Every finding on record at Franciscan Post-Acute Care Center

Based on observation, interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for one of five sampled residents (Resident 1) when Resident 1 had known behaviors of getting up unassisted from bed, refusing to use his walker, call light and TLSO brace (thoracolumbosacral orthosis, is a type of back brace used to limit motion and promote healing in the thoracic [upper midback] spine, lumbar [lower back] spine, and sacral [triangular bone at the base of the lumbar spine connecting the spine to the pelvis] areas) and the facility did not develop and implement interventions that were person-specific in the comprehensive care plan. This failure placed Resident 1 at risk for falls and had the potential for pain and complications from his L1 fracture (a break in the first vertebra of the lower back [lumbar spine]). (Cross reference F658)Findings: During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of fifth lumbar vertebra (one of the bones that make up the spinal column), protein calorie malnutrition (undernutrition resulting from insufficient intake of protein and/or calories), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (heart disorder which causes the heart to not pump blood efficiently), low back pain, and falls.During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was not cognitively impaired.During a concurrent observation and interview on 4/20/26 at 10:28 a.m. with Resident 1, Resident 1 was lying on his bed dressed and wearing nonskid socks on his feet. Resident 1 stated he had a history of falls prior to his admission at the facility. Resident 1 had a black back brace lying on his bedside table. Resident 1 stated he had a fracture in his back.During a concurrent observation and interview on 4/20/26 at 10:34 a.m. with Certified Nursing Assistant (CNA) 1, outside Resident 1's room, Resident 1 was observed getting out of bed and walking toward the bathroom unassisted and not wearing his back brace. CNA 1 stated Resident 1 had a recent fall on PM shift and injured his back. CNA 1 stated resident 1 needed supervision for safety when ambulating (walking) but he was not good at using his call light to ask for help walking to the bathroom.During a concurrent interview on 4/20/26 at 11:06 a.m. with CNA 2 and CNA 3, CNA 3 stated she had taken care of Resident 1 in the past and he was noncompliant with using his call light, asking for help while walking or using his walker. CNA 3 stated Resident 1 was alert and oriented and aware he needed help ambulating but would get up by himself anyway. CNA 2 stated Resident 1 would get wobbly when walking to the bathroom, so he required supervision. CNA 2 stated Resident 1 was not good about calling for help to the bathroom or using his walker.During an interview on 4/20/26 at 11:18 a.m. with the Physical Therapy Assistant (PTA), the PTA stated Resident 1 was not consistent with participating with therapy. The PTA stated Resident 1 needed to use his walker to ambulate safely but refused to use it.During a concurrent interview and record review on 4/20/26 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Nursing SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/25/26 was reviewed. The SBAR indicated, . c/o Unwitnessed fall. Change in mental status. The following orders were received: Sent out resident to acute [care hospital] . LVN 1 stated Resident 1 refused to use his walker and would not use his call light to call for help. Resident 1's fall care plan, dated 3/25/26, was reviewed and indicated, . had an unwitnessed fall. will be free of complications. TSLO [TLSO] brace for ambulation. LVN 1 stated she was unaware Resident 1 was supposed to wear a back brace when walking and had never seen him wear it. LVN 1 stated it was important for Resident 1 to follow the care plan and wear his TLSO brace to treat his fractures. LVN 1 reviewed Resident 1's care plans and was unable to locate a care plan related to his noncompliance with the call light, walker or back brace. LVN 1 stated care plans were used to notify the staff how to provide the residents with individualized care and meet their needs.During a concurrent interview and record review on 4/20/26 at 12:21 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was found on the ground in his room after an unwitnessed fall on 3/25/26. The DON stated Resident 1 was admitted to the hospital for pneumonia after his fall and was found to have an L1 fracture while at the hospital. The DON stated Resident 1 was not compliant with asking for help to the bathroom, wearing his back brace or using his walker. Resident 1's care plans were reviewed, the DON stated she was unable to locate a care plan for Resident 1's noncompliance with using his walker, back brace and call light. The DON stated there should be a care plan in Resident 1's medical records addressing his noncompliance and refusal of care. During an interview on 4/20/26 at 12:44 p.m. with Resident 1, in Resident 1's room, Resident 1 was sitting at the edge of his bed and the TLSO brace was observed on his bedside table. Resident 1 was evasive and stated he would wear the brace when I need it. During an interview on 4/20/26 at 12:49 p.m. with CNA 1, CNA 1 stated she was aware Resident 1had a back brace but was unaware he was supposed to wear it while ambulating according to the care plan. CNA 1 stated she had never seen Resident 1 use the back brace.During an interview on 4/20/26 at 12:51 p.m. with the Physical Therapy Assistant (PTA), the PTA stated Resident 1 had a TLSO brace at bedside but was noncompliant with wearing it. The PTA stated Resident 1 should wear the brace when he was out of bed because he had a fracture in his back.During a review of the facility's policy and procedures (P&P) titled Comprehensive Care Plans, dated 11/2017, the P&P indicated, . To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes. Care plan will include. Services that would have been provided but the resident has refused. care planning process will be an on-going process.During a review of the facility's P&P titled Resident Rights. Refusal of Treatment, dated 11/2017, the P&P indicated, . resident has the right to request, refuse and/or discontinue treatment. The resident has the right to refuse treatment or services. The facility is responsible to provide care that allows the resident to attain or maintain his or her highest practicable physical, mental and psychosocial well-being. Services that would otherwise be required, but are refused must be described in the comprehensive care plan.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of three sampled Residents (Resident 2) when Certified Nursing Assistant (CNA) 1 completed a two-person required mechanical lift (a mobile floor lift system that rolls on wheels and is intended to lift, suspend and transfer a medically dependent person from a bed, shower, toilet or wheelchair) transfer without assistance.This failure placed Resident 2 at risk for falls and significant injuries.Findings:During an observation on 4/20/26 at 10:25 a.m., Certified Nursing Assistant (CNA) 1 was observed operating a mechanical lift alone with Resident 2 in a sling, lowering him into his wheelchair. There were no other staff members observed in the resident's room.During an interview on 4/20/26 at 10:34 a.m. with CNA 1, CNA 1 stated she was using the mechanical lift without assistance of another staff member. CNA 1 stated there needed to be two staff members present when operating a mechanical lift for residents' safety. CNA 1 stated she was unable to find another CNA to help her but should have waited because it placed Resident 2's safety at risk and placed him at risk for falling.During an interview on 4/20/26 at 10:40 a.m. with Resident 3, Resident 3 was lying in bed dressed. Resident 3 stated the staff used a mechanical lift whenever they took her out of bed. Resident 3 stated occasionally a CNA would operate the mechanical lift alone, but there were usually two CNAs using it.During an observation on 4/20/26 at 11:03 a.m. with Resident 3, Resident 3 was lying in his wheelchair with a blue mechanical lift sling under him. Resident 3 was alert with confusion.During a concurrent interview on 4/20/26 at 11:06 a.m. with CNAs 2 and 3, CNA 2 stated they were required to always have a second staff member when using a mechanical lift. CNA 3 stated it was unsafe to use the lift alone because anything could happen without another person to guide the lift.During an interview on 4/20/26 at 11:18 a.m. with the Physical Therapy Assistant (PTA), the PTA stated there should always be two staff members using the mechanical lift. The PTA stated one staff member needed to operate the mechanical lift and the other staff to guide the resident onto the chair or bed and make sure they land in the correct place.During a concurrent interview and record review on 4/20/26 at 11:30 a.m. with the Director of Staff Development (DSD), the DSD stated all nursing staff were trained on using the mechanical lift with competency checked during the annual training on 6/12/25. The DSD stated the staff were instructed that two staff members were required to operate a mechanical lift for resident safety. The DSD stated the staff had to pass competencies before they were allowed to perform a skill on the floor. CNA 1's CNA Core Clinical Competencies, dated 6/12/25, indicated, . Date 6/12/25. Mechanical lift [pass box marked] .During an interview on 4/20/26 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated two people were required to use a mechanical lift. LVN 1 stated if a CNA could not find another CNA they should notify the nurse for assistance. LVN 1 stated if staff used the mechanical lift by themselves, it placed the residents at risk for falls. LVN 1 stated it was important to have two people during transfer, one to keep an eye on the resident and the second to step in if something gets stuck or help move the resident if they are not positioned correctly.During a review of Resident 2's Assistance for Daily Living (ADL) care plan, dated 10/12/2020, the care plan indicated, . has an ADL self-care performance deficit. Transferred by staff using mechanical lift 2-to-3-person assistance. Transfer: [name of resident] is totally dependent on (2) staff for transferring. requires Mechanical lift with (2) staff assistance for transfers.During an interview on 4/20/26 at 12:21 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the staff to have two people operating the mechanical lift for resident safety. The DON stated if the CNA could not find another CNA for assistance, they should have asked the nurse or herself to help.During a review of the facility's policy and procedure (P&P) titled, Accident Hazards/Supervision/Devices, dated 7/2018, the P&P indicated, . provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents. Assistive Devices/Equipment Hazards. Assistive devices and equipment will be used and maintained according to manufacturer recommendations. staff will be trained on the use of assistive devices and transfer equipment.During a telephone interview on 4/21/26 at 4:14 p.m. with the Administrator (ADM) the ADM stated the facility did not have a specific mechanical lift P&P and they followed manufacturer guidelines.During a review of the facility's Operating Instructions, undated, for the mechanical lift, the instructions did not indicate how many staff members were required to safely operate the mechanical lift.During a telephone interview on 4/22/26 at 10:29 p.m. with the DON, the DON stated the facility did not have a P&P for the mechanical lift but used the manufacturer's guidelines. The DON stated there were instructions hanging on each mechanical lift. The DON stated the manufacturer guidelines did not specify two person transfer but it was the facility's process to always use two people for mechanical lift transfers.

