1's medical record on 3/9/21 at 4:06 p.m. revealed the MAR documented a dosage of [MEDICATION NAME] being administered on 11/14/2020. It did not indicate the resident had been administered a dosage of [MEDICATION NAME] on 11/13/2020, as was documented on the controlled substance administration record and in the nursing progress notes. The 11/15/2020 SBAR revealed the RN (registered nurse) documented the resident had episodes of aggressive behavior on 11/13/2020, for which he was administered a dose of [MEDICATION NAME]. (See above controlled substance administration record) The resident had been drowsy since he was administered the dose of [MEDICATION NAME] on 11/13/2020. III. Failed to ensure the MAR was signed off for administered controlled substance medications A. Resident #8 status Resident #8, age 81, was admitted on [DATE]. According to the March 2021 CPO, the [DIAGNOSES REDACTED]. The 2/11/21 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of six out of 15. She required extensive assistance of one person with all activities of daily living. 1. Record review The March 2021 CPOs revealed the following physician orders: [MEDICATION NAME] ([MEDICATION NAME]) 2 MG/ML: give 0.25 ML sublingually every two hours as needed and 05 ML sublingually for restlessness AEB climbing in and out of bed, yelling out related to anxiety disorder - ordered 2/20/21 A review of Resident #8 ' s medical record revealed discrepancies in documentation between the MAR and the controlled substance administration record (CSAR) for the administration of [MEDICATION NAME] medication. It documented the following: On 2/5/21, the MAR documented the resident received one dose of 0.25 ML of [MEDICATION NAME]. The CSAR documented the resident received two doses of 0.25 ML of [MEDICATION NAME]; On 2/6/21 and 2/11/21, the MAR documented the resident received one dose of 0.5 ML of [MEDICATION NAME]. The CSAR documented the resident received two doses of 0.5 ML of [MEDICATION NAME]; On 2/7/21, the MAR documented the resident received one dose of 0.25 ML and one dose of 0.5 ML of [MEDICATION NAME]. The CSAR documented the resident received two doses of 0.5 ML of [MEDICATION NAME]; On 2/13/21, the MAR documented the resident received 0.25 ML of [MEDICATION NAME]. The CSAR documented the resident received one dose of 0.25 ML and one dose of 0.5 ML of [MEDICATION NAME]. The 0.5 dose was not documented on the MAR. On 2/19/21, 2/24/21, and 2/25/21 the CSAR documented the resident received 0.5 ML of [MEDICATION NAME]. Those doses were not documented on the MAR. The CSAR documented the resident received [MEDICATION NAME] on 3/3/21, 3/5/21, 3/6/21, 3/7/21 and 3/10/21. The March 2021 MAR documented the resident received [MEDICATION NAME] on 3/5/21, 3/6/21 and 3/7/21. It did not document the medication given on 3/3/21 and 3/10/21 as indicated on the CSAR. 2. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/10/21 at 1:58 p.m. She said she had cared for Resident #1 while he was at the facility. She said the resident was an introvert and liked to be by himself. She said Resident #1 could have aggressive behavior toward other residents and staff members. She said he had two incidents two weeks apart with the same resident before he passed away. She said the facility staff administered [MEDICATION NAME] to Resident #1 when he would have physically or verbally aggressive behavior. She said the staff attempted to provide re-direction before administering psychoactive medication. She said she did not believe the resident was supposed to receive more than 0.25 ML of [MEDICATION NAME] at one time. She said 1 ML of [MEDICATION NAME] administered would be considered a significant dose. She said each bottle of medication came with a syringe that had markings to indicate 0.25 ML, 0.5 ML, 0.75 ML and 1 ML. She said giving Resident #1 that excessive of a dose could be detrimental to his health. She said 1 ML of [MEDICATION NAME] could cause sedation. She said it could contribute to a functional decline. She said administering 1 ML of [MEDICATION NAME] would be considered a significant medication error due to the seriousness and type of the medication. She said when a controlled substance was administered, it should be signed off on the MAR and the CSAR. She said the correct dose, time and nurse signature should match both administration records. She said any discrepancy between the MAR and the CSAR was considered a medication error. The DON was interviewed on 3/10/21 at 5:42 p.m. She said each nurse was responsible to ensure they were administering the physician ordered dose of medication prior to administering the medication to the resident. She said a controlled substance should be signed off the MAR and CSAR when administered to a resident. She said the date, dosage amount and nurse signature should match on the MAR and CSAR. She said it was considered a medication error if the MAR and CSAR did not match. She confirmed the Resident #1 was administered 1 ML of [MEDICATION NAME] on 11/13/2020 and 11/14/2020. She said the resident was administered four times the physician ordered dose of [MEDICATION NAME]. She said she was unaware, until it was brought to her attention during the survey process, Resident #1 was administered an excessive dose of [MEDICATION NAME] on two occasions. She said the unit managers were responsible to review the controlled substance administration records every month. She said if a medication error was observed, then a medication error investigation would be conducted. She said she did not have documentation a medication error investigation occurred regarding Resident #1. She said, based on the documentation, it appeared the resident experienced a decline in eating beginning at the dinner meal on 11/13/2020. She said administering a 1ML dose of [MEDICATION NAME] could cause respiratory distress, lethargy and contribute to an overall decline. She said it appeared from the documentation, Resident #1 was over sedated beginning on 11/13/2020 after 4:30 p.m. (when he was administered the excessive dose of [MEDICATION NAME]) and that contributed to the start of the resident ' s functional decline. She confirmed the documentation indicated the resident was drowsy and remained in bed following the administration of [MEDICATION NAME] on 11/13/2020 and 11/14/2020. She confirmed the CSAR and the MAR for Resident #8 did not match. She confirmed the MAR did not document multiple administrations of the [MEDICATION NAME] medication. She said it appeared either the medical record had poor documentation or potential instances of drug diversion. She said she was unaware, until the survey process, of the medication errors for Resident #8. She said the unit managers were responsible to review the CSAR and MAR every month. She said she would change the process to ensure they were reviewed multiple times a month by the unit managers and herself. She said she would initiate a medication error investigation for Resident #1 and Resident #8. B. Resident #7 1. Resident #7 status Resident #7, age 66, was admitted on [DATE]. According to the March 2021 CPO, the [DIAGNOSES REDACTED]. The 2/18/21 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was independent with all activities of daily living (ADL). 2. Record review The March 2021 CPOs revealed the following physician order: -[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME], narcotic [MEDICATION NAME]) tablet 5-325 MG - give one tablet by mouth every six hours as needed for severe pain; ordered 11/11/2020. The February 2021 controlled substance administration record documented on 2/17/21, three doses of [MEDICATION NAME] were administered at 4:00 a.m., 1:00 p.m. and 7:07 p.m. The February 2021 MAR documented the resident only received two doses at 3:57 a.m. and 7:07 p.m. It did not document the dose given at 1:00 p.m., according to the controlled substance administration record. On 2/18/21 two doses of [MEDICATION NAME] were documented on the controlled substance administration record as administered at 4:30 a.m. and 2:30 p.m. The MAR indicated the resident did not receive any doses that day. The March 2021 narcotics sheet indicated on 3/5/21 four doses of [MEDICATION NAME] were administered at 4:15 a.m., 1:35 p.m., 1:45 p.m. and 6:05 p.m. The March 2021 MAR documented the resident only received two doses at 4:22 a.m. and 6:05 p.m. The March 2021 narcotics sheet indicated on 3/7/21 four doses of [MEDICATION NAME] were administered at 3:35 a.m., 9:35 a.m., 3:35 p.m., and 9:35 p.m. The MAR indicated that the resident only received three doses, at 9:33 a.m., 3:35 p.m., and 9:35 p.m. It did not document the resident received the fourth dose at 3:35 a.m. The narcotic sheet documented, Each dose signed for here requires charting on the medical record. 3. Staff interviews The director of nursing (DON) was interviewed 3/10/21 at 5:42 p.m. She said all medications signed out as administered on the controlled substance administration record should be recorded on the MAR. She said if dose was not signed out on both the MAR and the controlled substance administration record it was considered a medication error. She said narcotics sheets were reviewed every month by the unit managers. She said, due to the amount of medication errors, they were not reviewing the sheets enough. She said she would increase the review to weekly and she would be conducting the audits. She said the discrepancies between the MAR and the controlled substance administration record indicated either the facility had an issue with drug diversion or poor documentation. She said she would conduct an immediate investigation for the medication errors. She said she would begin reviewing the controlled substance administration records more frequently then monthly, which was the facility's current practice.

Based on observations, record review and family and staff interviews, the facility failed to ensure one (#194) of two residents reviewed for hydration of 40 sample residents, was provided with sufficient fluid intake to maintain proper hydration and health. Although the resident was at risk for dehydration upon admission, the facility failed to thoroughly assess and implement measures to ensure the resident received sufficient fluids to maintain hydration needs. The facility failures contributed to the resident's hospitalization and treatment for [REDACTED]. The findings included: A. Facility Expectations regarding Nutrition, Hydration and Care Planning The facility's Oral Nutrition and Hydration policy dated 2008 included the following procedures: -Each resident is provided with sufficient fluid intake to maintain proper hydration and health. -Supplements ordered with medication pass will be administered by the nurse/med tech and documented on the medication administration record. -Offer planned alternates if less than 50% of an item is consumed. If planned alternates are refused, additional items may be designated to be available at all times, e.g. peanut butter, cottage cheese, crackers, sandwiches, cold cereal, fruit, juice, and/or ice cream. -Bedtime or HS (hour of sleep) snacks are offered to residents . Assure the snack is within guidelines of the ordered diet. -Drinking water is provided to encourage adequate fluid intake. Provide fluids to residents during and in-between meals and during activities as appropriate. -Residents may be placed on intake or output monitoring, or both. The facility's Care Planning and Care Conference policy dated 2012 included the following procedures: -It is vital that care plans address and include the resident's voice, and that evidence is present of his or her involvement in the development and ongoing processes. -The care plan is a reference instrument for measurement of a resident's progress or decline in conditions or goals. -Upon arrival to the facility, the admitting nurse will perform an initial physical and mental evaluation of the resident and gather specific information from the following sources for development of the initial plan of care: Review physician's orders [REDACTED]. Review any transfer information required. -The admitting nurse must additionally communicate the resident's care needs to the direct care staff via verbal and written communication methods - Verbal report; Kardex/RCS (resident care specialist) assignment sheet update. -The IDT (interdisciplinary team) is required to continue to update the initial plan of care with new or changing interventions until the comprehensive care plan is fully developed and implemented. -The comprehensive plan of care must: Include treatment goals with measurable objectives . Include interventions to prevent avoidable decline in function or functional level . Include interventions to attempt to manage risk factors. B. Resident Status Resident #194, age 92, was admitted on [DATE] from an acute care facility. According to the 4/16 computerized physician orders, [DIAGNOSES REDACTED]. The resident did not have a documented history of [MEDICAL CONDITION] or [MEDICAL CONDITION]. According to the Admission Report Sheet, dated 4/22/16 and received by phone from the hospital nurse, the resident had acute diarrhea, [MEDICAL CONDITION], and [MEDICAL CONDITION]; was oriented to name, hard of hearing, had redness to bottom and very poor intake. According to the 4/29/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. He required extensive assistance for all activities of daily living except eating, for which he required supervision, oversight, encouragement and cueing. C. hospitalization Prior to Admission with Discharge Care Instructions Review of hospital documentation in the resident's medical record revealed he was hospitalized for [REDACTED]. He experienced weight loss at the hospital. The hospital history and physical dated 4/10/16 included, Patient is admitted to a telemetry bed with maintenance IV (intravenous) fluids with normal saline at 75 mL (milliliters) an hour for a couple of liters. A hospital nutrition assessment, dated 4/20/16, included: POA (power of attorney, family member) states the main reason pt (patient) hasn't been eating well is due to the taste/dryness of the food sent. POA would like extra gravy with meals, dessert options (cake) for pt and scrambled eggs, pancakes with syrup or oatmeal for breakfast. POA stated that he prepares pt meals at home and that he has a good appetite as long as the food is not dry . Nutrition-related labs: BUN (blood urea nitrogen) 16 WNL (within normal limits); Creatinine 0.9 WNL; Sodium 140 WNL; Potassium 4.1 WNL . Hospital discharge orders included Glucerna nutritional supplement 240 mL (milliliters) three times daily and minced/moist food texture with thin liquids. D. Resident's Assessed Nutrition Risk/Assistance Needs on LTC Admission Physician orders, dated 4/22/16, included instruction for a regular, mechanical soft texture diet with thin liquids, and an order for [REDACTED]. A speech therapy evaluation, dated 4/25/16, included: Patient arrived at the facility with orders for a mechanical soft, moist diet. The patient's (family member) states that the patient has had some difficulty chewing and swallowing due to his dementia. The patient has difficulty orienting to this environment due to dementia . To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: alternation of liquids/solids and eating paired with automatic tasks, upright posture during meals and for 30 minutes after meals, assist patient with eating if he is not initiating to eat, provide foods that he enjoys. (See observations below - staff failed to implement these instructions.) The Admission Nutrition Assessment, dated 4/26/16, identified the following information pertaining to the resident's nutritional status: -Height: 72 inches; Weight: 149.2 (pounds) -Alert, Verbal -Stage 1 pressure ulcer -Dehydration risk factors: diarrhea [MEDICAL CONDITION] -Eating ability - supervision; Regular/mechanical soft diet; average meal intake - 54% -Preferences obtained by family -Estimated daily calorie needs: 1700 - 2040 kcal/day (based on 25-30 kcal/kg (kilogram) -Estimated intake: 1100 kcal without snacks or supplement. Family providing multiple bedside snacks -Estimated daily protein needs: 68-82 g (grams) protein/day (based on 1.0 - 1.2 g/kg) -Estimated daily fluid needs: 1700-2040 mL/day (based on 25-30 mL/kg) -Provide diet as ordered and preferences -Provide Glucerna 1x/day by family -Offer 60 mL med pass BID (twice a day) for other supplements -Set-up assist, cues and encouragement