Based on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for one of five sampled residents (Resident 1) when Resident 1 sustained an L1 fracture (a break in the first vertebra of the lower back [lumbar spine]) during a fall at the facility on 3/25/26 and was hospitalized , the resident returned to the facility on 3/30/26 with an order from the acute care hospital to wear a TLSO (thoracolumbosacral orthosis, is a type of back brace used to limit motion and promote healing in the thoracic [upper midback] spine, lumbar, and sacral [triangular bone at the base of the lumbar spine connecting the spine to the pelvis] areas) brace while ambulating (ability to walk) and the facility did not enter the order or follow up with Resident 1's physician.This failure resulted in staff not being aware Resident 1 was supposed to wear his back brace while ambulating and his compliance with wearing the brace was not monitored placing Resident 1 at risk for severe back pain and further injury. (Cross reference F656)Findings:During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included a fracture of the fifth lumbar vertebra (one of the bones that make up the spinal column), protein calorie malnutrition (undernutrition resulting from insufficient intake of protein and/or calories), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (heart disorder which causes the heart to not pump blood efficiently), low back pain, and falls.During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was not cognitively impaired.During a concurrent observation and interview on 4/20/26 at 10:28 a.m. with Resident 1, Resident 1 was lying on his bed dressed and wearing nonskid socks on his feet. Resident 1 stated he had a history of falls prior to his admission at the facility. Resident 1 had a black back brace lying on his bedside table. Resident 1 stated he had a fracture in his back.During a concurrent observation and interview on 4/20/26 at 10:34 a.m. with Certified Nursing Assistant (CNA) 1, outside Resident 1's room, Resident 1 was observed getting out of bed and walking toward the bathroom unassisted and not wearing his back brace. CNA 1 stated Resident 1 had a recent fall on PM shift and injured his back. CNA 1 stated Resident 1 needed supervision for safety when ambulating but he was not good at using his call light to ask for help walking to the bathroom.During a concurrent interview and record review on 4/20/26 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Nursing SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/25/26 was reviewed. The SBAR indicated, . c/o Unwitnessed fall. Change in mental status. The following orders were received: Sent out resident to acute [care hospital]. LVN 1 stated Resident 1 refused to use his walker and would not use his call light to call for help. Resident 1's fall care plan, dated 3/25/26, was reviewed and indicated, . had an unwitnessed fall. will be free of complications. TSLO [TLSO] brace for ambulation. LVN 1 stated she was unaware Resident 1 was supposed to wear a back brace when walking and had never seen him wear it. Resident 1's Order Summary Report (OSR), undated, was reviewed and LVN 1 was unable to locate a physician order for the TLSO brace. LVN 1 stated it was important for Resident 1 to follow the care plan and wear his TLSO brace to treat his fractures.During a review of Resident 1's ACH document titled CT Spine Lumbar w/o Contrast, dated 3/25/26, the results indicated, . Nondisplaced fracture of the vertebral body of L1.During a concurrent interview and record review on 4/20/26 at 12:21 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was found on the ground in his room after an unwitnessed fall on 3/25/26. The DON stated Resident 1 was admitted to the hospital for pneumonia after his fall and was found to have an L1 fracture while at the hospital. Resident 1's Acute Care Hospital (ACH) Patient Discharge Instructions, dated 3/30/26, was reviewed and indicated, . Discharge Orders. Please wear TLSO brace when getting out of bed and working with therapy. The DON reviewed the OSR and stated she was unable to find an order for the brace. The DON stated the brace was in the hospital discharge instructions and should have been entered into the OSR when Resident 1 was readmitted on [DATE]. Resident 1's fall care plan dated 3/25/26 was reviewed and the DON stated the TLSO brace was on the care plan but also needed to be in the OSR so the staff could monitor for compliance and potential skin breakdown under the brace. The DON stated her expectation would have been for the admission nurse to review the hospital paperwork and notify Resident 1's physician of the order. The DON stated the TLSO brace was important to stabilize Resident 1's fracture while walking.During an interview on 4/20/26 at 12:44 p.m. with Resident 1, in Resident 1's room, Resident 1 was sitting at the edge of his bed and the TLSO brace was observed on his bedside table. Resident 1 was evasive and stated he would wear the brace when I need it. During an interview on 4/20/26 at 12:49 p.m. with CNA 1, CNA 1 stated she was aware Resident 1had a back brace but was unaware he was supposed to wear it while ambulating according to the care plan. CNA 1 stated she had never seen Resident 1 use the back brace.During an interview on 4/20/26 at 12:51 p.m. with the Physical Therapy Assistant (PTA), the PTA stated Resident 1 had a TLSO brace at bedside but was noncompliant with wearing it. The PTA stated Resident 1 should wear the brace when he was out of bed because he had a fracture in his back.During a review of the facility's policy and procedure (P&P) titled Physician Services, dated 6/2018, the P&P indicated, . support medical supervision of the care of each resident is provided by a physician and that orders for the resident's immediate care and needs are provided throughout the resident's stay. The physician admission orders for the resident's immediate care can serve as the physician's personal approval of the admission if the orders are provided by a physician.During a review of a professional reference retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC11878868/#:~:text=medication%20safety%2C%20readmissions-,Background,from%2015.8%25%20to%2011.3%25, titled Lessons Learned When Discharging Older Adults to Skilled Nursing Facilities, dated 6/3/2022, the reference indicated, . When patients transition from an inpatient hospital stay to a skilled nursing facility (SNF), the information that is sent with them is essential to proper care in the facility. To facilitate this transition, discharge paperwork from the hospitalization is provided to SNF medical staff immediately prior to and at the time of discharge. This includes. follow-up care they will need after discharge. The nursing staff at the SNF are under strict guidance to follow these instructions for care. Patients are vulnerable to complications during times of transition. follow-up is critical for patient safety. Communicate need for additional care, treatment, or procedures in the discharge paperwork so that the SNF can ensure these plans are enacted.

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one of six sampled residents (Resident 1) when: 1. Resident 1 was admitted to the facility with diagnoses of Type 2 Diabetes Mellitus (Type 2 DM- a disorder in which blood sugar or glucose levels are abnormally high) and licensed nursing staff did not develop an individualized care plan intervention to monitor Resident 1's blood glucose levels, from 5/4/25 to 5/18/25. This failure resulted in Resident 1 experiencing significant change in condition. On 5/18/25, Resident 1 was found with altered mental status (AMS- change in person's level of awareness, thinking, or behavior, a medical emergency requiring prompt evaluation and treatment), with a blood glucose level of 53 mg/dl (milligram per deciliters- unit of measurement), and requiring emergency transport to a higher level of care. Resident 1 was admitted to the hospital from [DATE] to 6/3/25. 2. Resident 1 was admitted to the facility with diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) and licensed nursing staff failed to implement the nursing care plan interventions to monitor Resident 1's oxygen level according to the physician's order. This failure resulted in Resident 1 experiencing significant change in condition. On 5/18/25, Resident 1 was found with AMS, with an oxygen level of 86% (percent- unit of measurement), and requiring emergency transport to a higher level of care. Resident 1 was admitted to the hospital from [DATE] to 6/3/25. Findings: 1. During a review of Resident 1 ' s admission Record, dated 6/6/25, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Muscle Weakness, Hypertension (high blood pressure), Cervicalgia (neck pain) and Congestive Heart Failure (CHF- heart is unable to pump blood efficiently). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], the MDS indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS- assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a concurrent interview and record review on 6/6/25, at 2:30 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. RN 1 confirmed she worked on 5/17/25 PM shift (afternoon shift, from 2:00 p.m. to 10:30 p.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/17/25 at 6:39 p.m. was reviewed. The note indicated, . Vital signs . BP (blood pressure) 139/60 - 5/17/25 15:57 (3:57 p.m.) . O2 (oxygen saturation- measure of how well oxygen is being transported throughout the body) 93% - 5/17/25 9:06 a.m . Oxygen via nasal cannula (NC-medical device that provides oxygen through a thin flexible tube with two prongs that fit into the nostrils) . Signed [RN 1] . RN 1 stated there was no documentation related to obtaining Resident 1's blood glucose levels every shift or daily, from admission [DATE]) to discharge (5/18/25). During a concurrent interview and record review on 6/6/25, at 2:33 p.m. with RN 1, Resident 1's Order Summary Report (OSR), dated 6/6/25 was reviewed. The OSR indicated, . Glipizide ER (medication to control Type 2 DM, use to lower blood glucose levels) Oral Tablet Extended Release 24 Hour 5MG (milligrams - unit of measurement). Give 1 tablet by mouth two times a day for DM type 2 . RN 1 stated Resident 1's record indicated he took the prescribed Glipizide from 5/4/25 to 5/17/25 twice a day. During a concurrent interview and record review on 6/6/25, at 2:37 p.m. with RN 1, Resident 1's Food Intake, dated 5/17/25 was reviewed. The Food Intake indicated, . 5/16/25 Breakfast - 51% to 75%, Lunch - Refused, Dinner - 51% to 75% . 5/17/25 Breakfast - Refused, Lunch - Refused, Dinner 51% to 75% . RN 1 stated Resident 1's intake from 5/16/25 to 5/17/25 were reduced compared to 5/15/25 (75% to 100%). During a concurrent interview and record review on 6/6/25, at 2:39 p.m. with RN 1, Resident 1's Diabetes Mellitus care plan dated 5/5/25 was reviewed. The care plan indicated, . Focus . [Resident 1] has Diabetes Mellitus, Glipizide ER Oral Tablet Extended Release 24 hour 5 MG . Interventions . Diabetes medication as ordered by doctor. Monitor/document effectiveness . Educate regarding medications and importance of compliance . RN 1 stated the careplan interventions should have been individualized to meet Resident 1's needs and it was not. RN 1 stated the care plan did not include a blood glucose check and hold glipizide administration during meal refusals. RN 1 stated taking glipizide without food intake could result to severe hypoglycemia (low blood sugar) and avoidable hospitalization. During a concurrent phone interview and record review on 6/12/25, at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. LVN 1 confirmed she worked on 5/18/25 NOC (evening shift, from 10:00 p.m. to 6:30 a.