for meals -Isolation tray while on isolation precautions -Offer snacks between meals and HS (at bedtime) -Monitor GI (gastrointestinal) symptoms -Monitor weight and intake -Encourage fluids as needed -Resident admitted from hospital with treatment for [REDACTED]. Weight loss during episode, unsure of how much but UBW (usual body weight) 175# . Glucerna TID (three times daily). Family providing 1x day and ok with snacks at other times . BMI (body mass index) is low for elderly at latest weight. Nursing reports diarrhea has stopped . The nutrition care plan, initiated 4/26/16, identified the resident was underweight with unintended weight loss r/t (related to) hospitalization with PNA (pneumonia) and [MEDICAL CONDITION]. -The goal was for the resident's intake to improve to 75 percent, and to gain weight toward his UBW of 175 pounds. -Interventions were: Offer snacks and supplements as ordered; Provide diet as ordered: regular/mechanical soft; Provide preferences; Sensitivity not allergy to dairy, banana, eggs; Provide [MEDICATION NAME] (an antidepressant) as ordered; Provide MVI/min (multivitamins/minerals), Vitamin C as ordered; Provide set-up assist, Provide cues and encouragement as needed at meals. -The care plan and meal ticket documented the resident disliked eggs, bananas and dairy. However, his food preferences were not documented (also see observation below where the resident was served scrambled eggs for breakfast). The cognitive function care plan, initiated 5/2/16, identified the resident had impaired cognitive function, dementia, and impaired thought processes related to short and long-term memory loss. Interventions included: Ask yes/no questions in order to determine the resident's needs; Cue, re-orient, and supervise as needed; Break tasks into one step at a time. E. Facility Failures in Response to the Resident's Dehydration Risk 1. Failure to care plan, communicate and monitor dehydration risk, fluid intake and interventions A dehydration care plan was not initiated until 5/11/16 (see below). A skin integrity care plan was not initiated. The 4/16 medication administration record (MAR) revealed the resident received Glucerna nutritional supplement three times daily for four days, from 4/23/16 through 4/26/16. Glucerna was discontinued on 4/27/16. No other nutritional supplements were listed on the MAR. -The MAR did not indicate the amount of Glucerna consumed by the resident on those four days. -The MAR did not include orders documenting fluid intake or offering fluids and HS snacks. 2. Change of Condition According to 5/3/16 nurses' notes, the resident had a [MEDICAL CONDITION] in his room: -2:05 p.m.: What I think is going on with the resident is: resident observed having a grand-mal [MEDICAL CONDITION] with convulsions and became unresponsive . -3:00 p.m.: Resident transferred to (hospital) via ambulance for convulsive [MEDICAL CONDITION], audible secretions, tachypnea (increased respiration rate), unresponsive to minimal responsiveness, sluggish pupils 1-2 mm, and left facial drooping. 3. hospitalization [DATE]-[DATE] According to the hospital emergency department report, dated 5/3/16 at 3:21 a.m., [AGE] year-old male presents . for altered mental status and [MEDICAL CONDITION] . mucous membranes dry . Patient somnolent, does not follow commands . Reason for IV Therapy: Dehydration. The hospital history and physical report, dated 5/3/16 at 6:36 a.m., included: According to nursing home staff he was awakened for vital signs and the patient had a witnessed generalized tonic-clonic [MEDICAL CONDITION] less than a minute. The patient was brought to the emergency department where he had a second witnessed generalized tonic-clonic [MEDICAL CONDITION] . The patient's urine was markedly concentrated in the emergency department . cachectic (general physical wasting) . agitated, oriented x 0 . BUN 26 (normal range 8-20), creatinine 1.43 (normal range 0.6-1.2) . Problem: New generalized [MEDICAL CONDITION], initial head scan was negative; Acute kidney injury versus [MEDICAL CONDITION]. Patient's creatinine is 1.43. There are no previous labs in this system to determine if this is acute or chronic. Plan: Obtain PCP (primary care physician) office notes and records from (previous hospital). 4. Readmission to LTC Facility 5/5/16 The resident was transferred back to the facility on [DATE]. According to the Admission Report Sheet, dated 5/5/16, the resident per hospital nurse phone call was alert/confused, stable - no more [MEDICAL CONDITION], redness to coccyx, poor intake, ice chips, HOH (hard of hearing). Physician orders, dated 5/5/16, included an order for [REDACTED]. There were no orders for a nutritional supplement. The 5/16 MAR did not include fluid intake to be monitored by the nursing staff (see policy indications above). The Readmission Nutrition Assessment, dated 5/10/16, identified the following information pertaining to the resident's nutritional status: -Weight: 141.4 (-5.2% from admission) -BMI (body mass index) low at 19.2 -Diet order: regular pureed, nectar thick liquids -Average percentage intake: Breakfast - 60%; Lunch - 80%; Dinner - 35% -Poor oral intake -Weight loss history and now recent weight loss since admission -Needs set-up assist/cues/encouragement -Working with SLP (speech therapist) due to dysphagia risk. -No supplements were reinstated. Review of the resident's nutrition care plan, initiated on 5/11/16, showed that no new interventions were added after readmission, including the change in diet to pureed texture, nectar thick liquids. A dehydration care plan was initiated by nursing on 5/9/16. The care plan identified the resident was at high risk for dehydration due to medication use, requiring cues and reminders for adequate fluid intake, and diarrhea related to [MEDICAL CONDITION]. The care plan did not list any interventions that would pertain to nurse aides, such as encouraging fluid intake or offering fluids between meals. There was no evidence of instruction for staff to document and monitor fluid intake. Review of meal intake records since the resident's admission revealed the record was incomplete and documented overall that the resident's intake was less than half his recommended fluid needs. For example, the meal intake record revealed on 5/10/16 he consumed 240mL each for breakfast, lunch and dinner; on 5/9/16, he consumed 240 mL for breakfast and lunch and 110 for dinner; on 5/8/16 he consumed 340mL for lunch and 240mL for dinner. Although the resident was readmitted to the facility on [DATE] with a new order for thickened liquids, CNAs were not alerted to encourage fluids between meals. Fluids or foods with high fluid content were not consistently offered between meals. The amount of fluids consumed at meals was not accurately documented in the resident's meal intake record (see observations below). 5. Resident Observations - Facility Failure to Provide, Assist, Encourage and Accurately Document Fluid Intake a. An observation was made of the resident in his room at the Columbine unit during a family interview (see below) on 5/10/16 at 10:15 a.m. The resident was resting in his wheelchair. No fluids were observed in the room. There was no igloo cooler containing thickened liquids in the resident's room (see staff interview below). b. Breakfast 5/11/16 On 5/11/16 at 8:20 a.m., the resident was out of his room. No fluids were observed in the room. There was a small refrigerator in his room which was empty. There was no igloo containing thickened liquids in the room. The following observations were made during breakfast service on 5/11/16 in the small dining room: -At 8:30 a.m., the resident was seated by himself at the back corner table. There was an eight- ounce cup in front of him, which was filled with approximately seven ounces of thickened juice. -At 8:35 a.m., a certified nurse aide (CNA #3) approached the table and asked the resident if he wanted to drink his juice. The resident picked up the cup and took a sip of the juice with a straw, and then placed the cup back down on the table. The aide left the dining room. -At 8:39 a.m., the resident took one sip of his juice. -At 8:47 a.m., CNA #3 brought a bowl of scrambled eggs (see care plan above - the resident disliked eggs) and a bowl of cream of wheat to the resident. The CNA picked up the resident's fork and gave him a bite of eggs while standing. The CNA did not encourage the resident to drink. The CNA left the table. -Between 8:47 a.m. and 8:56 a.m., the resident did not eat or drink. -At 8:56 a.m., CNA #3 walked up to the table and said, while standing, Hi, do you want a drink? The CNA lifted the cup with the straw up to the resident's mouth and he took one sip. The CNA put the cup down and left the table. -At 8:57 a.m., CNA #3 came back to the table and said, Let's work on this, okay? The resident took one sip of juice, and the CNA left the table. -At 8:59 a.m., CNA #3 came up to the resident and said, Are you hungry? The resident said, No. The CNA left the table. -At 9:00 a.m., CNA #3 pulled up a chair at the table and said, Do you want a bite? The resident said, Okay. The CNA gave the resident three bites of scrambled eggs, two bites of cream of wheat, and two sips of juice. -At 9:02 a.m., CNA #3 stood up and wheeled the resident out of the dining room. The CNA did not ask the resident if he was finished with eating, or offer any alternates. -The resident had consumed approximately three ounces (88 mL) of fluids, and less than 10 percent of his breakfast meal. -At 9:44 a.m., another staff member (#8) recorded in the electronic system that the resident consumed 75-100% of his breakfast that morning, and had a fluid intake amount of 240 mL. No staff members were seen observing the amount of food consumed by the residents who ate breakfast in the small dining room prior to the dirty dishes being removed from the dining room by the dietary staff. c. Between breakfast and lunch on 5/11/16, the resident was observed to spend time in the therapy room and in his room on his bed. No fluids were observed to be offered to the resident during that period of time. d. Lunch 5/11/16 On 5/11/16, the following observations were made during lunch service in the small dining room: -At 11:40 a.m., the resident was wheeled into the dining room. -From 11:40 a.m. to 12:15 p.m., the resident sat at the table by himself, with no interaction with staff. There were two stacked clean cups on the table. -At 12:15 p.m., the resident was served a pureed meal consisting of mashed potatoes, green beans, chicken, and two six-ounce cups, each filled with five ounces of thickened water. A speech therapist sat down next to the resident to observe his swallowing ability. -By 12:45 p.m., the resident had left the dining room. He had consumed no water from one of the cups, and approximately three ounces (88 mL) from the other cup. A CNA later documented in the electronic record that the resident's fluid intake for that meal was 360 mL. e. Resident observations on 5/10 and 5/11/16 revealed he was unable to ambulate independently or use his call light. He was thin and frail. He was often hunched over in his wheelchair dozing, or was sleeping in bed. He would answer a question if someone spoke loudly into his ear, but would not otherwise converse with anyone. During observed mealtimes, he could slowly lift a cup and drink from a straw, but he would take only one or two sips and then put the cup down. He could take a bite of food and would then put his fork back down. He needed encouragement to eat and drink again after stopping. If an igloo cooler with thickened liquids had been in his room, he would not have been able to access it independently. F. Family Interview The resident's family member was interviewed on5/10/16 at 10:15 a.m. She said the resident had never had a [MEDICAL CONDITION] prior to the one experienced on 5/3/16 in the facility. She came to the facility for about two hours every day. During each of those visits, she had not seen staff offering fluids to the resident. The Ensure nutritional supplement the family brought in for the resident was not being given to the resident. The resident did not like thickened liquids. G. Staff Interviews CNA interviews revealed snacks, including foods with high fluid content, and fluids were not consistently offered to the resident between meals and at bedtime (per facility policy above). CNAs were unaware the resident's diet order changed upon readmission from thin liquids to thickened liquids. An evening-shift CNA (#22) at the Columbine unit was interviewed on 5/11/16 at 5:50 p.m. She said she was not aware the resident had an order for [REDACTED]. Instead, they put notes about residents on a piece of paper which was kept in their pocket. She had not offered fluids to the resident since coming on her shift at 2:00 p.m. Bedtime (HS) snacks, such as sandwiches, ice cream, yogurt, crackers and milkshakes, were only given to residents who asked. The resident was not offered HS snacks. Thickened liquids were stored in the refrigerator at the nurses' station. - At 5:55 p.m., an observation was made of the nurses' station refrigerator with CNA #22 and a nurse. No thickened fluids were observed in the refrigerator. A day-shift CNA (#16) at the Columbine unit was interviewed on 5/12/16 at 8:55 a.m. She said she was unaware the resident had an order for [REDACTED]. A day-shift CNA (#3) at the Columbine unit was interviewed on 5/12/16 at 9:00 a.m. She said when aides came on the shift, nurses told them about any updates or changes made to a resident's plan of care. Nurse aides did not use the facility's Kardex system for communication about residents. An igloo cooler (containing thickened liquids) in a resident's room was the method by which aides knew the resident had an order for [REDACTED]. Prior to the resident's hospitalization , she sometimes saw that the resident drank 350 mLs at breakfast and lunch. She did not observe him drinking or eating snacks between meals. The consultant registered dietitian (RD) was interviewed on 5/12/16 at 9:35 a.m. She said residents at high risk for dehydration included those who had infections and wounds, vomiting, diarrhea, or had an order for [REDACTED]. -The RD said the resident's order for Glucerna nutritional supplement (240 mL three times a day) was discontinued after four days on 4/27/16 because the resident was not drinking much of it, and the family wanted him to consume meals and snacks throughout the day. -She relied on the accuracy of the meal intake records for evaluating residents' nutrition and hydration status. She was not aware the resident's meal intake records were inaccurate (see observations above), or that the resident was not being offered fluids and snacks between meals. -The resident was supposed to be offered snacks every evening before bed. She was not aware the resident was not being offered HS snacks. -When the resident was readmitted , he was not eating well. He was assessed to need constant encouragement and cueing with eating and drinking. Alternates were supposed to be offered if the resident expressed he did not like the food items served to him. -She said residents on a thickened liquid diet should have a bedside igloo cooler with thickened liquid in it, which would remind staff that the residents needed thickened liquids and staff needed to offer and assist the residents to consume between meals. The director of nursing (DON) was interviewed on 5/12/16 at 10:18 a.m. She said the Kardex system was a tool whereby customized care plan interventions were communicated to staff. If an intervention such as encourage fluids between meals was added to a care plan, it would be transmitted to the CNA Kardex. - She said new nurse aides were not in-serviced on recording meal intakes. Audits were not conducted to ensure the accuracy of meal intake records. -The resident's fluid intake was not monitored between meals. The resident care management director (RCMD) was interviewed on 5/12/16 at 12:06. She said the resident's dehydration care plan was not initiated until 5/9/16. Based on his [DIAGNOSES REDACTED]. -She said CNAs were not currently using the Kardex system. Nurses were responsible for ensuring the nurse aides were informed of residents' current plans of care. -Water was supposed to be passed out to each resident between meals. The facility did not track if water was being offered to residents between meals. -HS snacks were supposed to be offered to each resident every evening.