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/18/25 at 3:15 a.m. was reviewed. The note indicated, . CN (Charge Nurse) was informed by the CNA (Certified Nurse Assistant) that resident was coughing and was having difficulty expelling mucus (phlegm) to clear throat. CN immediately assess resident . CN noticed that resident was not responding verbally to any commands. Multiple attempts for verbal response were ineffective. VS (Vital Signs) 154/63 (blood pressure), O2 (oxygen) sat [saturation] 86-88% via NC (nasal cannula) at 3L (liters- unit of measurement) . [Ambulance] was call[ed] at 03:55 a.m. left resident via gurney at 04:15 a.m. LVN 1 stated several paramedics came to the facility and checked Resident 1's vital signs, including oxygen level and blood glucose levels. LVN 1 stated she was informed by one paramedics who responded to the emergency call that Resident 1's initial blood glucose level was 53 mg/dl and was given D5W (dextrose, a liquid solution containing 5% dextrose [a type of sugar]). During a concurrent phone interview and record review on 6/12/25, at 8:49 a.m. with LVN 1, Resident 1's Order Summary Report, dated 6/6/25 was reviewed. LVN 1 stated there was no order to check Resident 1's BS (blood sugar) every shift or daily. Resident 1's Food Intake, dated 5/17/25 was reviewed. LVN 1 stated she was not aware of Resident 1's refusing meals while taking his Glipizide. Resident 1 ' s Diabetes Mellitus care plan dated 5/5/25 was reviewed. LVN 1 stated the careplan interventions should be resident specific and it was not. LVN 1 stated the care plan did not include monitoring of meal intake and blood glucose check. LVN 1 stated Resident 1's low level of blood glucose resulted to altered mental status and subsequent hospitalization. During a concurrent interview and record review on 6/12/25 at 2:21 p.m. with the Director of Nursing (DON), the DON stated Resident 1 has a diagnosis of COPD, CHF, Cervicalgia and Type 2 DM. The DON stated Resident 1 was transferred to an acute care hospital (ACH) on 5/18/25 due to AMS, and did not return to their facility. The DON stated Resident 1 was previously admitted (4/20/23) to the facility and was on blood glucose monitoring and she was unsure why it was discontinued on his most recent readmission [DATE]). The DON reviewed Resident 1 ' s Type 2 DM care plan dated 5/5/25 and stated the care plan intervention column was incomplete. The DON stated the purpose of a care plan was to guide staff for a resident's plan of care and the interventions in place to meet the resident goals. The DON stated Resident 1's care plan should be individualized and specific, without specific interventions, Resident 1 could experience a negative outcome, including hypoglycemia or hyperglycemia. During a review of Resident 1's Acute Hospital History and Physical, dated 4/28/25, the record indicated, . [Resident 1] . male with PMHx (Patient's past medical history) sig (significant) for COPD, CHF . DM . who presented to the ER with complaint of mild SOB (shortness of breath) . Recent Labs [laboratory] . Glucose 189 ml/dl . Plan: Admit . Insulin regimen, hypoglycemic precautions . During a review of Resident 1's Ambulance Service Record, dated 5/18/25, the record indicated, . 04:00 [4:00 a.m.] . Chief Complaint . not acting like his usual self . Vital Signs BP [blood pressure] 166/67 . Oxygen Saturation 92% (percent- unit of measurement) . Blood Glucose 53 mg/dl . Comments: low blood sugar . Narrative: Pt found semi-Fowlers in bed at [Facility Name]. Family at scene. Staff states that pt (patient) is not his usual self. Usually converses more but this morning he just yells. Pt has history of COPD and is on 2 LPM (liters per minute - unit of measurement) via nasal cannula. Pt has an oxygen saturation of 88 %, EMS [Emergency Medical Staff] increased oxygen to 3 LPM this improved his oxygen saturation to 93%. Glucose check showed 53 mg/dl. Pt moved to gurney to unit . During a review of Resident 1's Acute Hospital ED [Emergency Department] Physician Notes, dated 5/18/25 at 7:26 a.m., the note indicated, . Patient presenting from the [Facility Name] for altered mental status male history of COPD, diabetes, hypertension presents for altered mental status. Vital signs with borderline tachycardia (faster heart rate) hypoxemia (low oxygen level) to the low 90s and high 80s on supplemental oxygenation. Exam with diffuse wheezing (sound heard throughout the chest) as well as significant weakness in bilateral upper and lower extremities (arms and legs). Considered a broad differential (symptoms could be attributed to a large number of potential conditions) for this patient who present for altered mental status found to be hypoglycemic . Final Diagnosis this visit: COPD with acute exacerbation (worsening of condition) . Acute hypoxemic respiratory failure . Altered mental status . Hypoglycemia . Disposition: transfer to other hospital [Hospital name] . Condition: Guarded (patient's condition is uncertain) . During a review of the facility ' s policy and procedure (P&P) titled Comprehensive Care Plans, dated 11/2017, the P&P indicated, . provide each resident with a person-centered, comprehensive care plan to address the resident ' s medical, nursing, physical, mental and psychosocial needs . facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-center care plan for each resident that includes measurable objectives and timeframes that meet a resident ' s medical, nursing, physical, mental, and psychosocial needs . It will drive the type of care and services that a resident receives and will describe the resident ' s medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences . During a review of the professional reference titled, Lippincott procedures-Care plan preparation, long-term care, dated 5/19/22, the professional reference indicated, .The care plan for each resident must include: . resident goals, expressed in measurable objectives with timetables to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment, interventions that describe the services the interdisciplinary team employs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, evaluation of the fulfillment of goals .The care plan should reflect elements of person-centered are, make every effort to understand what each resident is communicating verbally and non-verbally, and identify what daily routines are important each resident . During a review of a professional reference retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-skilled-nursing-facilities#:~:text=This%20helps%20keep%20you%20aware,kind%20of%20services%20you%20need titled What ' s a care plan in skilled nursing facilities, undated, the reference indicated, . When your health condition is assessed, skilled nursing facility (SNF) staff prepare or update your care plan . This helps keep you aware of how the care you get will help you reach your health care goals . may include . what kind of services you need . How often you'll need the services . What kind of equipment or supplies you need . Your health goal (or goals), and how your care plan will help you reach your goal . 2. During a review of Resident 1 ' s admission Record, dated 6/6/25, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included COPD, Type 2 Diabetes Mellitus, Muscle Weakness, Hypertension, Cervicalgia and CHF. During a review of Residents 1's MDS assessment dated [DATE], indicated Resident 1's BIMS scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a concurrent interview and record review on 6/6/25, at 2:42 p.m. with RN 1, RN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. RN 1 confirmed she worked on 5/17/25 PM shift (afternoon shift, from 2:00 p.m. to 10:30 p.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/17/25 at 6:39 p.m. was reviewed. The note indicated, . O2 93% - 5/17/25 9:06 a.m. Oxygen via nasal cannula . Signed [RN 1] . RN 1 stated there was no record of Resident 1's oxygen level taken during her shift (from 2:00 p.m. to 10:30 p.m.). During a concurrent interview and record review on 6/6/25, at 2:46 p.m. with RN 1, Resident 1's OSR dated 6/6/25 was reviewed. The OSR indicated, . Administer oxygen @2-3Lmin (Liter per minute - unit of measurement) via nasal cannula . Order Date 5/5/25 . Check oxygen saturation PRN (as needed) every 8 (eight) hours as needed for Dyspnea (shortness of breath) /Cyanosis (discoloration of the skin due to a lack of oxygen in the blood) . Order Date 5/5/25 . RN 1 stated Resident 1's physician's order to check oxygen saturation was not followed. RN 1 stated Resident 1's oxygen saturation level was not checked for 17 hours (from 9:07 a.m. to 2:20 am). RN 1 stated Resident 1's changed in condition could have been discovered sooner if his oxygen saturation level was checked once a shift. Resident 1 ' s COPD and CHF care plan dated 5/5/25 was reviewed. The care plan indicated, . Focus . [Resident 1] has oxygen therapy r/t [related to] CHF. Administer oxygen @2-3L/min via nasal cannula, Continuous for Chronic COPD . Interventions/Tasks . Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (physician): increased respirations (breathing) . decreased pulse oximetry . cough . RN 1 stated the careplan interventions was not followed. RN 1 stated Resident 1's oxygen saturation level was not checked according to the care plan and physician's order. RN 1 stated Resident 1's changed in condition could have been discovered sooner if his oxygen saturation level was checked during her shift. During a concurrent phone interview and record review on 6/12/25, at 8:45 a.m. with LVN 1, LVN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. LVN 1 confirmed she worked on 5/18/25 NOC (evening shift, from 10:00 p.m. to 6:30 a.m.) and was the charge nurse for Resident 1. Resident 1's Nursing Note, dated 5/18/25 at 3:15 a.m. was reviewed. The note indicated, . CN (Charge Nurse) was informed by the CNA (Certified Nurse Assistant) that resident was coughing and was having difficulty expelling mucus (phlegm) to clear throat. CN immediately assess resident . CN noticed that resident was not responding verbally to any commands. Multiple attempts for verbal response were ineffective. VS (Vital Signs) 154/63 (blood pressure), O2 (oxygen) sat [saturation] 86-88% via NC (nasal cannula) at 3L (liters- unit of measurement) . [Ambulance] was call[ed] at 03:55 a.m. left resident via gurney at 04:15 a.m. LVN 1 stated several paramedics came to the facility and checked Resident 1's vital signs, including oxygen level and blood glucose levels. During a concurrent phone interview and record review on 6/12/25, at 8:55 a.m. with LVN 1, Resident 1's OSR dated 6/6/25 was reviewed. The OSR indicated, . Check oxygen saturation PRN every 8 hours as needed for Dyspnea/Cyanosis . Order Date 5/5/25 . LVN 1 stated Resident 1's physician's order to check oxygen saturation was not followed by the previous shift. LVN 1 stated Resident 1's oxygen saturation level was not checked for more than 12 hours (from 9:07 a.m. to 2:20 am). LVN 1 stated Resident 1 was on continuous oxygen and checking the oxygen saturation level was part of the vital signs, and it was not done. During a concurrent phone interview and record review on 6/12/25, at 9:00 a.m. with LVN 1, Resident 1 ' s COPD and CHF care plan dated 5/5/25 was reviewed. The care plan indicated, . Focus . [Resident 1] has oxygen therapy r/t CHF. Administer oxygen @2-3L/min via nasal cannula, Continuous for Chronic COPD . Interventions/Tasks . Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD: increased respirations (breathing) . decreased pulse oximetry . cough . LVN 1 stated the careplan interventions should be implemented and it was not. LVN 1 stated the facility failed to follow Resident 1's care plan interventions and physician's order to monitor oxygen saturation level every shift, and resulted to altered mental status and subsequent hospitalization. During a concurrent interview and record review on 6/12/25 at 2:21 p.m. with the DON, the DON stated Resident 1 has a diagnosis of COPD, CHF, Cervicalgia and Type 2 DM. The DON stated Resident 1 was transferred to an acute care hospital (ACH) on 5/18/25 due to AMS, and did not return to their facility. The DON reviewed Resident 1's COPD and CHF care plan dated 5/5/25 and stated the care plan intervention to monitor oxygen saturation level every shift was not followed on 5/17/25. The DON stated the purpose of a care plan was to guide staff for a resident's plan of care and the interventions in place to meet the resident goals. The DON stated failure to follow the nursing care plan interventions could lead to a negative outcome, including low oxygen level and respiratory distress. During a review of Resident 1's Acute Hospital History and Physical, dated 4/28/25, the record indicated, . [Resident 1] is a [AGE] year old, male with PMHx (Patient's past medical history) sig (significant) for COPD, CHF . DM . who presented to the ER with complaint of mild SOB (shortness of breath) . Recent Labs [laboratory] . Glucose 189 ml/dl . Plan: Admit . Insulin regimen, hypoglycemic precautions . During a review of Resident 1's Ambulance Service Record, dated 5/18/25, the record indicated, . 04:00 [4:00 a.m.] . Chief Complaint . not acting like his usual self . Vital Signs BP 166/67 . Oxygen Saturation 92% . Blood Glucose 53 mg/dl . Comments: low blood sugar . Narrative: Pt found semi-Fowlers in bed at [Facility Name] . Family at scene. Staff states that pt (patient) is not his usual self. Usually converses more but this morning he just yells. Pt has history of COPD and is on 2 LPM (liters per minute - unit of measurement) via nasal cannula. Pt has an oxygen saturation of 88 %, EMS increased oxygen to 3 LPM this improved his oxygen saturation to 93%. Glucose check showed 53 mg/dl. Pt moved to gurney to unit . During a review of Resident 1's Acute Hospital ED Physician Notes, dated 5/18/25 at 7:26 a.m., the note indicated, . Patient presenting from the [Facility Name] for altered mental status . 74 y.o. male history of COPD, diabetes, hypertension presents for altered mental status. Vital signs with borderline tachycardia, hypoxemia to the low 90s and high 80s on supplemental oxygenation. Exam with diffuse wheezing as well as significant weakness in bilateral upper and lower extremities. Considered a broad differential for this patient who present for altered mental status found to be hypoglycemic . Final Diagnosis this visit: COPD with acute exacerbation . Acute hypoxemic respiratory failure . Altered mental status . Hypoglycemia . Disposition: transfer to other hospital [Hospital name] . Condition: Guarded . During a review of the facility's P&P titled Comprehensive Care Plans, dated 11/2017, the P&P indicated, . provide each resident with a person-centered, comprehensive care plan to address the resident ' s medical, nursing, physical, mental and psychosocial needs . facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-center care plan for each resident that includes measurable objectives and timeframes that meet a resident ' s medical, nursing, physical, mental, and psychosocial needs . It will drive the type of care and services that a resident receives and will describe the resident ' s medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences . During a review of the professional reference titled, Lippincott procedures-Care plan preparation, long-term care, dated 5/19/22, the professional reference indicated, .The care plan for each resident must include: . resident goals, expressed in measurable objectives with timetables to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment, interventions that describe the services the interdisciplinary team employs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, evaluation of the fulfillment of goals .The care plan should reflect elements of person-centered are, make every effort to understand what each resident is communicating verbally and non-verbally, and identify what daily routines are important each resident . During a review of a professional reference retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-skilled-nursing-facilities#:~:text=This%20helps%20keep%20you%20aware,kind%20of%20services%20you%20need titled What ' s a care plan in skilled nursing facilities, undated, the reference indicated, . When your health condition is assessed, skilled nursing facility (SNF) staff prepare or update your care plan . This helps keep you aware of how the care you get will help you reach your health care goals . may include . what kind of services you need . How often you'll need the services . What kind of equipment or supplies you need . Your health goal (or goals), and how your care plan will help you reach your goal .

Based on observation, interview, and record review, the facility failed to ensure resident's food preferences were honored for one of six sampled residents (Resident 3) when sliced tomatoes was placed on Resident 3's lunch plate despite tomatoes being listed as a dislike. This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, compromising Resident 3's nutritional and medical status. Findings: During a concurrent observation and interview on 6/6/25, at 1:27 p.m., with Resident 3, inside Resident 3's room, Resident 3's meal tray ticket indicated disliking tomatoes. Resident 3 received fresh sliced tomatoes with his lunch. Resident 3 stated, I do not like tomatoes. I told them before and it keeps on happening. Resident 3 stated he ate the chicken tenders, potato salad and lemon pudding for lunch. The sliced tomatoes with parsley flakes were left untouched. During a concurrent observation and interview on 6/6/25, at 1:47 p.m., with Certified Nursing Assistant (CNA) 1, inside Resident 3's room, CNA 1 checked Resident 3's meal tray ticket and stated, [Resident 3] was served with chicken tenders, potato salad, tomato marinated tomato salad, lemon pudding and 2% milk. Verification of meal tray ticket with CNA 1, confirmed dislikes in meal ticket were fish, spinach, brussels sprouts or tomatoes. CNA 1 stated the dietary and nursing staff failed to review the contents of Resident 3's meal tray prior to serving his meal. CNA 1 stated the failure could result in reduced meal intake. During a concurrent interview and record review on 6/6/25, at 1:49 p.m., with Dietary [NAME] (DC) 1, Resident 3's lunch meal tray ticket, dated 6/6/25 was reviewed. DC 1 stated Resident 3 was served a marinated tomato salad. DC 1 stated the bottom part of the meal tray ticket indicated Resident 3's dislikes of tomatoes. DC 1 stated the dietary staff failed to honor Resident 3's food preference and could potentially result to reduce meal intake and compromising Resident 3's nutritional status. During an interview on 6/12/25, at 1:49 p.m., with the Dietary Manager (DM), the DM stated the expectation was for the dietary aide and dietary cook to compare the contents of the meal tray to the meal tray ticket during meal preparation. The DM stated Resident 3's meal preferences was not followed on 6/6/25, Resident 3 was served a marinated tomato salad, despite a note on his meal ticket indicating dislikes of tomatoes. The DM stated Resident 3's nutritional status was currently not compromised but could be a potential issue if the mistake keeps on happening during meal preparation. During a review of the facility's policy and procedure (P&P) titled, Menus and Therapeutic Diets, dated 7/2018, the P&P indicated, . 1. Facility menus will meet the nutritional needs of residents in accordance with established national guidelines . 4. Facility will make reasonable effort to accommodate religious, cultural and ethnic needs of the resident population, as well as other input received from residents . During a review of the facility's P&P titled, Provision of Diet to Meet Needs of Each Resident, dated 7/2018, the P&P indicated, . The facility will provide residents with nourishing, palatable and well-balanced diet to meet daily nutritional and special dietary needs. This will be done while taking into consideration the preferences of each resident . There will be ongoing communication and coordination, taking an IDT approach, to meet the daily nutritional and dietary needs and choices of residents .

Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when 2 (Resident #4 and Resident #11) of 2 sampled residents reviewed for PASARR were diagnosed with a new serious mental illness. Findings included: A facility policy titled Resident Assessments PASARR Screening Coordination, revised 07/2018, indicated 7. The facility will refer to the appropriate state-designated authority any resident with newly evident or possible serious mental disorder, intellectual disability or related condition. 1. An Admission Record indicated the facility admitted Resident #4 on 06/14/2017. According to the Admission Record, the resident received a diagnosis of major depressive disorder on 08/09/2017, anxiety disorder on 04/29/2022, and bipolar disorder on 07/29/2022. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression, and bipolar disorder. Resident #4's Care Plan Report revealed a focus area initiated 04/23/2022 and revised 12/26/2024, that indicated the resident was administered Depakote for a diagnosis of bipolar disorder. Resident #4's Care Plan Report revealed a focus area initiated 06/22/2024 and revised 01/02/2025, that indicated the resident was administered an antianxiety medication related to a diagnosis of anxiety disorder. Resident #4's Care Plan Report revealed a focus area initiated 03/12/2025, that indicated the resident was administered an antidepressant medication related to a diagnosis of depression. Resident #4's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a level II PASARR evaluation when the resident received a new mental illness diagnosis. During an interview on 04/09/2025 at 10:08 AM, the Quality of Life Director (QLD) stated that when a resident received a new psychiatric (mental illness) diagnosis, it was relayed to the Administrator so that a new PASARR could be completed. The QLD stated Resident #4's PASARR should have been updated when the resident received a new psychiatric diagnosis in 2022 to determine if a level II was required. During an interview on 04/09/2025 at 1:11 PM, the Director of Nursing stated a new PASARR should be completed when the resident received a new mental illness diagnosis. During an interview on 04/09/2025 at 1:19 PM, the Administrator stated he expected a new PASARR to be completed when a resident received a new mental illness diagnosis. 39438 2. An Admission Record indicated the facility admitted Resident #11 on 12/10/2015. According to the Admission Record, the resident received a diagnosis of schizoaffective disorder on 12/15/2022. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2025, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an active diagnosis to include schizophrenia. Resident #11's Care Plan Report included a focus area initiated 12/15/2022, that indicated the resident had a diagnosis of schizoaffectiveInterventions directed staff to administer medication as ordered and monitor for a decrease or increase in behaviors and notify the physician if the resident did not improve (initiated 12/15/2022). Resident #11's medical record revealed no evidence to indicate a PASARR screening was conducted after the resident was diagnosed with schizoaffective disorder on 12/15/2022. During an interview on 04/09/2025 at 10:08 AM, the Quality of Life Director (QLD) stated that when a resident received a new psychiatric (mental illness) diagnosis, it was relayed to the Administrator so that a new PASARR could be completed. During a follow-up interview on 04/09/2025 at 11:07 AM, the QLD stated a new PASARR should have been done when Resident #11 received the new psychiatric diagnosis. During an interview on 04/09/2025 at 1:11 PM, the Director of Nursing stated a new PASARR should be completed when the resident received a new mental illness diagnosis. During an interview on 04/09/2025 at 1:19 PM, the Administrator stated he expected a new PASARR to be completed when a resident received a new mental illness diagnosis.