Based on observation, interviews and record review, the facility failed to ensure residents, including two of 41 sample residents (#98, #82) were free from verbal, physical and mental abuse. Specifically: Resident #98 and resident #148, both of whom had a history of [REDACTED]. Resident #148 was independent and frequently returned to the facility intoxicated. Resident #98 was dependent and alcohol-free for [AGE] years but feared he could relapse. Resident #148's intoxicated state and resident #98's dependency made resident #98 feel abused, fearful of his safety, and fearful of relapse. The facility failed to take steps to limit resident #148's intoxication and his abusive behavior toward resident #98 and other residents in the facility when intoxicated, contributing to resident #98's fears and creating the potential for other residents to feel harassed and fearful. The findings include: A. Facility Policy According to the facility's "Abuse and Neglect Prohibition" policy, revised on June 2013, "Each resident has the right to be free from mistreatment, neglect, abuse ...mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation ...Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of age, ability to comprehend, or disability ..." B. Residents #98 and #148 1. Resident #98 and Resident #148's status a. According to the face sheet, resident #98 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 02/16/14 significant change in status Minimum Data Set (MDS) assessment documented the resident as having a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. The MDS also indicated that there were no behaviors exhibited. He was an extensive assist for bed mobility, dressing, toilet use, and personal hygiene. Review of the resident's care plan revealed he was care planned for alcohol history and risk for relapse as he can sometimes feel "triggered." -The goals included "Increase safety of resident, decrease risk of relapse and respond to supportive interventions that promote abstinence daily x 90 days." -The approaches included "-encourage resident to be proactive, request support at times of struggle, monitor/ document signs and symptoms of withdrawal or relapse, provide calm, reassuring environment, limit resident exposure to alcohol, do not allow roommates to drink in shared room, or if possible place with roommate who also abstains from alcohol use. b. Resident #148 According to the face sheet, resident #148 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 01/17/14 admission Minimum Data Set (MDS) assessment documented the resident as having a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. He was independent (with supervision) for transfers, walk in room, walk in corridor, and locomotion on and off the unit. Resident #148 was care planned 01/13/14 for depression, psychoactive medication use, and substance abuse/alcohol. -His depression care plan was updated 3/9/14 to monitor for change in behaviors and concerns while consuming alcohol. "Resident chooses to drink alcohol- has order for 2 beers/day." -His substance abuse/alcohol care plan directed staff in pertinent part, to monitor for relapse, educate on facility policy and notify authorities in the event of uncontrollable, escalating behavior. Per updated 4/8/14, he refused counseling services. 2. Concerns/Grievances filed by resident #98 and facility response a. 4/10/14 According to the concern form dated on 4/10/14, resident #98 stated, " ...my roommate goes out and comes back intoxicated. The people who work here just look the other way ...it's been happening more than a few times. And still nothing is done about it. Makes me feel like I should go out and do the same thing but it's not what I want for myself but to be in a safe place then this is happening. This has happened more than once and still nothing is done. So I decided if he is going to be rooming with me, I need to either sit by and let it happen or wait for something bigger to happen. I will not be idle anymore waiting for management to do something but call the police for intoxicated person in the same room and let them handle it." -4/10/14, response by management, " ...offered resident a room change and he declined ...states feels when roommate drinks he might be unpredictable because that's how he was." "Resident #148 stated didn't realize it was bothering his roommate #98 and he will not drink in the room to prevent bothering roommate." -4/11/14, concern form from roommate #148, "Resident complained about resident #98 being rude, crude ...interference of nurses coming in and talking to them..." -4/14/14, response by management, " ...Spoke with resident #148 and he said it was all frivolous. Just venting. He said he and resident #98 are fine, they just don't talk." b. 4/17/14 On 4/17/14, a concern form from resident #98, "Resident complained of roommate drinking alcohol-he stated the smell "triggers" him. He used to be an alcoholic." -4/17/14, response from management, "Spoke with resident #98 and he understands there are no options for room move at this time ...he confirms that roommate is not drinking alcohol in the room. Denies need for counseling, support, or alcoholics anonymous ...." 3. Resident #98 and Resident #82 interviews a. On 4/23/14 at 8:49 a.m. and 4/24/14 at 10:30 a.m. resident #98 stated: -When resident #148 was first admitted , he was "ok." When he went out for errands, he would come back intoxicated and brought beer back into the room. "He was drinking it here in the room and stunk up the room." Resident #98 said he was afraid he might relapse (start abusing alcohol again). -"When I complained about it, they said it was ok with the doctor. His liquor was not controlled and he would drink whenever he wanted. Once he starts drinking, he gets rude. He said resident #148 had closed the door on a janitor lady and had made sexual comments about the female residents and made them feel uneasy. He stated, "I thought this setting would be a safe environment for us." -"In some ways resident #148 (is) abusing me. I felt like I am defenseless but I didn't let him know that. He would say, 'damn bastard' and 'let's see what happens later on.' I would tell him 'I am not afraid'. He had a knife one day. The nurse showed it to me. I've gotten stabbed in the past. It scared me a little. I can't defend myself being in bed. I didn't want to show fear ... I was aware of what he could do to me. I had my phone and my call button in case something happened." -"I tried to tell one of the nurses but she told me 'what they do on the outside (drinking beer) we have no control of.' That's when I wrote my second concern form and I told them if you guys don't do anything this time I will call 911." He stated that he felt concern for the other residents at the facility because they couldn't protect themselves. b. Resident #82 was interviewed on 04/23/14 at 2:44 p.m. She stated resident #148 has come in drunk before. She said that one day he came into their room and was not obscene yet but it was leading up to that. It went on for about 15-20 minutes. She said resident #148 told her that she was "a big woman" and asked her if she "played for the Green Bay Packers." 4. Record review and staff interviews confirming resident #148's intoxication and inappropriate behaviors when intoxicated. a. Record review Nurses' notes: -On 4/23/14 (during survey - see observations below), " ...Appears intoxicated, speech slurred at times ...silly, inappropriate remarks to staff ...late entry for days that resident appears intoxicated, slurred speech, ... Noted resident signs himself out of facility often ..." -On 4/22/14, " ...RN observed resident with slightly unsteady gait. Approached resident noted smell of alcohol on breath ..." -On 4/10/14, "...Resident continues with [MEDICAL CONDITION], slurred speech ..." -On 3/30/14, "...Resident requested RN call MD ...Resident approached RN and stated "If my doctor doesn't call me back in ten minutes, and give me what I want, there's going to be a problem. RN stated "a voicemail was left for the doctor. Resident stated 'then you might as well call the police. There's going to be a problem.'" The police was called. The RN stated "he can stay if he can stop the threatening behavior and cooperate with staff." Social services notes: -On 4/24/14, " ...He does have an order for [REDACTED]. -On 04/23/14, "...received information from staff, including nursing, that resident appears to be drunk on a daily basis ...He has been asked to leave resident rooms and staff lounge repeatedly this week ..." b. Staff interviews On 4/22/14 at 3:38 p.m., a certified nurse aide (CNA #1) who was familiar with resident #148 was interviewed. -She said she told the nurse one day that resident #148 had been "really loud in the room and when you tell him to lower his voice because there are people here who need to sleep, he gets belligerent. The way he talked was inappropriate." He would say "I don't like my roommate #98, I don't want to be here, the room stinks, he stinks." -She said, "He would also mention inappropriate things about women, including the female staff. "It feels abusive and residents shouldn't have to listen to that. When he drinks he gets loud and overfriendly with some of the residents and touches their shoulders. When you tell him not to do that he blows it off and goes to the next resident. I've heard him say things to other residents in the dining room including, 'I f--- all the time, I go out for it, I come back for it, I do it all the time.'" -On 4/22/14 at 4:00 p.m., CNA #2 was interviewed. She stated resident #148 had been "drinking daily to the point of staggering around. He's abusive to the residents and staff. He says stuff that is inappropriate. Some residents are aware of it and they ask 'what is wrong with him and do they allow him to do that here (to resident #98 and resident #82).' "The CNA stated she told the nursing home administrator (NHA) about her concerns and she stated the NHA had responded that it's "not under our control." -On 4/23/14 at 10:06 p.m., a NAT (nursing aide in training) was interviewed and she stated that she had heard of abuse here with this resident #148 but she hadn't seen it. -On 4/23/14 at 11:00 a.m., a housekeeping staff member was interviewed and she stated "(Resident #148) comes in quite often intoxicated and upsets our staff. He gets mouthy and starts talking sexually and stuff." -On 4/23/14 at 11:20 a.m., CNA #3 was interviewed and she stated she keeps an eye on resident #148 to make sure he isn't harassing anybody when he gets verbal and starts cussing. She said, "I know it makes the residents uncomfortable." She said she considers his behavior "inappropriate." -On 4/24/14 at 9:48 a.m., a charge nurse-licensed practical nurse (LPN #1) was interviewed and she stated that she had seen (resident #148) come into the building intoxicated. She said in pertinent part, "Most of the time, he will drink it here in his room." He normally leaves the building at 10:30 a.m. and again at around 2:30 p.m. "and that is when he gets his beer." She said resident #98 had complained about resident #148's drinking and coming in intoxicated; he could smell it ... It was reported a couple of weeks ago." -On 4/24/14 at 11:26 a.m., two charge nurses LPNs (#1 and #2) were interviewed. "(Resident #148) is allowed to have two beers per day and to him that means 32-40oz beer and he will drink it." One of the LPN's stated that she had seen this resident with a knife when he first arrived but the knives (2-3) had been locked up. She stated that when he was sober, he was calm and polite but when he drank, he started to cuss and got loud at times. -On 4/24/14 at 3:10 p.m., the director of nursing (DON) was interviewed. She stated resident #148 had been intoxicated at times at the facility. "He drinks most days, few days per week." -On 4/24/14 at 4:30 p.m., a registered nurse (RN #1) was interviewed. She stated resident #148 goes out on pass from time to time. "He appears intoxicated and his sense of humor is not funny for this crowd. More to the staff but the residents can hear it." She said, "When he isn't drinking, he is pleasant but when he is drinking, he is loud and obnoxious." -On 4/24/14 at 5:10 p.m., the social worker (SW) was interviewed and she stated resident #148 was found in a resident's room and was intoxicated. "Yesterday, he was going into residents' rooms and some are uncomfortable with a male in their room. I explained to him that this was inappropriate. It's happening more. Some residents are comfortable and some residents are not comfortable with him. I am working on getting him independent housing and he has refused 5. Observations On 4/21/14 at approximately 7:00 p.m., the resident was observed to be walking across Main Avenue, diagonally, headed away from a liquor store towards the facility. On 4/23/14 at approximately 10:30 a.m., the resident was observed speaking loudly. He approached three residents in the main dining room and gave them "massages." He did not ask their permission. One of the residents who had received the massage was interviewed and she stated that "he is usually intoxicated most days. I am appalled by his behavior. I told him not to come here trashed and that he has two choices- to stop drinking or leave." On 4/24/14 at 3:30 p.m., the resident was observed to lean close to one of the nurses in the dining room and spoke loudly. The nurse was interviewed at 3:42 p.m. and she said resident #148 was intoxicated. She stated, "I educated him that this is a facility and the patients here feel unsafe. These residents have people coming in and out all day and may not be able to express discomfort." 6. Facility failure to take steps to limit resident #148's intoxication and his abusive behavior toward resident #98 and other residents in the facility when intoxicated. a. Failure to timely clarify orders for alcohol consumption Physician orders [REDACTED].#148 "may have 2 beers every day at resident's request." On 4/24/14 at 3:30, a RN said she called the physician "this day" to confirm how much alcohol he ordered the resident could consume. She stated that the resident thought he is supposed to have two 24oz (ounce) cans of beers/ day and his physician had when called today, that the resident was supposed to have two 12oz cans of beers/ day. She confirmed that there should have been a limitation to his beer consumption. b. Failure to develop a plan to address the resident's behaviors. See resident #98 interviews above; he was told by a nurse 'what they do on the outside (of the facility) we have no control of.' On 4/24/14 at 3:00 p.m., the NHA said the facility has no protocol for behavioral contracts. She stated would probably be issuing the resident a 30 day notice of discharge. On 4/24/14 at 5:10 p.m., the social worker, when asked if there was anything in place for resident #148's behaviors, stated she planned to expedite him living independently. However, she did not address any immediate plans to ensure facility residents were not verbally, mentally, or physically abused while the resident remained in the facility.