Based on observation, interview, and record review, the facility failed to address the risk of fire while smoking for one of three sampled residents (Resident 1), when staff were aware of Resident 1's need for oxygen (a colorless, odorless gas that is essential for life), history of smoking and bringing in cigarettes and lighters into the facility and did not implement effective measures to ensure Resident 1's safety from fire. These failures resulted in Resident 1 smoking unnoticed while wearing oxygen on 2/4/25, catching fire and suffered avoidable second-degree burns (injury that damages both the outer layer of skin and part of the underlying layer) to the face and right forearm, swelling and severe pain, requiring emergency transport to a higher level of care and hospital with a Burn Unit (a hospital ward that treats patients with burns). Resident 1 was admitted to the acute care hospital (ACH) Burn Unit for two days and may suffer pain and scarring (a mark remaining after injured tissue has healed) as a result of the burns and possible reduced mobility. Findings: During an interview on 2/5/25 at 9:23 a.m. with the Administrator (ADM), the ADM stated on 2/4/25 around 1:00 a.m., a Certified Nursing Assistant (CNA) heard a loud noise coming from Resident 1 ' s room. The CNA went into the room, and the oxygen tubing and nasal cannula (NC-medical device that provides oxygen through a thin flexible tube with two prongs that fit into the nostrils) were on fire. The ADM stated it was reported Resident 1 had blood on his nose, soot (black powder that forms when something is burned) on his face and his beard was burned off. The ADM stated Resident 1, and his roommate Resident 2, were removed from the room and Resident 1 was transported by ambulance to the ACH Burn Unit for treatment. The ADM stated they did not know where the lighter came from. The ADM stated facility staff was aware Resident 1 was a smoker and would smoke when he was at hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). During a review of Resident 1 ' s Admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), end stage renal disease (ESRD-irreversible kidney failure), shortness of breath and dyspnea (difficulty breathing). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 2/5/25 at 9:38 a.m. with the Maintenance Supervisor (MS), the MS stated he received a call on 2/4/25 around 1:00 a.m. from facility staff and was told there was a fire at the facility. The MS stated when he arrived, the fire department was already at the facility and had reset the fire alarm. The MS stated he walked into Resident 1 ' s room, saw burnt areas on the floor next to the bed and holes burnt into Resident 1 ' s mattress. During a concurrent observation and interview on 2/5/25 at 9:43 a.m. with the Maintenance Supervisor (MS) in Resident 1 ' s room, Resident 1 ' s bedframe was in the room, but the mattress was gone. The MS stated he had removed the mattress and replaced the burnt tiles on the floor. Resident 1 ' s mattress was observed lying on the ground outside and there were three floor tiles next to the mattress. The MS pointed to the blackened areas on the floor tiles and stated they were caused by the nasal cannula landing on the floor when it was on fire. The mattress had five holes in it, the MS pointed to the largest hole which had discolored areas on the foam with an irregular surface and appeared to have melted a small area. The MS stated it was a fire retardant (substance used to slow down or stop the spread of fire) mattress which prevented to mattress from continuing to burn. During an interview on 2/5/25 at 10:10 a.m. with Resident 2 ' s Paid Caregiver (PCG) in Resident 1 and 2 ' s room, the PCG stated she visited Resident 2 over the weekend and saw Resident 1 with a cigarette in the room. The PCG stated Resident 1 had wheeled over to the sliding glass door and opened it part way. The PCG stated she saw the cigarette and asked what Resident 1 was doing and he replied he was going to smoke. The PCG stated, I told him you are not going to smoke that in here. The PCG stated she mentioned Resident 1 ' s cigarette to a staff member, but did not know if anything was done about it. During an interview on 2/5/25 at 10:13 a.m. with CNA 1, CNA 1 stated she normally worked day shift and was responsible to get Resident 1 ready for HD. CNA 1 stated the staff had been notified to watch Resident 1 ' s belongings for cigarettes or lighters because he had previously been caught with them in his room. During an interview on 2/5/25 at 10:27 a.m. with CNA 2, CNA 2 stated Resident 1 was a known smoker and had been caught smoking at the facility even though the facility was smoke-free. CNA 2 stated the staff was told to make sure Resident 1 was not smoking, have cigarettes or a lighter. CNA 2 stated Resident 1 would go to HD and bring cigarettes and lighters back with him. During a review of Resident 1 ' s Nursing Note, dated 2/4/25 at 5:07 a.m., the note indicated, . 0100am [1:00 a.m.] CNA heard a noise coming from [Resident 1 ' s room], Upon entering CNA noted smock [smoke] and fired flames on the floor with nasal cannel [cannula] burning on the floor, CNA immediately put out the fired [sic], Code RED [emergency indicating fire or smoke] was activated . Resident stated I just wanted smoked a cigarette, Resident led [lit] a lighter for a cigarette, Resident was on contentious [continuous] oxygen nasal Cannula, the lighter blew up on his face, CN [charge nurse] noted blood on his mouth and nose and soot all over face, noted soot stains in bed matters [mattress], Noted resident in a sitting position . took resident to hospital for eval and TX [treatment] . During a review of Resident 1 ' s Nursing Note, dated 2/4/25 at 5:30 a.m. indicated, . resident was admitted to Burn Unit [name of hospital] . During a review of Resident 1 ' s Nursing Note, dated 2/4/25 at 10:26 a.m., the note indicated, . CN called [name of ACH] for an update . resident is currently in the ER [emergency room ] trauma unit [hospital department which treats patients with severe injuries], he will be admitted to the burn center . has superficial partial thickness burns [burn that damages the top two layers of skin] to his face, over his nose, left eye, and mouth area. He also has swelling to the left eye and lips . During a concurrent interview and record review on 2/5/25 at 10:37 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a history of bringing cigarettes and lighters into the facility. Resident 1 ' s Nursing Note, dated 10/31/24 at 9:05 a.m. was reviewed. The note indicated, . Resident noted to have 8 Norco ' s [medication used to treat severe pain] in his bag, a pocketknife, and a lighter. Educated resident that he cannot have medications, knife, or lighter at bedside. Resident stated that he needs his lighter for when he goes to dialysis. Informed resident that he can take the lighter while he goes out for dialysis, but he needs to give it back to the nurse to put in the narcotic box after he comes back . Resident 1 ' s Nursing Note, dated 10/31/24 at 2:06 p.m. was reviewed, the note indicated, . Resident returned . Lighter put in narcotic [substance used to treat severe pain] box . LVN 1 stated facility was smoke-free but the notes indicated the nurse had given Resident 1 his lighter when he left for dialysis. LVN 1 stated the nurses kept Resident 1 ' s cigarettes and lighter locked in the medication cart if they were aware he had them, but he was found with them in his room, so it was not always effective. Resident 1 ' s Order Summary Report, dated 2/2025 was reviewed, the orders indicated, . Administer oxygen @ [at] [SPECIFY] 3_L/min [liters (unit of measurement) per minute] via nasal cannula, For SOB every shift for Dyspnea . LVN 1 stated Resident 1 had been on oxygen continuously since admission. The medication cart narcotic drawer was observed, there were two lighters in the cart, but neither belonged to Resident 1. During an interview on 2/5/25 at 12:44 p.m. with the Admissions Coordinator (AC), the AC stated it was her responsibility to review the admission documents with the residents and have the signed. The AC stated when Resident 1 was admitted , she reviewed the facility ' s smoking policy and procedures (P&P) with him and had notified him it was a smoke-free facility. The AC stated when she gave Resident 1 resident a copy of the P&P, the resident became upset, crumpled up the P&P and threw it on the bed. During a concurrent interview and record review on 2/5/25 at 1:10 p.m. with the Director of Nursing (DON), Resident 1 ' s Nursing Note, dated 12/4/24 at 1:04 p.m. was reviewed. The note indicated, . [Name of Resident 1 ' s responsible party] said that she did not give him cigarettes. He is asking a driver to buy him cigarette . Per Resident daughter [name] he had accident in the past while smoking with oxygen on . The DON stated she contacted Resident 1 ' s daughter because the facility staff was concerned, he was smoking at dialysis with his oxygen on. The DON stated Resident 1 ' s daughter told her about the resident smoking with oxygen on was nothing new and he would not stop because he was stubborn. The DON stated the nurses would check Resident 1 for cigarettes and lighter when he returned from dialysis and would lock them up. The DON was aware the staff gave Resident 1 his cigarettes when he left for dialysis with oxygen on. The DON stated Resident 1 would smell like smoke when he returned from dialysis. The DON stated on 11/10/24, Resident 1 was caught smoking in his room with oxygen on. Resident 1 ' s IDT (Interdisciplinary team-involves team members from different disciplines working collaboratively, with a common purpose to set goals, make decisions and share resources for the best interest of the resident) note dated 11/11/24 was reviewed, the note indicated, . spoke with [Resident 1] on 11/8/24 about being a nonsmoking facility. [Resident 1] was subsequently found to be smoking outside of his sliding door on 11/10/24 . spoke with him againg [sic] today and reminded him that there is no smoking allowed in this facility. Writer offered to refer him to another facility or to get an order for a nicotine patch. [Resident 1] declined both options . The DON stated on 1/10/25 the transportation company had notified her he tried to smoke in the van, and they threatened to stop transporting him. The DON stated the facility did not investigate why the nurses were giving Resident 1 his cigarettes and lighter when he left for dialysis and stated they should not have. The DON stated Resident 1 was admitted to the burn unit at the ACH on 2/4/25. Resident 1 ' s care plan dated 11/10/24 was reviewed, the care plan indicated, . Focus . [Resident 1] is a smoker . Goal . will not smoke in the facility premises . Interventions . The facilities [sic] smoking policy was reviewed and accepted by the resident and/or resident family . The resident requires a cigarette holder while smoking . the resident requires a smoking apron while smoking . The DON stated the campus was smoke-free and she did not know why the interventions included the smoking apron and cigarette holder because the resident was not supposed to smoke onsite. The DON stated the care plan was not accurate. The DON stated the purpose of care plans were to guide staff on the plan of care and interventions to meet the resident goals. The DON stated they should be individualized and specific to each resident. Resident 1 ' s care plan dated 12/6/24 was reviewed and indicated, . behavior issue risk and benefit of smoking explained. Per patient he smokes outside the dialysis and not in post acute care center premises . Goal resident will have fewer episodes . education on risk of smoking with oxygen use provided to patient. Non compliant behavior noted during dialysis days . The DON stated Resident 1 was provided education to not smoke while on oxygen. The DON stated Resident 1 was known to be non-compliant and the intervention of providing education was not effective. During an interview on 2/5/25 at 2:16 p.m. with the ADM, the ADM stated Resident 1 had a history of smoking in the facility. The ADM stated on 11/8/24 Resident 1 had gone outside his room to smoke. The ADM stated the IDT met to discuss interventions for the resident ' s care. The ADM stated the facility had Resident 1 sign a risk versus benefit form regarding smoking while on oxygen. Resident 1 ' s nurse ' s notes dated 10/31/24 indicated, Resident 1 left for dialysis and the nurse had given him the lighter while wearing oxygen. The ADM stated he was aware Resident 1 ' s cigarettes were kept in the medication cart and given to him when he left for dialysis, but did not know the nurses had provided him the lighter while he wore oxygen. The ADM stated, We cannot control what he does when he is out of the facility. The ADM stated, He is going to do what he is going to do. The ADM stated Resident 1 had a right to not be searched when he returned from dialysis. During a telephone interview on 2/5/25 at 5:08 p.m. with CNA 