Based on observation, interviews and record review, the facility failed to ensure five of 41 sample residents (#9, #35, #80, #139, #143), and 13 residents who were served in the assisted dining room, received care and services in a manner to promote dignity and respect. Specifically, the facility failed to: -Provide timely call light response and adequate staffing resulting in incontinence; -Provide dignified transport to the shower room; -Ensure a resident's clothing was clean, and the correct size to cover the resident's abdominal area; -Ensure that residents' care information was not posted on resident room doors where other residents and visitors could easily read it; and -Promote dignity with dining in the assisted section of the dining room. Resident #143 stated that when she was incontinent due to slow call light response, she felt "irritated ... I don't like sitting in pee," and added that "it doesn't matter (to facility staff) if it irritates me." The findings included: 1. Incontinence due to slow call light response Cross-Refer to F353 Insufficient Nursing Staffing Resident #143, under [AGE] years old, was admitted to the facility on [DATE]. According to her 3/21/14 Minimum Data Set (MDS), she was cognitively intact with no mood or behavior symptoms. Her [DIAGNOSES REDACTED]. She needed extensive two-plus assistance for bed mobility, transfers, dressing and toilet use, and was dependent for bathing. She was frequently incontinent of bladder and always continent of bowel. -Resident #143 was interviewed on 4/23/14 at 1:35 p.m. She said she had experienced incontinence because there was "not enough staff" and call light response was delayed. When asked how she felt about this, she said, "I don't like it." -The resident said she had reported her concerns to the director of nursing (DON) and her former ambassador, and "Their response is, 'Oh, we have plenty of help.' I ask for help and they turn my light off and say, 'I'm the only one on the floor - you'll have to wait.' I do know there's a lot of people here, so one person can't do everything." -"I want a shower every day and they (CNAs) said, 'You're not getting a shower every day - that's just not going to happen.' ... They say I'm an hour-long shower and I have to wear ted hose, so that takes more time to get me dressed. I'm not happy about it either. I tell them, 'I don't like (ted hose) any better than you do.' " -"When I have to go to the bathroom, there have been times - this irritates me, but it doesn't matter if it irritates me - I have to get out of bed with the sit- to-stand (lift), go to the toilet with a sit-to-stand, get back into bed with the sit-to-stand. It irritates me. Just the other day I had one of those toilet risers and I needed to poop. I put my bell on, but sometimes it takes them awhile to get back, so I put myself on the toilet, and I did have a BM (bowel movement), but I ended up getting some on my diaper before I got on the toilet, so I had to call for help. That's why I say I think they need more help, but they don't think they do ...what do I know?" -"Now they have me labeled as noncompliant. When I tell them I need the bathroom, they say, 'Oh, (your incontinence brief is) not even wet ... Once you pee in it you'll pee again and again and again, but their theory is, 'It holds more.' That's great, just what I want to do, take off a ten-pound diaper. It's not even that exciting wearing a diaper. And I'm on [MEDICATION NAME] ... I don't like sitting in pee - so what if it holds more? I don't like it." -"Going to the bathroom is a hassle; it's a really big hassle." -"Sometimes it will be 15-20-30 minutes for call light response. Sometimes they don't come back." -"I'm a two-person assist. There have to be two people here before they can take me to the bathroom. Sometimes they turn my call light off, go to find someone and they can't find anyone. I think I should just leave the call light on until two people get here." 2. Undignified transport to the shower room Cross-Refer to F242, Choices Resident #80, under [AGE] years old, was admitted to the facility on [DATE] with documented [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated 3/5/14, resident #80 was totally dependent on staff for bed mobility, transfers, and toilet use, and required extensive assistance with dressing and personal hygiene. She was totally dependent on staff for bathing. Resident Observation: On 4/21/14 at 4:30 p.m., resident #80 was observed sitting in a rolling shower chair and was being pulled backwards by a certified nurse aide (CNA) down the hallway from her room into the shower room. She was clothed only in a white bath blanket that was wrapped around her. 3. Clothing Resident #35, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident Status: Minimum Data Set (MDS) The MDS dated [DATE] documented that the resident had a brief interview of mental status score of nine indicating moderate cognitive impairment. He required extensive assistance with bed mobility and toilet use. He required limited assistance with dressing, personal hygiene, and bathing. The care plan dated 2/27/14 documented in part: -The resident required staff assistance and interventions for completion of all his activities of daily living needs. He required limited to extensive assistance of one staff member. The resident at times would refuse to wear his attends. -The goal was, "The resident will have his activities of daily living needs identified and met with staff assistance and intervention while maintaining the highest level of independent function possible." -Approaches included, "The staff will gather and provide needed supplies. Staff will allow the resident adequate time to complete task. The staff will encourage the resident to change soiled pull-ups, clothing, and will provide assistance." Observations: On 4/21/14 at 12:53 p.m. the resident was sitting in his wheelchair in the hallway. The resident was asking about popcorn, saying that he thought it was popcorn day. The resident's shirt was observed to be stretched tightly across his belly with part of his lower belly uncovered. The top middle portion of the shirt was wet. Three staff members were observed to walk down the hall past the resident. They were not observed to offer to help him change his shirt. On 4/22/14 at 8:55 a.m. the resident was observed wearing blue shorts and a gray shirt. A staff person was observed to walk past him and said to the resident, "Your pants are falling off, you need to pull them up." The staff did not stop to assist the resident. His gray shirt was wet with drool running down the front under the neck. The resident's shirt was observed to be pulled up, exposing his belly. On 4/23/14 at 8:15 a.m., the resident was sitting in his wheelchair in the hallway. The top of his T-shirt had a small wet area in the middle. The resident was wearing incontinence briefs with a small portion hanging out the right side of his upper pants. The resident asked the surveyor for help to apply his elastic suspenders. The Nursing Home Administrator (NHA) was nearby, heard the resident ask for help, and assisted the resident to his room to provide help. On 4/24/14 at 11:20 a.m., the resident asked this surveyor for help pulling his pants up in the back. The resident's shirt was observed to be wet and moist in the upper middle area. The resident was observed to drool slightly and was wiping his mouth with a Kleenex. 4. Posting of Care Information a. Resident #9, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident Status: According to the MDS dated [DATE], the resident had short-term and long-term memory problems. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene; and had total dependence for bathing. She was not steady with balance and required assistance to stabilize. She used a walker for mobility. The care plan dated 8/15/12 in part read: -The resident required staff assistance and intervention for completion of activities of daily living. The resident used a walker for mobility. -The goal was, "The resident will have her activities of daily living needs identified and met with staff assistance and intervention while maintaining her highest level of independent function." -Approaches included, "The staff will gather and provide needed supplies. The staff will encourage active participation in tasks and praise all efforts." Observations Throughout the survey conducted 4/21/14 through 4/24/14, a sign was posted on the outside of the resident's door. The sign was visible to all staff, other residents, and visitors. The sign read, "Walk to dine with rollator and oxygen tank." b. Resident #139, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident Status: The MDS dated [DATE] documented that the resident had a brief interview of mental status score of 13, indicating she was cognitively intact. She required extensive assistance of one person with bed mobility, transfers, dressing, toilet use, and personal hygiene. She was not steady and was only able to stabilize with assistance. The care plan dated 9/29/13 documented in part: -The resident required staff assistance and intervention for completion of all activities of daily living and required limited assistance of one staff member. -The goal was, "The resident will have her activities of daily living needs identified and met with staff assistance and intervention while maintaining her highest level of independent function." -Approaches included, "The staff will gather and provide needed supplies. The staff will allow the individual adequate time to complete task. The staff will encourage active participation in task and praise all efforts." Observations: During the survey, conducted 4/21/14 through 4/24/14, multiple observations were made each day of the sign posted on the resident's door, which read: "Walk to dine, contact guard, follow with a wheelchair, assistive device of a front wheel walker." Staff Interview: On the evening of 4/24/14 the Director of Nurses (DON) was interviewed. She was informed of the observations related to resident #35 of his soiled shirt and exposed abdomen. The DON said the resident would often refuse care to change his clothes or take his bath, and the staff tried to be aware and offer assistance when needed. The DON was informed of the dignity issue and observations of resident information that was posted on the residents' doors. The DON said that none of the residents had a concern with the signs on the doors and none of the residents had complained about the sign on their door. The DON said she would find another way to post the information. 5. Assisted Dining Room Observations of three meals and interviews with staff revealed non-interviewable residents in the assisted dining room waited for long periods to be served, and were not served at the same time as their tablemates. The facility had open dining, with dinner served from 5 to 7 p.m. and lunch served from 11 a.m. to 1 p.m. Cross-refer to F353, Insufficient Nursing Staffing. Observations: Dining observations during dinner on 4/22/14 from 5:42 p.m. to 6:15 p.m. revealed the following: -At 5:42 p.m., 13 residents were seated in the assisted area of the dining room, near the Mariposa nurses' station where the nurse was preparing and passing medications from the med cart in the hall. There was no activity, no conversation, and no music playing. The residents sat at their tables and looked at each other and at staff members, but did not interact. -At 5:42 p.m., only one resident had a plate of food in front of her. The resident was feeding her meal to the male resident sitting next to her (this was her husband per the charge nurse). He had eaten most of her dinner roll, and she was feeding him bites of her mashed potatoes. -Residents had water in carafes at the center of each table. Some residents had drinks and three did not. Three residents had supplements (confirmed by the nurse) that they were already drinking. Resident #171 was drinking two supplements (to address pressure ulcers and health issues per the nurse). -At 5:48 p.m. the female resident and her husband (see above) were served and he was eating his own meal. The female resident's plate was empty and she was helping him eat his own food. Residents were beginning to be served in the assist area: first one resident at a table of four, then resident #171 at a table of three. The female resident (#42) sitting across from resident #171 had no food and no drink. At 5:50 p.m., a resident at a third table was served her meal but her tablemate had no food. A male resident in a wheelchair entered the dining room at 5:51 p.m., staff greeted him by name and brought him a supplement to drink. He had had no food and had just arrived at the table. Seven residents were sitting at assist tables without food, watching their tablemates eat. -At 5:52 p.m., resident #171 was served an iced cola. He was eating and getting assistance but his tablemates had no food. His male tablemate who had just arrived was being assisted by staff to drink a supplement with a straw. -At 5:53 p.m., two additional residents at a four top table next to the married couple were being served. One resident at this table still had no food. -At 5:55 p.m., four residents in the assistance dining room were still not served. They were sitting at tables with residents who were already eating. -At 5:58 p.m., the second resident at a two-top table was served, and the fourth resident at a four-top table was served. At resident #171's table, a staff person asked his male tablemate, who was being assisted to drink his supplement with a straw, if he was "full," and told him, "You don't have to finish it if you don't want to." At 6 p.m., he had not yet been served his food, but he had almost finished his supplement. At 6:05 p.m., he was served a hamburger and a glass of milk. He did not touch the burger, but began to drink his milk. The female tablemate (resident #42, sitting across from resident #171) was served her food at 6:06 p.m., and she began to eat. -At 6:09 p.m., the nursing home administrator (NHA) offered to cut the male resident's burger in half for him. A certified nurse aide (CNA) put clothing protectors on the male resident and resident #42 without asking first. Four CNAs were in the dining room assisting residents to eat. Resident #171 had eaten about half his meal and all of his chocolate pudding. His male tablemate still had not touched the hamburger. Resident #42 was eating her dinner. Most residents in the assistance dining room were eating very slowly, or were not eating at all. A female resident was slowly eating her chocolate pudding although a CNA at her table was encouraging her to eat her entree, and asking her if it was good at 6:12 p.m. -At 6:15 p.m., a female resident was wheeled out of the dining room. She had eaten only a few bites of food. A CNA said that was "typical for her at dinner - her son feeds her breakfast every morning and she eats well then. She usually drinks but doesn't eat much for dinner." The resident had almost finished her milk. The resident who had been feeding her husband said she had "enough to eat," and her husband ate "very well." When asked, she said, "Yes, this is my husband. The plate in front of her was empty, and his plate was almost full. Lunch observations from 12:13 p.m. to 12:34 p.m. revealed: In the assisted dining area, there was no activity, no conversation, and no music playing. The residents sat at their tables and looked at each other and at staff members, but did not interact. -At 12:13 p.m., four residents had no food although their tablemates did. One resident was refusing to eat everything that was offered to her. Resident #171 had finished eating but his tablemate had no food. -At 12:17 p.m., the last resident at a four-top table was served. -At 12:24 p.m., the last resident at the far right table was being served. -At 12:27 p.m., one resident at the nearest table on the left had no food, although both her tablemates had their food and were being assisted to eat by staff. One resident had a supplement that was 2/3 finished but no food. -At 12:32 p.m., a female resident with no food wheeled herself away from table and sat by the medication cart. Her tablemates had their food but she did not. A CNA said her tray was "coming." At 12:34 p.m., her soup arrived and staff assisted her back to the table and encouraged her to taste it. She was the last resident served. Dinner observations on 4/23/14 from 5:24 p.m. until 5:48 p.m. revealed the following: -At 5:24 p.m., 11 residents were in the assisted dining area. None had food but most had drinks. There was no conversation or activity. Residents were sitting at their tables looking at staff members and each other, but were not interacting. -At 5:26 p.m., resident #171 received his meal. His female tablemate had no food. -At 5:29 p.m., resident #171's tablemate was wheeling away from the dining room into her room. Staff were trying to direct her back to the dining room, but she said, "No" to three attempts. The director of nursing (DON) approached and asked her if she wanted to go into her room and wait for dinner. -At 5:31 p.m., a female resident at a four top table was served her meal. She smiled at the staff person who served her and sat next to her to begin assisting her with her meal. Her three tablemates had no food. At 5:32 p.m., one of her tablemates was served, but two were not. -At 5:33 p.m., the NHA brought a plate of food for another of the resident's tablemates. -At 5:35 p.m., the married couple were served their trays at the same time. -At 5:36 p.m., resident #171 had a different tablemate, who was being served her food, ten minutes after he had been served. -At 5:40 p.m., six residents in the assist section had no food yet, but they were seated together at a two-top (resident #42 and a male resident) and a four-top (all female residents) table. -At 5:45 p.m., three residents at the four-top table were being served, three at the same time by three staff persons. The fourth resident received her food at 5:46 p.m., one minute later. -At 5:48 p.m., resident #171 was receiving his supplements and had eaten most of his meal. Three residents still had no food, including resident #42. The nurse went to get one of the residents, who had not been served, a cup of coffee. -At 5:51 p.m., resident #42's tray was served, and at 5:52 p.m., the last two residents in the dining room were served. At 5:54 p.m., another resident was brought into the dining room and seated. Staff Interviews: A CNA, interviewed at 3:30 p.m. on 4/22/14, said, "Residents in the assist dining room wait 45 minutes to an hour (to be served). It makes it worse when kitchen staff gets a little short, too. That's a management decision, that residents are seated in the dining room, but assist residents get served last." Another CNA, interviewed at 4 p.m. on 4/22/14, said, "They need a waitress to take orders, but we're getting up residents and they're saying (to the CNAs), 'Go over there and start taking orders.' Sometimes I like it when (surveyors) are here because everybody pitches in." Another CNA, interviewed at 10 a.m. on 4/23/14, said that when they were short staffed, "Residents will try to to talk to me (during cares) but I say, 'I'm sorry, I'll have to talk to you in the dining area.' ... Yes, in the assist area they wait a long time, because they are the last to eat, because they need somebody to feed them. And if we feed them first, that would take all of the CNAs not able to pass the trays that are going out. So we try to serve the residents who are independent first, and the others last so we can feed them ourselves in the dining room. Some wait just 15 minutes, but they probably wait 20 minutes at least." Another CNA, interviewed at 10:30 a.m. on 4/23/14, said, "CNAs pass trays and assist residents are served last, so every CNA is available to sit over there and help them eat." A charge nurse on Mariposa, interviewed at 9:45 a.m. on 4/24/14, said, "The wait for residents in the assist area is a good 20 to 30 minutes or longer for breakfast. It depends on what time they get up. They get coffee or tea or hot chocolate immediately. Most residents like juices and water. They usually wait about the same amount of time at lunch. They serve the main dining room first and then the assisted. Because otherwise we're having CNAs sitting down and nobody in the dining room serving the rest of the food. We nurses help as we can." When asked, the charge nurse acknowledged that she had seen residents in the assisted dining room wait 45 minutes to an hour for their food. She added, "We've tried it several different ways and I know they're working on something else, but nobody knows what it is yet. Supplements before meals? A lot of them don't eat that much anyway. What I try to do personally is give supplements at end of the meal when I see that they're pretty much almost done." The nursing home administrator (NHA) was interviewed at 3 p.m. on 4/24/14. Upon review of the observations above, she acknowledged that residents in the assistance dining room were served last, waited too long for meals, and were sometimes not served together. She said they had made adjustments to their dining service, and planned to do so again. She said they planned to add staff when the dining committee made adjustments to the "dining zones." She said they were planning to divide the dining areas into zones with specific staff assigned to specific groups of residents.

Based on observations, record review and interview, the facility failed to ensure two of 41 sample residents (#30 and #111) received the care and services necessary to attain and/or maintain their highest practicable level of physical and mental well-being. Specifically: -The facility failed to identify resident #30's risk for bowel complications, monitor her bowel status and communicate her bowel status to the physician. The resident was transferred to the hospital and diagnosed with [REDACTED]. -The facility failed to monitor and address resident #111's diabetes as ordered and care planned. The findings include: A. Bowel management According to "Clinical Nursing Skills and Techniques," by Perry, Potter & Ostendorf, 8th Edition (copyright 2014), page 842: "Regular elimination of bowel waste products is essential for normal body functioning... elimination patterns and habits vary among individuals. When patients' functional status changes or they become ill, they may not be able to maintain normal elimination habits. ...If left unrecognized, constipation can lead to fecal impaction in which stool blocks the intestinal lumen. If a patient is constipated, you will likely administer enemas or digitally remove impacted stool ...Constipation has shown to be a side effect of opioid use, decreased mobility, and changes in fluid and diet intake ..." 1. Resident #30 Resident #30 was admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED]. According to the [MEDICAL CONDITION] Foundation, Waste Management as You Age, www.msfocus.org/article-details.aspx?articleID=85d <http://www.msfocus.org/article-details.aspx?articleID=85d>, (8/2012): "Constipation is by far the most common issue in ... people with MS ... Constipation can be exacerbated by the lack of mobility, weak abdominal muscles, and inadequate hydration ...Medications can also cause constipation, including narcotics, iron, calcium, antidepressants, and [MEDICATION NAME] agents ... " Review of the 10/26/13 Minimum Data Set (MDS) revealed the resident was severely cognitively impaired, dependent on staff for activities of daily living (ADLs) except eating, and incontinent of bladder and bowel. 2. Failure to assess bowel status and care plan interventions to prevent complications Review of a 2/30/13 Evaluation for Bowel and Bladder was incomplete; the bowel assessment section of the form was void of documentation on laxative use, description of bowel patterns, and contributing factors including neurological conditions. Review of the resident's care plans revealed there was no care plan that addressed the resident's bowel elimination. Further, the approaches for all care plans were reviewed, and there were none that addressed her risk for constipation. 3. Failure to implement orders and/or facility protocol to prevent bowel complications. a. Orders and expectations Review of the resident's admission orders [REDACTED] -[MEDICATION NAME] (laxative) 8.6 milligrams (MG), two tablets by mouth twice daily as needed for constipation -[MEDICATION NAME] (stool softener) 100 MG by mouth twice daily as needed for constipation -[MEDICATION NAME] (laxative) 5 MG [MEDICATION NAME] coated tablets x2, by mouth daily as needed for constipation -Fleet Enema (for evacuation of colon) per rectum, once daily as needed for constipation not relieved by suppository Review of the facility's "Bowel Protocol In-Service," (undated and which serves as the facility's policy and procedure) provided by the Director of Nurses (DON) on 4/24/14 at 8:15 a.m. revealed: -Night shift to pull BM (bowel movement) report every night from (computer software program). -No BM x3 days/9 shifts: Resident is placed on Bowel Worksheet to receive oral laxatives. No BM x4 days/12 shifts: Resident is placed on Bowel Worksheet to receive suppository. No BM x5 x days/15 shifts: Resident is placed on Bowel worksheet for enema. -Night shift provides day shift nurse with Bowel Worksheet during report. Day shift passes to evening shift with report. Day shift nurse assesses the residents who have not had a bowel movement documented x3 days and administers an oral laxative and other interventions as appropriate. Evening shift nurse assesses the residents who have not had a bowel movement documented x 4 and 5 days and administers a suppository, enema or other interventions as appropriate. -If anything abnormal noted on the assessment, a nurse's note with intervention/follow up needs to be documented. If a laxative is administered, it must be documented, along with the effectiveness of the medication. If a resident refuses interventions, it must be documented in the nurse's notes, along with a bowel assessment and other interventions tried. b. Failure to Evaluate and Administer PRN and Bowel Protocol Medications: Review of the certified nurse aide (CNA) kiosk documentation "Bowel and Bladder Detail Report" from 10/24/13 through 12/13/13 included the following: -10/26/13 - 10/30/13 = No BM x 4 days. The Medication Administration Record (MAR) for October 2013 listed the PRN orders above; however, none were documented as given during this time. Likewise, there was no evidence the facility bowel protocol was implemented. -11/05/13 - 11/10/13 = No BM x 6 days. The MAR for November 2013 listed the PRN orders above; however, none were documented as given during this time. Likewise, there was no evidence the facility bowel protocol was implemented. -11/16/13 - 11/22/13 = No BM x 7 days. The MAR for November 2013 listed the PRN orders above; however, none were documented as given during this time. Likewise, there was no evidence the facility bowel protocol was implemented. -11/24/13 - 11/28/13 = No BM x 5 days. The MAR for November 2013 listed PRN orders above; however, none were documented as given during this time. Likewise, there was no evidence the facility bowel protocol was implemented. -12/09/13 - 12/13/13 = No BM x 5 days. The MAR for December 2013 documented that [MEDICATION NAME] tablets were given on 12/9/13 and 12/12/13, and a one-time order for Milk of Magnesia (antacid) was administered on 12/10/13. The PRN order for the Fleets enema, [MEDICATION NAME] suppository and [MEDICATION NAME] were available, but none were given during this time. Likewise, there was no evidence the facility bowel protocol was implemented. During the time periods above, there was no documentation to show the resident's lack of bowel movements was communicated to the physician. There was no discussion of the resident's lack of bowel movements and no assessments of the resident during the periods of time above when bowel movements were not documented for successive days until 12/7/13. c. Development of Bowel Complications The Nurse's Notes were reviewed for 12/7/13, which included "Resident evidently complained of constipation on a.m. shift, had mineral oil enema administered ..." The results of the enema were not documented, and there was no documentation that the physician had been notified. The Nurse's Notes were reviewed for 12/9/13 at 12:30 p.m., which included " ...BS (bowel sounds) not present in all quadrants, abdomen slightly distended and resident is having discomfort when this nurse palpated stomach. This nurse gave [MEDICATION NAME] 5 MG (two) due to signs and symptoms of constipation. Resident is having poor appetite this shift for breakfast and lunch ..." The Nurse's Notes were reviewed for 12/9/13 at "2-10" (p.m.), which included "Resident not feeling well, poor appetite. Complains of pain when being turned and very stiff. Temperature 99.4 (degrees Fahrenheit) and 99.6 (degrees Fahrenheit) ...hypoactive bowel sounds, [MEDICATION NAME] given on day shift ..." There was no documentation that the physician had been notified. The Nurse's Notes were reviewed for 12/10/13 at 1:00 p.m., which included "Resident continues with distended, firm abdomen. Bowel sounds hypoactive today. Resident has poor appetite and has complaints of discomfort when palpating abdomen. NP (nurse practitioner) notified and aware and will assess resident today ..." The Doctor's Progress Notes were reviewed for 12/10/13 at 3:30 p.m., which included "Report of increased pain, low grade fever, abdominal distention, decreased appetite ...Admits to pain, points to left lower anterior rib ...admits to poor appetite. Unsure when last BM ...Abdominal distention ...rule out bowel obstruction ...Plan: Send to ER (emergency room ) for increased GI (gastrointestinal) distention, pain." The note was written by the nurse practitioner. (See below; the resident was not transferred to the hospital until 12/13/13) The Physician's Telephone Orders were reviewed for 12/12/13 at 6:20 p.m., which included "If no BM verified by tomorrow a.m. and/or resident complains of abdominal pain or increased back pain, call (primary care physician) for order for ER evaluation." The Physician's Telephone Orders were reviewed for 12/13/13, which included "Non-Emergency transfer to (local hospital) ER via ambulance. Diagnosis: [REDACTED]." The (local hospital) Emergency Department Report dated 12/13/13 read in pertinent part that the resident reported no bowel movement "in many days" with some generalized crampy abdominal pain for the last several days ..." Her primary [DIAGNOSES REDACTED]. d. Physician interview On 4/23/14 at 2:46 p.m., the primary care physician for resident #30 at the time of the fecal impaction was interviewed. The physician was informed of the findings above regarding the CNA kiosk documentation (eight periods of time when the resident had gone 4 to 7 days without a bowel movement). The physician stated: -"I didn't know that she was going for days without having a bowel movement. I let the nurses do their work and figure they follow the bowel movements there ...If (a resident) is not having a bowel movement, then they need to call me, and there is something more we need to try. -My expectations are that they follow the bowel movements; that they are the managers of bowel movements because that cannot be managed by someone who is not there. There are PRN orders and a bowel protocol in place and they need to follow them." She agreed the bowel care that was provided to resident #30 did not meet her expectations and agreed a plan of care for constipation should have been in place for resident #30. She said she was unaware the resident did not have a care plan for this. 3. Change in status after readmission a. Hospice 12/23/13 and new medication orders, increasing risk for bowel complications The Physician's Telephone Orders dated 12/23/13 included: "1) Admit to Hospice, 2) Routine Hospice Medication: [MEDICATION NAME] 5mg/ml (milliliter) 0.25-1ml every 2-4 hours PRN pain/shortness of breath, [MEDICATION NAME] 2mg/ml every 2-4 hours PRN anxiety/shortness of breath, Hyosyne .125mg/ml, 1-2 ml sublingual as needed for secretions, Tylenol 650mg per rectum every 4-6 hours PRN pain/fever." According to "Saunders Nursing Drug Handbook 2014," (2014), the newly ordered Hospice medications have the following side effects: -[MEDICATION NAME] (opiate [MEDICATION NAME]), page 799: " ...Constipation ..." -Hyosyne (antimuscarinic), page 579: " ...Constipation ..." b. Continued facility failure to take steps to prevent bowel complications (1) Notwithstanding the resident's history of fecal impaction 12/13/13, and the addition of new medications with the potential for constipation, no care plan was developed instructing staff on interventions to promote to prevent constipation and other bowel complications. (2) Review of the CNA kiosk documentation "Bowel and Bladder Detail Report" from 12/13/13 through 4/3/14 included the following: -03/14/14 - 03/20/14 = No BM x 7 days. The MAR for March 2014 listed PRN orders for [MEDICATION NAME], and Fleets enema were available, but none were given during this time. There was no documentation in the Nurse's Notes that the physician was notified. -03/23/14 - 03/28/14 = No BM x 6 days. The MAR for March 2014 listed PRN orders for [MEDICATION NAME] suppository and Fleets enema were available, but none were given during this time. On 3/27/14, an attempt was made to give the resident Milk of Magnesia, but she refused. There was no documentation in the Nurse's Notes that the physician was notified. -03/30/14 - 04/03/14 = No BM x 5 days. The MAR for March and April 2014 listed [MEDICATION NAME] suppository and Fleets enema were available, but none were given during this time. --On 3/30/14, a routinely scheduled dose of [MEDICATION NAME] was not administered at 8:00 a.m. as ordered, and there was no documentation explaining the omission. --On 3/29/13 and 3/30/13, a routinely scheduled dose of [MEDICATION NAME] was not administered at 8:00 a.m., as ordered, and there was no documentation explaining these omissions. --On 4/2/13, a routinely schedule dose of [MEDICATION NAME] was not administered at 8:00 a.m. as ordered, and there was no documentation explaining the omission. --On 4/3/14, a routinely schedule dose of [MEDICATION NAME] was not administered at 8:00 a.m. and 12:00 noon as ordered, and there was no documentation explaining these omissions. There was no documentation in the Nurse's Notes that the physician was notified of the omitted routine medications above. The MAR for April 2014 included a routinely scheduled order for [MEDICATION NAME] 8.6 mg by mouth three times daily, for a [DIAGNOSES REDACTED]. There was no documentation the physician had been notified that the medication had not been given. (The DON per interview on 4/23/14 at 3:06 p.m. explained if a medication is scheduled to be given and it is circled on the MAR or is blank, it was refused or it wasn't given. She confirmed that refusals "should be documented on the back of the MAR.) 4. Staff interviews and action taken during and after survey a. Interviews On 4/23/14 beginning at 9:25 a.m., the MDS Coordinator was interviewed and provided 'worksheet' each night shift nurse completes if no bowel movement has occurred in three days. She said it is up to the nurse manager of each unit to make sure that at the end of each shift there was follow through and make sure a laxative was given. On 4/23/14 at 1:08 p.m., the licensed practical nurse (LPN) who routinely cares for resident #30 was interviewed. He explained that now that the resident is on Hospice, the goal is to keep her comfortable. When she refuses medication for constipation once or twice, he doesn't push the issue. On 4/23/14 at 3:06 p.m., the DON was interviewed. When asked how the facility staff addresses constipation she stated, "We will give them their PRNs and do assessments as needed ...We monitor bowel patterns and then provide PRN medications to try to have them have a bowel movement. If a PRN is not working, I would expect them to notify the physician and complete assessments." For residents with a history of a fecal impaction, she said, "There should probably be a change in medications to make sure they don't run into that same scenario. We normally would encourage fluids, monitor what they are doing, how their bowels are doing through those reports, to see if they fall on that list again. As an IDT (interdisciplinary team), we monitor their quarterly assessment and look at anything going on." The DON agreed that residents with a [DIAGNOSES REDACTED].