3, CNA 3 stated Resident 1 was rebellious. CNA 3 stated the staff frequently caught Resident 1 returning from HD with cigarettes and a lighter and he would smell like smoke when he returned. CNA 3 stated he worked the evening shift on 2/3/25 when Resident 1 returned from dialysis and checked his fanny pack. CNA 3 stated he did not find any cigarettes or a lighter which was unusual because Resident 1 normally had them when he returned. During a telephone interview on 2/5/25 at 5:23 p.m. with LVN 2, LVN 2 stated she was the charge nurse on duty during Resident 1 ' s incident on 2/4/25. LVN 2 stated she heard a CNA yell for her and went into Resident 1 ' s room. LVN 2 stated there was smoke coming out of the room and there was a fire on the ground that the CNA was trying to put out. LVN 2 stated they took the residents out of the room and pulled the fire alarm. LVN 2 stated she assessed Resident 1, and he had blood coming out of his nose and mouth and his face was black with soot. LVN 2 stated Resident 1 ' s face was smoking where his beard had been burned. LVN 2 stated the resident told her he just wanted a cigarette and when he lit the lighter, the nasal cannula caught on fire, and he threw it on the ground. LVN 2 stated Resident 1 had a lighter and cigarette with him, but she did not know where he had gotten them from. LVN 2 stated the CNAs searched Resident 1 ' s belongings and found more cigarettes. LVN 2 stated Resident 1 was on oxygen continuously and should not have been smoking. During a telephone interview on 2/6/25 at 7:21 a.m. with CNA 4, CNA 4 stated he was on duty at the time of Resident 1 ' s accident. CNA 4 stated he was in a room nearby and heard a loud noise coming from Resident 1 ' s room so he went in there. CNA 4 stated there was smoke everywhere and he saw the nasal cannula on fire on the ground. CNA 4 stated he turned off the oxygen concentrator (medical device that gives you extra oxygen) and put the fire on the ground out by stomping on it. CNA 4 stated Resident 1 ' s face was black, and his beard was burnt, and smoking and he had blood coming out of his mouth. CNA 4 stated, He looked shocked and wasn ' t saying anything, just quiet then said, ' the thing blew up ' and he ' wanted to go for a puff ' . During a review of Resident 1 ' s Acute Care Hospital ED [emergency department] Provider Notes, dated 2/4/25, indicated, . Chief Complaint . Burn . 2nd degree burns to face and right forearm from lighting cigarette while on oxygen . Face . Partial thickness burns to the left cheek. Superficial burns to the left eyelid. Burns to the lip. Soot noted in the nose. Singed hair to the face . During a review of Resident 1 ' s ACH document titled History and Physical (H&P) dated 2/4/25, the H&P indicated, . He went to hemodialysis yesterday . he decided to have a cigarette while wearing his oxygen. He accidently ignited the oxygen and suffered facial burns . Patient reports smoking about 4 cigarettes a day on days he goes to dialysis . burns are second degree . burn wounds with left eye swollen shut, lip and cheek swelling . A: [assessment] 1st and 2nd degree burn of face from contact with fire . Anticipate facial swelling, recommend nasal cannula in place at all times to stent [maintain pressure to promote healing] open the nostrils . During a review of Resident 1 ' s ACH document titled Burn Surgical Service, dated 2/4/25, the note indicated, . sustaining facial burns from smoking while using O2 [oxygen] . P: [plan] . Admit to Burn service . MMPC [multimodal pain control-treatment plan using multiple medications and therapies to control pain] . wound care . nothing by mouth for now . During a review of Resident 1 ' s ACH document titled Discharge Summary, dated 2/6/25, the DC summary indicated, . Patient c/o [complains of] nasal dryness with scab [protective crust that forms over a wound] formation making it difficult to breath[e] through his nose. He has some dyspnea [difficulty breathing] . 02/06 . Reports feeling better today but still reports pain in his face . Patient can be discharged today back to his skilled nursing facility . During a review of the facility ' s policy and procedure (P&P) titled Quality of Care Accident Hazards/Supervision/Devices, dated 7/2018, the P&P indicated, . provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents . facility recognizes the high-risk nature of the facility population and setting . Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Interventions will be modified when necessary . Identification of potential hazards in the resident environment and the risk of a resident having an avoidable accident . Identification of or development of interventions based on the severity of the hazard and immediacy of risk . Care plan intervention will be monitored for effectiveness and modified as necessary to increase effectiveness . During a review of the facility ' s P&P titled Physical Environment Smoke Free Facility, dated 3/2019, the P&P indicated, . provide a safe environment for residents . facility shall be designated smoke free . residents, visitors, contractors and staff are not permitted to smoke on the property at any time . non-smoking policy will be included in the admission packet . Residents will be informed that violation of the facility smoking policy could place the resident at risk for a facility initiated discharge due to endangerment of residents and individuals in the facility . Oxygen Therapy . resident with oxygen delivery systems will be informed of safety precautions and prohibitions for oxygen. Staff will monitor resident for compliance with the safety rules . During a review of a professional reference found at https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/oxygen-therapy/using-oxygen-safely#:~:text=Oxygen%20Therapy,-Oxygen%20survey&text=Oxygen%20is%20a%20safe%20gas,from%20what%20your%20doctor%20prescribedtitled Oxygen Therapy: Using Oxygen Safely, dated 12/15/23, the reference indicated, . Materials burn more readily in an oxygen-enriched environment . Oxygen Safety Guidelines . Keep Away from Heat and Flame . [NAME] ' t smoke and don ' t allow others to smoke near you . Keep sources of heat and flame at least five feet away . Always have a fire extinguisher [a portable devices that extinguishes a fire] nearby .

Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-a resident assessment tool used to identify resident cognitive and physical function) accurately reflected resident ' s health and functional status for one of three sampled residents (Resident 1) when Resident 1 ' s smoking status and oxygen use were not accurately coded on the MDS assessment. This failure had the potential for Resident 1's smoking and oxygen safety care needs to go unmet. (cross reference F689) Findings: During an interview on 2/5/25 at 9:23 a.m. with the Administrator (ADM), the ADM stated on 2/4/25 around 1:00 a.m., a Certified Nursing Assistant (CNA) heard a loud noise coming from Resident 1 ' s room. The CNA went into the room, and the oxygen tubing and nasal cannula (NC-medical device that provides oxygen through a thin flexible tube with two prongs that fit into the nostrils) were on fire. The ADM stated facility staff were aware Resident 1 was a smoker and would smoke when he was at hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). The ADM stated Resident 1 had a history of bringing cigarettes back in his belongings when he returned from dialysis. During a review of Resident 1 ' s Admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation (an irregular and often very rapid heart rhythm), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), end stage renal disease (ESRD-irreversible kidney failure), shortness of breath and dyspnea (difficulty breathing). During a review of Residents 1 ' s MDS assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 2/5/25 at 10:27 a.m. with CNA 2, CNA 2 stated Resident 1 was a known smoker and had been caught smoking at the facility even though the facility was smoke-free. CNA 2 stated the staff was told to make sure Resident 1 was not smoking, have cigarettes or a lighter. CNA 2 stated Resident 1 would go to HD and bring cigarettes and lighters back with him. During a concurrent interview and record review on 2/5/25 at 10:37 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a history of bringing cigarettes and lighters into the facility. Resident 1 ' s Nursing Note, dated 10/31/24 at 9:05 a.m. was reviewed. The note indicated, . Resident noted to have 8 Norco ' s [medication used to treat severe pain] in his bag, a pocketknife, and a lighter. Educated resident that he cannot have medications, knife, or lighter at bedside. Resident stated that he needs his lighter for when he goes to dialysis. Informed resident that he can take the lighter while he goes out for dialysis, but he needs to give it back to the nurse to put in the narcotic box after he comes back . Resident 1 ' s Nursing Note, dated 10/31/24 at 2:06 p.m. was reviewed, the note indicated, . Resident returned . Lighter put in narcotic [substance used to treat severe pain] box . LVN 1 stated facility was smoke-free but the notes indicated the nurse had given Resident 1 his lighter when he left for dialysis. Resident 1 ' s Order Summary Report, dated 2/2025 was reviewed, the orders indicated, . Administer oxygen @ [at] [SPECIFY] 3_L/min [liters (unit of measurement) per minute] via nasal cannula, For SOB every shift for Dyspnea . LVN 1 stated Resident 1 had been on oxygen continuously since admission. During a concurrent interview and record review on 2/5/25 at 12:05 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1 ' s MDS dated [DATE], was reviewed, the MDS indicated, . Section J . Current Tobacco Use [code 0] . No . The MDSC stated Resident 1 was known to smoke when he left for HD and would return smelling like cigarette smoke. The MDSC stated she automatically coded tobacco use as no for all residents because the facility was a smoke-free campus even though she was aware Resident 1 smoked while at dialysis with his oxygen on. The MDSC stated, If you answer yes [on the MDS], then it complicates the report because he is on oxygen. It triggers as critical. The MDSC stated Resident 1 had poor safety awareness and was at high risk for injury. Resident 1 ' s MDS dated [DATE], indicated, . Section O . Oxygen therapy [not marked] . The MDSC stated there was no check mark in the boxes for oxygen therapy which indicated the resident was not on oxygen. The MDSC stated Resident 1 had been on oxygen continuously since admission, so the MDS was not accurate. The MDSC stated it was very important for the MDS assessments to be accurate because it supports the resident ' s care needs to improve their health while in the facility. During a concurrent interview and record review on 2/5/25 at 1:10 p.m. with the Director of Nursing (DON), Resident 1 ' s MDS dated [DATE], was reviewed. The DON stated Section J did not indicate Resident 1 was a tobacco user. The DON stated the MDS ' for the facility residents were always coded no because the facility was smoke-free. The DON declined to answer if the MDS was accurate. Resident 1 ' s MDS dated [DATE] was reviewed, the DON stated oxygen use was not checked, and Resident 1 was admitted with oxygen, so it should have been answered yes. During a review of the facility ' s policy and procedure (P&P) titled Resident Assessment, dated 11/2017, the P&P indicated, . facility will conduct an initial and periodic comprehensive, accurate assessment of a resident ' s functional capacity which will include needs, strengths, goals, life history and preferences . results of the assessment will be used to develop, review and revise the resident ' s comprehensive care plan . The assessments will be conducted by individuals with the knowledge to complete an accurate assessment of relevant care areas and are knowledgeable about the resident ' s status . Individuals participating in the assessment will not willfully and knowingly certify a material or false statement . During a review of a reference located at https://nursinghomehelp.org/wp-content/uploads/2024/01/MDS-AND-CARE-PLANS-RAI.pdf titled MDS Accuracy and Comprehensive Care Plans, undated, the reference indicated, . Accuracy of Assessments . The assessment must accurately reflect the resident ' s status . Facilities are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . The assessment must represent an accurate picture of the resident ' s status . Accuracy of Assessments: Why . Proper care planning . MDS accuracy: How . Interview the resident . Interview to the family . Interview to the staff . Review the medical record . Observe resident ' s conditions care aspects . Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-a resident assessment tool used to identify resident cognitive and physical function) accurately reflected resident's health and functional status for one of three sampled residents (Resident 1) when Resident 1's smoking status and oxygen use were not accurately coded on the MDS assessment.