#30 should have a care plan that addressed that. She stated "If they have had a fecal impaction, then I would expect there to be a care plan." She said the unit managers and MDS coordinator were responsible for initiating care plans. b. Actions taken during survey (1) On 4/23/14, during the survey, the DON provided the following care plan that identified the following problems, goals and approaches: -"Alteration in bowel function: Potential. Episodes of constipation related to decreased mobility, disease process-MS, resident has history of fecal impaction, resident is on hospice-continued decline is expected." -The goal was that "(Resident #30) will have adequate bowel elimination with soft, formed stool at least every 3-5 days through next review ..." -The approaches included "Encourage fluids, Administer medications as ordered and observe for side effects and effectiveness, Encourage activity within ability, Observe for bowel pattern to ensure adequate bowel elimination ...Notify MD as indicated ...Complete abdominal assessment with complaint of constipation, Notify medical doctor (MD) as needed, Document refusal of scheduled and PRN (as needed) medications ...) On 4/23/14 at 4:46 p.m., the DON stated "I made a care plan for her for constipation because I agree that she needed one." (2) On 4/24/14 at 8:15 a.m., the DON provided a document titled "InService Monthly Attendance Form," dated 4/23/14 and 4/24/14, which included the course title "Bowel Protocol/Procedure." The form was attached to the "Bowel Protocol Inservice" and had the signatures of 15 staff members. It did not identify the disciplines of the staff members. The DON stated "We did everything we could do to prevent it (fecal impaction) from happening." c. Actions taken after the survey exit (4/24/14) On 4/28/14, the facility provided documentation titled "Doctor's Progress Notes, Chart Review," dated 4/25/14. The documentation included "Assessment of care: After careful review of chart including nursing notes, MAR and nurse practitioner's evaluation, I believe the care rendered at the facility was appropriate and the eventual outcome, the need for manual disimpaction, could not have been prevented." This documentation was provided by the physician (see above), who provided the interview on 4/23/14 at 2:46 p.m. and agreed the bowel care that had been provided to resident #30 did not meet her expectations. B. Diabetic Management B. Diabetic Management 1. Review of the facility policy and procedure for Diabetic Management last revised on June 2008, included instructions to staff on addressing [DIAGNOSES REDACTED] (identified in the policy as a blood glucose level is below 70 mg/dl) when the resident is presenting with signs and symptoms of [DIAGNOSES REDACTED]. Instructions included: -Reassess blood glucose levels after 15 minutes; -Notify the physician of abnormal blood glucose test results, symptoms exhibited and interventions implemented; and -If food is given (if more than 30 minutes until the next meal), recheck the blood glucose level 15 to 30 minutes after food is consumed to ensure maintenance of acceptable range. 2. Resident #111 a. Resident status Resident #111, an [AGE] year old female, was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. Care plan review revealed the resident had potential for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to a [DIAGNOSES REDACTED]. -Goal - the resident's blood sugar ranges will remain stable within the physicians prescribed parameters of 80 to 400 over the next 90 days. -Approaches - staff was to observe for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION], provide finger stick blood sugars as ordered, and provide sliding scale insulin as ordered. Staff will notify the physician as indicated. Review of the computerized physician's orders read in part: -Humalog insulin by sliding scale coverage administer subcutaneous Humalog insulin if blood glucose less than 200 no insulin, 201 - 250 administer 2 units before meals and administer 2 units if at bedtime, 251 - 301 administer 4 units if before meals and administer 3 units if at bedtime, 301 - 350 administer 6 units if before meals and administer 4 units if at bedtime, 351 - 400 administer 8 units if before meals and administer 5 units if at bedtime. Dated 5/30/12 -For blood sugars less than 80 or greater than 400 call the physician. Dated 5/30/12 b. Failure to follow physician orders and facility policy in managing the resident's diabetes (1) April 2014 During the first 23 days, documentation on the Blood Glucose Tracking/Sliding Scale Insulin Administration Record recorded 13 days out of 23 that the blood glucose levels were out of the parameters ordered by the physician (see above) with low blood glucose levels ranging from a low of 60 through 77. -There was no documentation the physician being notified per nurse's notes and MAR review. -There was no documentation what treatment the nurse provided. -There were no documented rechecks of the blood glucose. On 4/11/14 at 5:00 p.m. the blood sugar was recorded to be 347. There was no documentation that sliding scale insulin was provided. On 4/22/14 at 5:00 p.m. the blood glucose level was recorded to be 422. The nurse documented she administered 6 units of Humalog Insulin subcutaneous but there was no documentation she called the physician or provided a follow-up blood glucose check. (2) March 2014 On 3/2, 3/6, 3/12, and 3/16/14, the Blood Glucose Tracking/Sliding Scale Insulin Administration Record was void of morning blood glucose checks. There was no documentation explaining the omission. On 8 morning shifts, the blood glucose check was recorded to be below 80 with lows being 69 mg/dl through 79mg/dl. -There was no documentation the physician was notified. -There was no information that the nurse provided treatment for [REDACTED]. On 3/28/14, the nurse documented on the back of the facility form Blood Glucose Tracking/Sliding Scale Insulin Administration Record she provided the resident orange juice at 7:00 a.m. for the blood glucose level of 51 mg/dl. The nurse documented that she rechecked the blood glucose level at 7:15 a.m. (15 minutes after the orange juice). The resident's blood glucose level was 90 mg/dl at 7:15 a.m. There was no documentation to indicate that the nurse had notified the physician of the resident's low blood sugar at 7:00 a.m. (3) February 2014 On 2/21/14, the Blood Glucose Tracking/Sliding Scale Insulin Administration Record was void of documentation for the morning blood glucose check. The nurse's notes and the MAR record was void of information related to the blood glucose not being recorded. On 2/10/14 the morning blood glucose check was recorded to be 59 mg/dl at 7:00 a.m. The nurse documented that she provided orange juice and rechecked the blood glucose to be 87 mg/dl. (The record was void of the time of the recheck.) There was no documentation that the physician was notified about the 59 mg/dl blood glucose level. On four morning shifts (2/9, 2/11, 2/12, and 2/26/14) the 7:00 a.m. blood glucose levels were low at 70 to 78 mg/dl without documentation that the nurse treated the blood glucose level or that the physician was notified. c. Interviews On the afternoon of 4/24/14, the resident was interviewed about her diabetes and management of abnormal blood glucose levels. She said she can usually tell when her blood glucose levels are low. As she has trouble concentrating, feels weak, and gets jittery. She said when her blood glucose levels are low the nurse gives her orange juice or a supplement to drink. She said sometimes, but not always, the nurses recheck her blood sugar after she has orange juice or the supplement. On the evening of 4/24/14, the DON was interviewed about management of blood glucose levels. The DON said she was not aware of the issue related to low blood glucose levels. -She said she would have expected that the nurse follow the physician's orders to call the physician for blood glucose level of less than 80, per the physician's order. -She said the nurse should document on the back of the MAR any treatment provided for low blood glucose levels, and she would expect a recheck after 15 minutes to be documented on the back of the MAR. She said the nurses should document in the nurse's notes when the physician is informed of abnormal blood glucose levels and the treatment provided. -She said the facility policy and procedure for diabetic management should be followed. She said there would be reeducation for the nursing staff related to diabetic management.

Based on resident and staff interviews and record review, the facility failed to provide sufficient nursing staff to meet the needs of the residents. This failure contributed to resident #143 experiencing incontinence and had the potential to affect all residents on all four halls/neighborhoods in the facility. The findings included: 1. Cross-Reference to F241 Dignity and Respect; F309 Care and Services related to Behavior Management, Bowel Management and Diabetic Management; F311 Activities of Daily Living to Attain or Maintain Highest Practicable Physical Well-Being; and F312 Activities of Daily Living for Residents who require Extensive to Total Assistance. 2. Expectations According to the facility "Nursing Staffing" policy, dated 6/2007, provided by the nursing home administrator (NHA) on 4/24/14, it required in pertinent part the following: "Nursing service is provided by number and type of personnel to ensure that each resident: -Receives rehabilitative nursing care as needed; -Receives proper care to maintain their highest level of functioning (prevent decline in function or poor clinical outcomes); -Is kept clean, comfortable, and well-groomed; -Is protected from accidents, injury, and infection; and -Is encouraged, assisted, and trained in self-care and group therapy." 3. Resident Care Needs According to the Resident Census and Condition Report provided by the director of nursing (DON) on 4/21/14, the facility census was 122. Resident needs were documented as follows: -For bathing, 110 residents needed assistance by one or two staff, and five residents were dependent; -For dressing, 75 residents needed assistance, and five were dependent; -For transferring, 75 residents needed assistance, and five were dependent; -For toilet use, 75 residents needed assistance, and five were dependent; -For eating, eight residents needed assistance, and five were dependent. Regarding bowel/bladder status and mobility: 48 residents were occasionally or frequently incontinent of bladder and bowel; three residents were bedfast all or most of the time; 77 residents were in a chair all or most of the time; and 17 residents had contractures. Regarding mental status: ten residents had behavioral healthcare needs, and 50 residents had dementia. Regarding special care: seven residents received hospice care, four residents were on [MEDICAL TREATMENT], six residents received ostomy care, and two residents received tube feedings. 4. Resident Interviews Alert and oriented residents who resided on Sunflower, Junction Creek, and Mariposa Halls, interviewed 4/21/14 through 4/24/14, said the facility did not have sufficient nursing staff to ensure they did not have to wait too long for the care and services they needed. Resident comments included the following: -"There is not enough staff - they have too much to do." (Mariposa Hall) -"I think they need more CNAs (certified nurse aides) on this floor, maybe five more every shift. My longest call light wait was 30 minutes." (Junction Creek Hall) -"I feel they could use more CNAs throughout the facility. It's hard to find CNAs during evening hours when I'm getting ready for bed. I was left on the toilet for over 30 minutes once." (Sunflower Hall) -"We need a new CNA on this hall. When there are only two (CNAs) on, it is really hard ... An extra person would be good." (Mariposa) -"They need more help ... We could use two more CNAs in this hall, all shifts." (Sunflower) -"I think they could use more CNA help on all shifts." (Junction Creek) -"I have had to wait 25 minutes for my call light to be answered." (Junction Creek) -Resident #143 was interviewed on 4/23/14 at 1:35 p.m. She said she had experienced incontinence because there was "not enough staff" and call light response was delayed. When asked how she felt about this, she said, "I don't like it." -The resident said she had reported her concerns to the director of nursing (DON) and her former ambassador, and "Their response is, 'Oh, we have plenty of help.' I ask for help and they turn my light off and say, 'I'm the only one on the floor - you'll have to wait.' I do know there's a lot of people here, so one person can't do everything." -"I want a shower every day and they (CNAs) said, 'You're not getting a shower every day - that's just not going to happen.' ... They say I'm an hour-long shower and I have to wear ted hose, so that takes more time to get me dressed. I'm not happy about it either. I tell them, 'I don't like (ted hose) any better than you do.' " -"When I have to go to the bathroom, there have been times - this irritates me, but it doesn't matter if it irritates me - I have to get out of bed with the sit- to-stand (lift), go to the toilet with a sit-to-stand, get back into bed with the sit-to-stand. It irritates me. Just the other day I had one of those toilet risers and I needed to poop. I put my bell on, but sometimes it takes them awhile to get back, so I put myself on the toilet, and I did have a BM (bowel movement), but I ended up getting some on my diaper before I got on the toilet, so I had to call for help. That's why I say I think they need more help, but they don't think they do ...what do I know?" -"Now they have me labeled as noncompliant. When I tell them I need the bathroom, they say, 'Oh, (your incontinence brief is) not even wet ... Once you pee in it you'll pee again and again and again, but their theory is, 'It holds more.' That's great, just what I want to do, take off a ten-pound diaper. It's not even that exciting wearing a diaper. And I'm on [MEDICATION NAME] ... I don't like sitting in pee - so what if it holds more? I don't like it." -"Going to the bathroom is a hassle; it's a really big hassle." -"Sometimes it will be 15-20-30 minutes for call light response. Sometimes they don't come back." -"I'm a two-person assist. There have to be two people here before they can take me to the bathroom. Sometimes they turn my call light off, go to find someone and they can't find anyone. I think I should just leave the call light on until two people get here." Resident #82 was interviewed at 2:44 p.m. on 4/23/14. She said, "I think they could use more staff. Everyone gets rushed. The girls try real hard to get things done. Sometimes the rushing is ... just because we (residents) don't move as fast as we used to ... We mentioned at resident council that we could use a third CNA on this floor. We could use one days and evenings. At night there's just one nurse and one CNA on Mariposa. I think it takes longer occasionally for them to get to somebody, but they've already been pretty good to me. I brought it up in resident council and (the nursing home administrator/NHA) said she was going to check to see if they were able to provide that third CNA on Mariposa D Hall." Resident #80 was interviewed at 3 p.m. on 4/23/14. She said, "I think they try really hard with the budget that they've got to work with. I know it all comes down to budget and money allocations and everything. I need two-person assist. Sometimes I wish they had more staff. I can't tell you when (what shifts) ... I don't feel like I do without, I just have to wait a little longer. They always do what I need ... When I need (assistance) I ask for it and I get it. Only like once or twice in a very long time is it a problem, rarely. Because I'm a go-getter if something's happening. Staffing has been brought up in resident council, and they keep working on it. It's still a problem. It sure would be nice to have more staff at certain times of the day. They're really good to all of us. We just need more. But if they added more staff would it be too expensive for people to live here?" 5. Staffing Schedule According to the "Daily Nursing Schedule," reviewed 1/1/14 through 4/23/14, staffing expectations were as follows: Junction Creek Rehab Hall: 29 residents resided on this hall, four of whom needed two-person assist. Two nurses and two CNAs on all shifts. Sunflower Hall: 45 residents resided on this hall, nine of whom needed two-person assist. Two nurses and four CNAs on day and evening shift. One nurse and two CNAs on night shift Mariposa Hall: 37 residents resided on this hall, nine of whom needed two-person assist. Two nurses and three CNAs on day and evening shift. One nurse and one CNA on night shift [MEDICATION NAME] Hall (secure unit): 11 residents resided on this hall One nurse and one CNA on day and evening shifts, with a nurse from Mariposa passing medications. One nurse or CNA on night shift with staff from Mariposa relieving during breaks. One restorative CNA was scheduled for the facility, on day shift. No bath aides were noted on the schedule. Actual Staffing Review of the staffing schedules revealed nursing staff called off, did not complete their shifts, or did not sign in, leaving the facility short-staffed on a daily basis from 1/1/14 through 4/23/14. There was no restorative CNA until 4/2/14. 6. Staff Interviews Staff members, interviewed on all shifts and all halls, made the following comments about staffing: -"On Mariposa, there are two nurses and three CNAs, one on each side and a float, if we're fully staffed. There are ten residents who need two-person assist. If you have three it's enough. With two, you're cutting things back. Now there are more heavy care residents, and we need that third aide. If we had a third aide, I wouldn't be here this afternoon." -"I'm sorry to say, but residents do without ... You have to hurry, do your thing, ship them out the door, you don't have time to talk things through with them, you just have to get things done. Sometimes I'd rather be the one to brush their teeth and make sure it's done, but when you're not staffed, you get them to do it themselves, or they wait until the next shift." -"When we are short staffed, residents do without grooming and incontinence care, help to the bathroom, laying them down, answering their call lights, getting their food to them. Those things suffer." -"Sometimes we have anywhere from four to seven room trays down here. Residents in (the assistance) dining room wait 45 minutes to an hour to be served. It makes it worse when kitchen staff gets a little short too." -"I know we need a third person (on Mariposa). We need to be staffed that way, and up front, too (Sunflower and Junction Creek); they should have four CNAs at all times. It's heavy care up there." -"Some of the nurses will let the call lights go off and ignore them ... Other staff members rarely answer call lights." -"We don't have enough staff most of the time. Each resident takes a lot of time. If they want quality of care they have to staff at least three, but most of the time it's two. Lately they say we can't do too much overtime ... They tell us to go home, which leaves two until the next shift. I've worked a double shift today ... Within two weeks I've done that about seven times. I think they staff extra because you all are here (survey)." -"Residents are doing without quality time, going to bed when they want, changing and toileting. They need a waitress to take orders (in the dining room), but we're getting up residents and they're saying, 'Go over there and start taking orders.' Sometimes I like it when (surveyors) are here because everybody pitches in." -"They need four people up there on Sunflower, three on Mariposa, one plus a nurse on [MEDICATION NAME] (secure unit), probably two or three on (Junction Creek) depending on census. Usually they move us around to cover. Residents know when they're supposed to get up and they ask, 'Where are you?' and we have to tell them we're going as fast as we can. They like showers in the morning and we have to have the third aide to give showers. It would be awesome to have bath aides but we have to do everything. Our main concern is short staff. They keep having CNA classes here but they don't stay." -"We're always short and then we have to go run over there, come back over here ... (One nurse will) just tell us a light's going off (instead of answering it herself). You're helping one resident and she'll want you to help another." -"The other CNAs (on the opposite side of Sunflower) are supposed to help if we're wrapped up, but they don't. When we don't have enough staff they put the residents up front and around the nurses' station so the nurses can watch out for them. Some of them will just stand up and try to start walking." -"Here and there, yes we're finding residents incontinent as a result (of short staffing). We're having more falls, residents are doing without incontinence care and toileting, turning and repositioning ..." -"I did a double yesterday and I'll do a double (shift) today. We don't have anybody. It gets to you when the nurses yell at you even though you're trying so hard to do your work ... " -"I help out wherever they're short ... Restorative comes and helps sometimes, too. For CNAs we need two for each hall because it's teamwork, and you get done better and faster. When there are only three CNAs? Oh, gosh. It's very difficult ... Getting stuff done will take longer and it will take me until the end of shift to actually finish ... Then residents will try to to talk to me, but I say, 'I'm sorry, I'll have to talk to you in the dining area.' " -"Sometimes we're short on staff - sometimes (residents) have to wait a little while till we get somebody out of the restroom and somebody in. Showers take more time ... Residents get help but it takes a little bit more time ... I see people working five days a week, working doubles - I don't know how they do it." -"When there are only two of us and when we're both (assisting a resident who needs two-person assist) ... we can't hear the call light. But I was told in training that the nurses are supposed to go check on the light or tell them to wait a minute and then come to us and let us know. But ... I think we'd just have to let them sit first. That's what happened to me and (another CNA) this morning. We were helping (a resident) and the call light in (another resident's) room was going off. (The first resident) was sitting strapped in the lift, sitting in his wheelchair. They told us, 'If nobody gets to that call light right away, if they fell or whatever, you always have to get to it,' and I know the nurse was doing (medication pass) this morning." -"Lately we've been short staffed ... When we're short staffed the biggest thing is showers. If we can't do it, we always try to tell the next shift. If they can fit it in. And it's happened before. One we couldn't do. We told the nurse and she was pretty upset, but this hall is one of the busiest ones. We try our best." -"Sometimes they take people straight to activities from the dining room and sit them in there. And they'll see them wet and let us know. ... The last one I had was like two weeks ago. ... They always try to do their activities maybe an hour after lunch and then we have time to get them situated, fit their showers in. This morning (a resident) wanted a shower but we were too busy, and I said, 'If we can get all our morning showers in.' We're short staffed and we do what we can for them." -"I feel we're short staffed everywhere, all over the building. I see residents waiting a little longer than maybe they should ... Only two CNAs on my hall and over 20 people for those two girls." -"There are times where there are only three CNAs down here, and I know it gets hard on them ... There are residents who get angry because they're not up. They could use more and we're all short staffed right now." -"There are often three (CNAs) on Sunflower where I work. We're supposed to have four, so we're rushing around trying to get things done, trying to get showers done, but often cannot get to call lights on time. Incontinence as a result? Yes. (Resident #143) is one of our main ones ... We have been short staffed most of the time within the last four months." (See resident interview above.) The NHA was interviewed at 3 p.m. on 4/24/14. She said they were constantly assessing their staffing situation, and constantly advertising, and added, "That is no secret." She said they planned to add staff when the dining committee made adjustments to the dining zones to assist residents in a more timely manner. The director of nursing (DON) was interviewed at 4 p.m. on 4/24/14. -The DON said, "I think we have open communication with our staff. We monitor them throughout the day, go through the training process with them ... We've had concerns of people (staff) being rough, moving too fast with cares, that type of stuff." She said they addressed those concerns as they were reported and identified. -The DON said they addressed staffing concerns brought to their attention by resident council by "reviewing staffing, census, acuity, we're trying to have three on that unit (Mariposa D Hall). At the same point they still have two nurses. My expectation is that everybody chips in. We look at our staffing patterns, look at the residents, if we have more residents we need more staff to take care of those residents. We have nurses on the floor who help out - all staff are expected to answer call lights."

Based on record review and staff and nurse practitioner interview, the facility failed to provide sufficient fluids to maintain adequate hydration for one of 24 sample residents (#6). Specifically, the facility failed to adequately assess, care plan, monitor for, and recognize the development of dehydration in resident #6. These failures contributed to the resident's hospitalization for treatment of [REDACTED]. The findings include: I. Professional References regarding acute [MEDICAL CONDITION], dehydration and [MEDICAL CONDITION] A. Acute [MEDICAL CONDITION] Mayo Clinic's website, "Kidney failure, acute," MayoClinic.com, states in pertinent part as follows: "Acute kidney failure is the sudden loss of your kidneys' ability to perform their main function of eliminating excess fluid and salts (electrolytes) as well as waste material from your blood. When your kidneys lose their filtering ability, dangerous levels of fluid, electrolytes and wastes accumulate in your body. "Acute kidney failure, which is also called acute kidney injury, develops rapidly over a few hours or a few days. Acute kidney failure is most common in people who are already hospitalized , particularly in critically ill people who need intensive care. "Acute kidney failure can be fatal and requires intensive treatment. However, acute kidney failure may be reversible. If you're otherwise in good health, you may recover normal kidney function. "Signs and symptoms of acute kidney failure may include: Decreased urine output, although occasionally urine output remains normal; Fluid retention, causing swelling in your legs, ankles or feet; Drowsiness; Shortness of breath; Fatigue; Confusion; Nausea; [MEDICAL CONDITION] or coma in severe cases; Chest pain or pressure. "Diseases and conditions that may slow blood flow to the kidneys and can lead to kidney failure include: Blood loss, Blood pressure medications, [MEDICAL CONDITIONS], Severe dehydration. "Potential complications of acute kidney failure include: - Permanent kidney damage. Occasionally, acute kidney failure causes permanent loss of kidney function, or [MEDICAL CONDITION]. People with [MEDICAL CONDITION] require either permanent [MEDICAL TREATMENT] - a mechanical filtration process used to remove toxins and waste from your body - or a kidney transplant to survive. - Death. Acute kidney failure can lead to loss of kidney function and, ultimately, death. The risk of death is highest in people who had kidney problems before experiencing acute kidney failure." B. Dehydration According to the website: nursinghome.org, the following identifies the specific needs for adequate hydration and the signs and symptoms of dehydration in the elderly population in pertinent part: "Next to oxygen, water is the nutrient most needed for life. A person can live without food for a month, but most people can survive only three or four days without water. All of us start life in a watery cradle of amniotic fluid and to this day remain water's creature. Water makes up 85% of the blood, 70% of the muscles and about 75% of the brain, and is present in and around each of our cells. In the body, water acts as a solvent, coolant, lubricant, and transport agent. It's needed to regulate body temperature, carry nutrients, remove toxins and waste materials, and provide the medium in which all cellular chemical reactions take place. Fluid balance is vital for body functions and adequate blood volume. A significant decrease in the total amount of body fluids leads to dehydration. Dehydration occurs when the amount of water you take in is less than the amount you are losing. Fluids can be lost through the urine, skin, or lungs. Along with fluids, essential electrolytes, such as sodium and potassium, are also perilously depleted in a dehydrated individual." "Dehydration and the Elderly: Elderly individuals are at a heightened risk for dehydration because their bodies have a lower water content than younger people. An elderly person weighing 150 pounds has about seven liters less water than a young person of the same weight. As a result of this lower water content, elderly individuals can become dehydrated more quickly. Because of visual, cognitive, or motor impairments, elderly persons may have difficulty getting fluids for themselves. They also may have only a muted perception of thirst. Unfortunately, many symptoms of dehydration do not appear until significant fluid has been lost. Practitioners in the field know that dehydration can happen very rapidly, in less than an eight-hour shift. The consequences of dehydration among the elderly can be life threatening and the symptoms are alarmingly swift. Nursing facility residents are particularly at risk for dehydration." "Signs and Symptoms of Dehydration: It is important that staff members be able to recognize the signs and symptoms of dehydration to promptly assure correction and prevention of complications. Without timely correction, dehydration can lead to decreased functional ability, predisposition to falls due to orthostatic [MEDICAL CONDITION], constipation, predisposition to infection, and death." According to the chapter on "Dehydration: Prevention and Recognition" published by Long Term Care Educator, staff members should be alert to the following symptoms: "Confusion can be an early sign of dehydration. Caregivers who work regularly with a resident may be best able to detect subtle changes in mental status that are present when dehydration develops. Dehydration should be one of the first problems suspected when a resident has a sudden change in mental status. ? Poor skin turgor (elasticity) accompanies dehydration, but this can be a difficult sign to assess because most older residents have an age-related reduction in skin turgor under normal circumstances. If skin turgor is to be used in assessing for dehydration, the best areas to test are the skin over the sternum and forehead because these areas maintain better skin turgor than other areas. Generally, skin will feel warm and moist with dehydration. ? An inspection of the oral cavity can yield useful insight into a resident's hydration status. A dry oral mucosa and dry furrowed tongue are good indicators of dehydration. Staff should be cautioned that residents who are taking certain medications (such as [MEDICATION NAME] drugs) may have dry oral mucosas in the absence of dehydration. ? An assessment of vital signs will reveal a decrease in blood pressure and increase in pulse when dehydration is present. ? A review of bowel elimination patterns can assist in assessing dehydration. Recent diarrhea can offer an explanation for a dehydrated state, while constipation is a common occurrence when dehydration exists. Likewise, bladder elimination patterns can provide useful insights: excess voiding can contribute to dehydration while scanty output can indicate insufficient fluid intake. Concentrated urine is a common sign. ? Because such a large percentage of the body is comprised of fluid, weight loss is often present. If any of the above symptoms are noted, steps should be taken as soon as possible to further assess the resident for dehydration and take corrective action as necessary." C. [MEDICAL CONDITION] According to the Center for Disease Control website at CDC.com, "[MEDICAL CONDITION] (C.difficile) causes a potentially life-threatening antibiotic-associated diarrhea and [MEDICAL CONDITION]. The organism produces a spectrum of disease, ranging from simple and self-limited diarrhea to its most advanced and characteristic form, pseudomembranous [MEDICAL CONDITION]. It is well recognized as the major, if not the only, important cause of infectious diarrhea that develops in patients/residents following hospitalization or admission to a long-term care facility. Clinical symptoms include: watery diarrhea, fever, loss of appetite, nausea and abdominal pain/tenderness. Complications of [DIAGNOSES REDACTED]icile infections include: Dehydration. Severe diarrhea can lead to