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan to prevent accidents for one of three sampled residents (Resident 1) when nursing staff was aware of Resident 1 ' s smoking status, attempts to bring cigarettes and lighters into the facility without staff knowledge and previous attempts at smoking while wearing oxygen at the facility and did not develop and implement effective care plan interventions to prevent smoking related injuries. This failure resulted in Resident 1 suffering second degree burns (injury that damages both the outer layer of skin and part of the underlying layer) requiring transportation to the emergency department (ED) by ambulance, admission to the acute care hospital (ACH) burn unit (a hospital ward that treats patients with burns) and had the potential to cause significant harm to the other residents. (cross reference F689) Findings: During an interview on 2/5/25 at 9:23 a.m. with the Administrator (ADM), the ADM stated on 2/4/25 around 1:00 a.m., a Certified Nursing Assistant (CNA) heard a loud noise coming from Resident 1 ' s room. The CNA went into the room, and the oxygen tubing and nasal cannula (NC-medical device that provides oxygen through a thin flexible tube with two prongs that fit into the nostrils) were on fire. The ADM stated facility staff was aware Resident 1 was a smoker and would smoke when he was at hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). The ADM stated Resident 1 had a history of bringing cigarettes back in his belongings when he returned from dialysis. During a review of Resident 1 ' s Admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation (an irregular and often very rapid heart rhythm), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), end stage renal disease (ESRD-irreversible kidney failure), shortness of breath and dyspnea (difficulty breathing). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 2/5/25 at 10:27 a.m. with CNA 2, CNA 2 stated Resident 1 was a known smoker and had been caught smoking at the facility even though the facility was smoke-free. CNA 2 stated the staff was told to make sure Resident 1 was not smoking, have cigarettes or a lighter. CNA 2 stated Resident 1 would go to HD and bring cigarettes and lighters back with him. During a review of Resident 1 ' s Nursing Note, dated 2/4/25 at 5:07 a.m., the note indicated, . 0100am [1:00 a.m.] CNA heard a noise coming from room [ROOM NUMBER] [Resident 1 ' s room], Upon entering CNA noted smock [smoke] and fired flames on the floor with nasal cannel [cannula] burning on the floor, CNA immediately put out the fired [sic], Code RED [emergency indicating fire or smoke] was activated . Resident stated I just wanted smoked a cigarette, Resident led [lit] a lighter for a cigarette, Resident was on contentious [continuous] oxygen nasal Cannula, the lighter blew up on his face, CN [charge nurse] noted blood on his mouth and nose and soot all over face, noted soot stains in bed matters [mattress], Noted resident in a sitting position . took resident to hospital for eval and TX [treatment] . During a concurrent interview and record review on 2/5/25 at 10:37 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a history of bringing cigarettes and lighters into the facility. Resident 1 ' s Nursing Note, dated 10/31/24 at 9:05 a.m. was reviewed. The note indicated, . Resident noted to have 8 Norco ' s [medication used to treat severe pain] in his bag, a pocketknife, and a lighter. Educated resident that he cannot have medications, knife, or lighter at bedside. Resident stated that he needs his lighter for when he goes to dialysis. Informed resident that he can take the lighter while he goes out for dialysis, but he needs to give it back to the nurse to put in the narcotic box after he comes back . Resident 1 ' s Nursing Note, dated 10/31/24 at 2:06 p.m. was reviewed, the note indicated, . Resident returned . Lighter put in narcotic [substance used to treat severe pain] box . LVN 1 stated facility was smoke-free but the notes indicated the nurse had given Resident 1 his lighter when he left for dialysis. Resident 1 ' s Order Summary Report, dated 2/2025 was reviewed, the orders indicated, . Administer oxygen @ [at] [SPECIFY] 3_L/min [liters (unit of measurement) per minute] via nasal cannula, For SOB every shift for Dyspnea . LVN 1 stated Resident 1 had been on oxygen continuously since admission. Resident 1 ' s oxygen therapy care plan dated 10/24/24 was reviewed. The care plan indicated, . change resident position frequently . For residents who should be ambulatory, provide extension tubing . If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal . OXYGEN Settings: O2 2-3L via NC . LVN 1 stated Resident 1 had been on oxygen at 3 liters per minute continuously and the interventions should have been individualized to reflect the resident ' s orders and usage. Resident 1 ' s smoker care plan dated 11/10/24 was reviewed, the care plan indicated, . is a smoker or user of electronic cigarette/vape device . Goal . [Resident 1] will not smoke in the facility premises . Interventions . facilities [sic] smoking policy was reviewed and accepted by the resident and /or resident family . resident requires a cigarette holder while smoking . resident requires a smoking apron while smoking . LVN 1 stated Resident 1 ' s care plan was not accurate because the facility was smoke-free and the care plan should not address what equipment to provide for him to smoke. LVN 1 stated the focus should specify if the resident used cigarettes, electronic cigarette or a vape device so the staff was aware of the specific problem. Resident 1 ' s smoking behavior care plan dated 12/6/24 was reviewed and indicated, . Focus . [Resident 1] has a behavior issue risk and benefit of smoking explained. Per patient he smokes outside the dialysis and not in the post acute care center . resident will have fewer episodes of (SPECIFY: behavior) . Anticipate and meet The resident ' s needs . Educate the resident . on successful coping and interaction strategies such as (SPECIFY) . education on risk of smoking with oxygen use provided to patient . Non compliant behavior noted during dialysis days . LVN 1 stated the care plan should not have (SPECIFY) on it. LVN 1 stated the care plans were auto populated with those areas and needed to be edited with accurate, personalized information for each resident. LVN 1 stated Resident 1 ' s care plans did not address his behaviors of sneaking cigarettes into the facility. LVN 1 stated the nurses were locking his cigarettes in the medication cart and giving them to him when he left for dialysis which should have been addressed as an intervention to prevent him from smoking onsite. LVN 1 stated Resident 1 smoked in his room on 2/4/25 which caused his burn injuries, and the care plans were not effective in preventing the incident. During a concurrent interview and record review on 2/5/25, at 11:34 a.m. with the Director of Staff Development (DSD), Resident 1 ' s smoker care plan dated 12/6/24 was reviewed. The DSD stated the interventions did not address Resident 1 ' s behaviors and did not meet his safety needs. The DSD stated Resident 1 was non-compliant with the facility rules and education was not an effective intervention. The DSD stated the care plan interventions of using a cigarette holder and smoking apron did not make any sense because the facility was smoke-free. The DSD stated care plans were very important to make sure all staff was aware of the resident ' s identified problems, put a plan in place and provide interventions to keep the residents safe. During a concurrent interview and record review on 2/5/25 at 1:10 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had a history of smoking at dialysis, had been caught smoking at the facility and previously attempted to smoke in the transport van. The DON stated the nurses would check Resident 1 for cigarettes and lighter when he returned from dialysis and lock them up. The DON stated Resident 1 smoked in his room on 2/4/25 and the nasal cannula had caught fire causing burns to his face. The DON stated Resident 1 was admitted to the burn unit at the acute care hospital (ACH). The DON reviewed Resident 1 ' s care plan dated 11/10/24 and stated she did not know why the interventions included the smoking apron and cigarette holder because the resident was not supposed to smoke onsite. The DON stated the care plan was not accurate. The DON stated the staff checked the resident for cigarettes and a lighter when he returned from dialysis and locked them up but she did not know why the intervention was not documented on the care plan. The DON stated the purpose of a care plan was to guide staff for a resident ' s plan of care and the interventions in place to meet the resident goals. The DON stated they should be individualized and specific to each resident. Resident 1 ' s care plan dated 12/6/24 was reviewed, the DON stated she had printed patient education regarding the risk of smoking and went over them with Resident 1 in December, but he continued to smoke when he left for dialysis. The DON stated Resident 1 was known to be non-compliant and the intervention of providing education was not effective. During a review of the facility ' s policy and procedure (P&P) titled Comprehensive Care Plans, dated 11/2017, the P&P indicated, . provide each resident with a person-centered, comprehensive care plan to address the resident ' s medical, nursing, physical, mental and psychosocial needs . facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-center care plan for each resident that includes measurable objectives and timeframes that meet a resident ' s medical, nursing, physical, mental, and psychosocial needs . It will drive the type of care and services that a resident receives and will describe the resident ' s medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences . During a review of a professional reference retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-skilled-nursing-facilities#:~:text=This%20helps%20keep%20you%20aware,kind%20of%20services%20you%20need titled What ' s a care plan in skilled nursing facilities, undated, the reference indicated, . When your health condition is assessed, skilled nursing facility (SNF) staff prepare or update your care plan . This helps keep you aware of how the care you get will help you reach your health care goals . may include . what kind of services you need . How often you ' ll need the services . What kind of equipment or supplies you need . Your health goal (or goals), and how your care plan will help you reach your goal . Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan to prevent accidents for one of three sampled residents (Resident 1) when nursing staff was aware of Resident 1's smoking status, attempts to bring cigarettes and lighters into the facility without staff knowledge and previous attempts at smoking while wearing oxygen at the facility and did not develop and implement effective care plan interventions to prevent smoking related injuries.