a significant loss of fluids and electrolytes. This makes it difficult for your body to function normally and can cause blood pressure to drop to dangerously low levels. "Kidney Failure: In some cases, dehydration can occur so quickly that kidney function rapidly deteriorates (kidney failure)." II. Resident #6 A. Facility Record Review Resident #6 was an [AGE] year-old male, readmitted to facility on [DATE], with [DIAGNOSES REDACTED]. The face sheet failed to code (ICD-9 434.91) the recent cerebro-vascular accident ([MEDICAL CONDITION], stroke) for which he was hospitalized prior to this re-admission. Minimum Data Set (MDS) Resident #6's admission minimum data set assessment (MDS), dated [DATE], revealed he was moderately impaired in cognitive skills for daily decision-making, required assistance with all activities of daily living except eating, his balance during transfers and walking was not steady and only able to stabilize with assistance, used a wheelchair and he was incontinent of bowel and bladder. Of note is that the MDS active diagnosis (section I) did not include a cerebro-vascular accident ([MEDICAL CONDITION] - stoke) for which he was hospitalized for [REDACTED]. He was coded to have no complaints of pain, his height was 5 foot 7 inches and his weight was 146 pounds and he was on a mechanically altered therapeutic diet. Care Plan The care plan for "nutrition", dated [DATE], included the following approaches: "1. Diet as tolerated, 2. Monitor weight/intake, 3. Diuretics as ordered." - There was no evidence in the record that the resident's intakes had been routinely monitored and recorded to ensure that he was receiving adequate fluids. The care plan for "risk for fluid deficit" related to dysphagia (difficulty swallowing) and refusing liquids, dated [DATE], included the following approaches: "1. Monitor vital signs as indicated, 2. Place fluids at bedside in resident's reach, 3. Provide ,[DATE] ounces of fluids at each med pass as tolerated, 4. Interdisciplinary referral - Speech Therapist, 5. Notify physician of change of status as indicated, 6. Monitor lab values as ordered, 7. Provide nectar thick liquids ordered by physician." - There was no evidence in the record that the care plan was updated after resident #6 developed severe diarrhea from [DIAGNOSES REDACTED]icile that would require more rigorous assessment, monitoring and interventions. Nutritional Therapy Review The medical nutritional therapy review, dated [DATE], revealed that he had full dentition, had swallowing impairments, his BUN was 16, creatinine was 1.1, and potassium was 4.1, he was on a diuretic and his fluid needs were estimated to be 2018 cc/day and his estimated intake was only 1440 cc/day. The assessment stated, "Resident's intake does not meet needs ... Also working with ST (speech therapy) on dysphagia with regular thin liquids as the goal." Nurses' Notes The nurse's notes included the following in pertinent part: - [DATE], 2:00 p.m. - 10:00 p.m., "Family in to visit this evening ... refused tray X3, refused alternate X2 - denied nausea and vomiting, diarrhea continues 2X this shift. Stated he was not hungry 'at all', family encouraged resident to eat. Total zero intake dinner. Fluids encouraged, resident accepted 300 cc. this shift." - [DATE], 10:00 p.m. - 6:00 a.m., "24 hour check. No new MD notes. Recent labs with change to plan of care. Critical labs reported to MD with change to [MEDICATION NAME] and potassium and new order for more labs." The nursing daily skilled summary notes included in pertinent part the following: - [DATE], 6:00 a.m. -2:00 p.m., "Pt (patient) has frequent loose stools. Sent for culture . . ." - [DATE], 6:00 a.m. -2:00 p.m., "Pt is [MEDICAL CONDITION] positive. Pt having frequent BM. Encouraged pt to drink more fluids . . ." - [DATE], 6:00 a.m. -2:00 p.m., "Pt. encouraged to drink more fluids ... " [DATE], 6:00 a.m. -2:00 p.m., "Patient sleepy ... Patient not having as much diarrhea. Patient encouraged to drink more fluids. . ." - [DATE], 10:30 a.m., "Patient being transported to (hospital) for eval on labs for dehydration/kidney function. Family notified and was sent by family nurse practitioner for facility." - This was the first reference to dehydration in the nursing notes. Medication Administration Record The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Encourage fluids Q (every) shift X 14 days secondary to [MEDICATION NAME] (antibiotic)." - Although there was documentation that each shift encouraged fluids until his transfer to the hospital, on [DATE], there was no evidence that his intake was measured or monitored for consuming less than the RD deemed necessary (see assessment above). Hospital Transfer Form The resident transfer form from the facility to the hospital, dated [DATE], cited "high creatinine and decreased responsiveness" as the reason for transfer. His blood pressure at time of transfer was ,[DATE]. Physician Discharge Summary The physician discharge summary with discharge, date of [DATE], included the following in pertinent part: "Final Diagnosis: [REDACTED]. "Provisional Diagnosis: [REDACTED]. "Condition on Discharge: Unstable - sent to (hospital) ED for ARF (acute [MEDICAL CONDITION]) and decreased responsiveness and [DIAGNOSES REDACTED]." Physician Orders The following relevant physician telephone and hand written orders were recorded: - [DATE], 12:00 p.m., "Encourage fluids ..." - [DATE], 9:45 a.m., "Send to ER for critical labs - acute [MEDICAL CONDITION] and [MEDICAL CONDITION]." physician progress notes [REDACTED]. - [DATE], "Assessment and Plan: 82 y/o male with [MEDICAL CONDITION], CAD,[MEDICAL CONDITION]- s/p admit for [MEDICAL CONDITION] exacerbation and stroke at (hospital) now here for rehab. Needs cardiology f/u for [MEDICAL CONDITION]. Pt has lost 16.6 pounds since admit here. . . " - [DATE], "Pt. with diarrhea, + [DIAGNOSES REDACTED]. Will Rx with [MEDICATION NAME] X 14 days." - [DATE], "PT director states family concerned with dehydration and decreased nutrition. RD notified and I will get labs ordered for tomorrow today with a UA to check specific gravity." - [DATE], 9:40 a.m., "Reviewed labs of [DATE] ... Observation: Resident sleeping. Aroused but lethargic ... Assessment: Acute [MEDICAL CONDITION] r/t dehydration. Plan: Send to ER." Intake and Output Records Intake and Output records were requested but none were submitted by the facility for review. B. Hospital Record Review A review of resident #6's most current hospital record was initiated at 8:20 p.m. on [DATE]. Resident #6 was admitted to hospital emergency department, on [DATE], and was transported via ambulance. His emergency room record recorded the following in pertinent part: "Impression: dehydration probable pre-[MEDICAL CONDITION] with azotemia (an elevation of blood urea nitrogen, BUN and serum creatinine), [MEDICAL CONDITION] (elevated potassium and supra-therapeutic INR (international normalized ratio) related to blood-clotting factors ... Will give initial 200cc [MEDICATION NAME] over ? hour then 180cc hour as appears clinically dry, apparent pre-renal ... [MEDICATION NAME] started [DATE] for C.diff . . .Patient complains of diarrhea. "Physical Examination: dry appearing, weak . . . lethargy, dehydrated ... dehydration secondary to [DIAGNOSES REDACTED]. "Per son, requests labs be drawn secondary to his concerns for dehydration, decreased activity, decreased responsiveness ... last 2 days staying in bed and questionable patient intake." History and Physical The hospital history and physical, dated [DATE], reported the following in pertinent part: "Chief Complaint: Dehydration with acute [MEDICAL CONDITION] and [MEDICAL CONDITION] diarrhea. "History of Present Illness: The patient is a chronically ill gentleman who was hospitalized here ... from [DATE]th to [DATE]th and then transferred to (the long term care facility). Initially he did okay there however, per his family, he developed diarrhea about four or five days ago. He subsequently had [MEDICAL CONDITION] testing done which was positive and he started treatment for [REDACTED]. He has become increasingly anorexic, lethargic, fatigued and seemingly dehydrated. His [MEDICATION NAME] and potassium dosing was lowered yesterday February 2nd. Despite that he has continued to do poorly and because of his dietary restrictions he has not really felt like eating and drinking much anyhow. He is on thickened liquids and puree diet. Per his part, the patient is very lethargic and somnolent but he does respond to my questions. He says he is not in any pain. He feels like he is dehydrated and he denies any active chest symptoms or [MEDICAL CONDITION] symptoms. He denies dysuria and so on although he is not a very effective historian right now. "Physical Examination. Vital Signs: His vitals have shown borderline low blood pressure. General: As noted, he is quite somnolent, withdrawn, ill-appearing and responsive but not very verbal. Head: Atraumatic, normocephalic. His pupils are reactive. TMs (tympanic membranes) and oropharynx are normal except he has very dry mucous membranes ... Diagnostic Data: Potassium - 5.3 High (normal 3XXX,[DATE].1 mmol/L), Creatinine - 2.8 High (normal 0XXX,[DATE].3 mg/dL), BUN - 99 Critical (normal ,[DATE] mg/dL)." "Assessment and Plan: 1. This patient presents with significant dehydration secondary to diminished oral intake both food and liquids and [MEDICAL CONDITION] associated diarrhea. He will be rehydrated with IV fluids tonight and we will re-obtain a speech therapy evaluation in terms of his aspiration risk and attempt to get him taking better nutrition by mouth. 2. Acute [MEDICAL CONDITION] secondary to #1. Again he will acutely get IV fluids tonight quite liberally and then we will cut back later as he is at risk for re-entering acute [MEDICAL CONDITION]. 3. History of significant heart failure with poor ventricular function. The patient's current heart failure medicines ... will be held given his dehydration . . . 4. Mild [MEDICAL CONDITION] secondary to volume depletion. Again IV fluids will be pushed. 5. The patient has had a recent stroke with right [MEDICAL CONDITION] and [MEDICAL CONDITION]. This thing (effects of stroke) apparently has improved but very difficult to evaluate him neurologically right now because of his very sick condition ..." C. Interviews The nurse practitioner, who worked with resident #6's attending physician, was interviewed at 1:56 p.m. on [DATE]. She stated, "I didn't know (resident #6) that well. The way I remember it, (the nursing staff) did not call me. I was in the nurses' station and the PT director was there. I overheard her say that (family) voiced concern to PT that (resident #6) was dehydrated. That was the first I had heard of it. So I ordered labs. If nurses had said this guy looks bad then I would have gone to see him. I didn't go and see him that day. The next day - I came in, looked at labs in computer, saw they were critical, looked at the resident and immediately sent him to ED (the emergency department) right then ... I knew he had [DIAGNOSES REDACTED] and was on [MEDICATION NAME] . Yes, I would expect them (the nurses) to be looking at his hydration status ... and I would expect them to initiate I&O (intake and output) as nursing intervention for assessment for dehydration. I haven't ordered I&O that frequently ... Even when I have asked for that (I&O) it is kind of a hard thing to get done here." The family interview was deferred out of respect for their loss, as resident #6 had recently expired in another facility. On [DATE] at 8:37 a.m., a licensed practical nurse (LPN) was interviewed. He stated, "C. diff. - what to look for? Obviously dehydration because that comes with the diarrhea ... also they are in isolation ... Document that we watch food intake of meals. Aides let us know how many episodes they have had. I would start intake and output - to monitor for dehydration ... Other symptoms to look for include dark colored urine, poor skin turgor, dry lips, dry oral cavity. If we observe that they are dehydrated, inform aides have aides push fluids, monitor I&O, notify MD, would document I&O and all monitoring efforts." The physical therapist (PT) was interviewed at 10:55 a.m. on [DATE]. The PT stated, "We were having a family meeting and I was one (staff member) left in the room. They (the family) started asking me medical questions about dehydration. So I told them that people on thickened liquids were at higher risk for dehydration ... the knowledge I had was from therapy standpoint. So I left the room and told the nurse at the desk and the nurse practitioner was there too, so I let her know what their (the family) concerns were." A registered nurse (RN) was interviewed at 11:06 a.m. on [DATE]. The RN stated, "C. diff. is transmitted by contact - usually not doing good hand washing, and it's on toilet seats ... Loose stool? I would be concerned that they might get dehydrated ... You check their skin turgor and offer them fluids frequently. If you were concerned, yes, you would check for concentration of the urine ... Yes you should document - I don't think it gets done that often." The director of nursing (DON) and nursing home administrator (NHA) were interviewed at 9:07 a.m. on [DATE]. Regarding [DIAGNOSES REDACTED] and nursing assessment and monitoring for dehydration, the DON stated, "(If diagnosed with [REDACTED].? Encourage fluids, monitor VS (vital signs), urine concentration and labs." When asked when intake and output would be initiated, the DON responded, "It (I&O) could be a nursing intervention and if low we would request IV fluids." In response to the finding of no documentation related to dehydration in the nurses' notes or summaries except the transfer-to-the-hospital note, the DON said, "We are charting by exception." III. Facility Policies and Procedures The facility's policy and procedure regarding "Weight/Hydration Management," dated February 2010, submitted by the DON at 8:10 a.m. on [DATE], stated, in pertinent part: "Residents identified with hydration issues via the 24-hour report process and/or at the morning, interdisciplinary meeting will be reviewed by the IDT. The Hydration Management Worksheet is available to identify risk factors that impact hydration status. The IDT will determine who should be discussed. "Preparation for the Care Management Risk Review Meeting: 1. Residents identified with hydration concerns will be added to the Hydration Management Worksheet including any residents who: a. Were recently treated for [REDACTED].g. fever, diarrhea). 2. The Hydration Management Worksheet will be given to the IDT at the morning meeting the day of or the day before the Care Management Risk Review Meeting. 3. Meal intake records, supplement-nourishment/ Med Pass 2.0/ snack/ fortified food lists with intake information and diet order list should be brought to meeting by the Dietary Manager and/or Registered Dietician. 4. Dietary Manager and/or Registered Dietitian may visit with resident, family and care staff regarding hydration status and acceptable interventions. 5. The IDT will determine if Intake and Output (I and O) monitoring is needed as an intervention. MD will be notified of recommendation of the IDT and MD order obtained if warranted. I and O's will also be completed as ordered by MD. 6. The DON or designee will ensure communication to staff members on the changes in interventions related to hydration status determined by the team." - Of note, there were no Hydration Management Worksheets in resident #6's medical record, nor were they submitted for review by the facility. IV. Facility Failures Although it was documented that the resident was encouraged to take fluids, there was no documentation, in the four days that resident #6 was exhibiting diarrhea, that the nurses assessed him for signs/symptoms of dehydration or measuring/monitoring his intake and output to ensure he was receiving the adequate amount of fluids to meet his needs. The family members were the initiators of concern about the resident's dehydration. The nursing staff failed to identify that resident #6 was severely dehydrated. This failure contributed to the resident being admitted to the hospital after developing acute renal (kidney) failure secondary to dehydration while in the facility.