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 1, 2 and 4) were free from abuse when: 1. Staff failed to separate Residents 1 and 2 immediately after an altercation on 12/25/24 at 3:00 p.m., then Resident 2 sat next to Resident 1 in the sunroom and scratched Resident 1 in the face while the CNA ' s back was turned. Residents 1 and 2 had a known history of verbal altercations with each other. This failure had the potential to cause both residents harm and emotional distress due to cognitive (pertaining to reasoning memory and judgement) impairments. 2. Staff did not provide adequate supervision for Resident 1 after the altercation on 12/25/24 at 3:00 p.m. to prevent an altercation between Residents 1 and 4 on 12/25/24 at 4:40 p.m. This failure resulted in Resident 1 biting Resident 4 on the shoulder and had potential for Resident 4 to be harmed and experience emotional distress. Findings: 1. During a concurrent observation and interview on 1/13/25 at 10:50 a.m. with Resident 2, Resident 2 was lying in bed dressed. Resident 2 stated she did not remember any altercations with another resident. Resident 2 was alert and confused. During a review of Resident 1 ' s Admission Record (AR), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and anxiety disorder (emotional state characterized by feelings of unease, worry, fear of apprehension). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 03 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 ' s cognition was severely impaired. During a concurrent observation and interview on 1/13/25 at 10:53 a.m. with Resident 2 in her room, Resident 2 ' s privacy curtains were completely closed. Resident 2 was lying in bed, dressed. Resident 2 stated I want to sleep leave me alone. During a review of Resident 2 ' s AR, undated, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood), dementia, and anxiety disorder. During a review of Residents 2 ' s Minimum Data Set assessment dated [DATE], indicated Resident 2 ' s BIMS assessment scored 06 of 15. The BIMS assessment indicated Resident 2 ' s cognition was severely impaired. During a concurrent observation and interview on 11/13/25 at 10:56 a.m. with CNA 1, CNA 1 stated she was assigned to one-on-one supervision (1:1-to provide continuous observation of a resident) of Resident 2, to prevent confrontations between Resident 2 and the other residents. CNA 1 stated Resident 2 had a known history of going into other resident ' s rooms and getting close to them which upset the other residents. CNA 1 stated Resident 2 was able to move quickly and needed someone to stay with her. CNA 1 stated Resident 2 did not like other people close to her or loud noises and would become agitated (feeling of severe restlessness, crankiness or uneasiness). During an interview on 1/13/25 at 11:21 a.m. with CNA 2, CNA 2 stated Residents 1 and 2 had a history of not getting along with each other and the staff would try to keep them apart. CNA 2 stated Resident 1 was frequently agitated and would yell loudly which caused Resident 2 to become agitated. CNA 2 stated Resident 2 was on a 1:1 because she threatened to kill Resident 1. CNA 2 stated Resident 1 was frequently involved in verbal altercations in the memory care unit and staff would have to remove her from the situation because she was difficult to redirect. CNA 2 stated Resident 1 should have been on a 1:1 after the altercation because she would normally cause issues with the other residents when agitated. CNA 2 stated the process for resident-to-resident altercations was to immediately separate the residents and move them away from each other. During a concurrent interview and record review on 1/13/25 at 11:41 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Nursing Note, dated 12/25/24 at 3:37 p.m. was reviewed, the note indicated, . [Resident 1] was walking to sit them in the sun room when [Resident 2] called her Ugly. [Resident 1] threw water on [Resident 2 ' s] face. [Resident 2] instantly got up and tried to hit her w/ [with] the walker. CNA tried to redirect to separate both of them, but [Resident 2] refused instead sat next to [Resident 1]. When [CNA] turned to move the table [Resident 2] reached [Resident 1] and scratch her cheek. [Resident 2] said I can kill her anytime. She lives close to me . Resident 1 ' s IDT (Interdisciplinary Team- involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident) note dated 12/26/24 was reviewed. The IDT note indicated, . The Interdisciplinary Team (IDT) met to review a resident-to-resident interaction incident occurring on 12/25/24 . Staff attempted to separate the ladies from each other but they both refused. The CNA turnedto [sic] move a table and the peer then reached over and made contact with [Resident 1] by scratching her face . IDT recommends: Monitoring [Resident 1] on q [every] 15 min [minute] behavior monitoring . Resident 2 ' s IDT note dated 12/26/24 indicated, . met to review a resident-to-resident interaction incident occurring on 12/25/24 . IDT recommendation: [Resident 2] was placed on q [every] 15 min [minute] monitoring. We will begin [Resident 2] on one-on-one monitoring . LVN 1 stated staff knew Residents 1 and 2 did not had issues with each other. LVN 1 stated Resident 1 would easily become agitated and get verbally aggressive and loud. LVN 1 stated, [Resident 2] does not like loud noised and it will set her off. LVN 1 stated Resident 1 would frequently cause verbal altercations with other residents, and she was not sure why Resident 1 was not placed on a 1:1 after the incident. LVN 1 stated Resident 2 was placed on a 1:1 because she threatened Resident 1. LVN 1 stated Resident 1 and 2 needed supervision when near each other because their behaviors were unpredictable. LVN 1 stated when there was an altercation between residents the most important thing was to move them away from each other immediately for safety. LVN 1 was unsure why Resident 2 was close enough to scratch Resident 1 after the initial altercation. LVN 1 stated the residents should have been separated after Resident 1 threw the water in Resident 2 ' s face and Resident 2 tried to hit her with the walker. During an interview on 1/13/25 at 1:50 p.m. with the Director of Nursing (DON), the DON stated Residents 1 and 2 had issues with each other prior to the altercation on 12/25/24. The DON stated on 12/25/24 at 3:00 p.m. Residents 1 and 2 had an altercation which started when Resident 2 called Resident 1 ugly, and Resident 1 threw water in her face. The DON stated Resident 2 tried to hit Resident 1 with her walker, but the staff intervened. The DON stated the staff was unable to redirect Resident 2 and she sat next to Resident 1, when the CNA turned their back Resident 2 scratched Resident 1 on the face. The DON was unable to explain why the CNA would turn their back on the residents during an altercation or why Resident 2 was able to sit next to Resident 1. The DON stated Resident 2 was placed on a 1:1 because she threatened to kill Resident 1 and was physically capable of harming her. During an interview on 1/13/25 at 3:25 p.m. with the Social Services Director (SSD), the SSD stated Residents 1 and 2 had an altercation on 12/25/24. The SSD stated Residents 1 and 2 have had verbal altercations with each other in the past. The SSD stated she was part of the IDT meeting on 12/26/24 regarding the incident. The SSD stated a CNA was present during the altercation and had stopped Resident 2 from hitting Resident 1 with her walker but turned their back on the residents to move a table and Resident 2 reached over and scratched Resident 1 ' s face. The SSD stated Resident 2 had stated she knew where Resident 1 lived and could kill her at any time, so the IDT placed Resident 2 on a 1:1 for Resident 1 ' s safety. During a telephone interview on 1/14/25 at 10:51 a.m. with Registered Nurse (RN) 1, RN 1 stated she was the charge nurse on duty on 12/25/24 during Resident 1 and 2 ' s altercation. RN 1 stated after Resident 1 threw the water at Resident 2, and Resident 2 swung her walker at Resident 1 staff attempted to direct Resident 2 to another chair, but she refused and sat next to Resident 1. RN 1 stated Resident 2 sat next to Resident 1 and when the CNA turned their back, she scratched Resident 1 on the face. Resident 2 told the CNA she could kill Resident 1 at any time. RN 1 stated the residents should not have been close enough for Resident 2 to scratch Resident 1 ' s face. RN 1 stated after an altercation, residents should be moved away from each other to prevent injury. During a telephone interview on 1/20/24 at 11:15 a.m. with CNA 6, CNA 6 stated she was the assigned CNA in the sunroom on 12/25/24 during Residents 1 and 2 ' s altercation. CNA 6 stated Resident 2 was in the sunroom and after the altercation started, she had tried to redirect Resident 2 to a chair away from Resident 1. CNA 6 stated she was unable to redirect Resident 2, and she insisted on sitting next to Resident 1 even though they were agitated with each other. CNA 6 stated she turned her back on the residents briefly and Resident 2 scratched Resident 1 ' s face while her back was turned. CNA 6 stated the process for resident-to-resident altercations was to separate the residents as soon as possible. 2. During an interview on 1/13/25 at 11:17 a.m. Resident 4 was unable to recall altercation with Resident 1 on 12/25/24. During a review of Resident 4 ' s Admission Record (AR), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of senile degeneration of the brain (group of disorders that cause a gradual decline in cognitive function), anxiety disorder and pain. During a review of Residents 4 ' s Minimum Data Set assessment dated [DATE], indicated Resident 4 ' s BIMS assessment scored 03 of 15. The BIMS assessment indicated Resident 4 ' s cognition was severely impaired. During an interview on 1/13/25 at 11:21 a.m. with CNA 2, CNA 2 stated she was not working the PM shift on 12/25/24 during the altercations between Residents 1 and 2 and Residents 1 and 4. CNA 2 stated she was made aware of the altercations and the staff had been told Resident 2 was on a 1:1. CNA 2 stated Resident 4 was calm and she was surprised Resident 4 was involved in an altercation. CNA 2 stated, I think with that altercation, [Resident 4] was in the wrong place at the wrong time. CNA 2 stated after Resident 1 and 2 ' s altercation earlier in the day, Resident 1 should have been on a 1:1 because she would had a history of causing issues with the other residents when agitated. CNA 2 stated she had asked Resident 4 if she remembered what happened with Resident 1 and she did not remember the incident. CNA 2 stated the process for resident-to-resident altercations was to immediately separate the residents and move them away from each other. During a concurrent interview and record review on 1/13/25 at 11:41 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 4 ' s IDT Note, dated 12/29/24 was reviewed. The IDT note indicated, . IDT met to review a resident-to-resident event occurring on 12/25/24. [Resident 4] stood up from a chair to adjust herself, she intended to sit back in chair. A female peer [Resident 1] went to sit in the same chair as [Resident 4] was sitting back down. The peer then lightly bit [Resident 4] on her left shoulder . Staff separate the two residents . Resident 1 ' s IDT note, dated 12/29/24, indicated, . resident-to-resident event occurring on 12/25/2024 . [Resident 1] lightly bit the peer on her shoulder . IDT recommendation: [Resident 1] was placed on 15-minute visual monitoring for 5 days . LVN 1 stated Resident 1 had two altercations on 12/25/24. LVN 1 stated Resident 1 had history of causing verbal altercations with other residents. LVN 1 was unsure why Resident 1 was unsupervised in the dining room after her earlier altercation with Resident 2. LVN 1 stated Resident 4 was calm and not usually involved in altercations. During an interview on 1/13/25 at 1:50 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had two altercations on 12/25/24, an hour and a half apart. The DON stated Residents 1 and 2 had an altercation at 3:00 p.m. and then Resident 1 bit Resident 4 on the shoulder around 4:40 p.m. The DON stated Resident 1 was placed on every 15-minute checks after the first altercation and she was unsure how Resident 1 was in the dining room unsupervised at 4:40 p.m. The DON stated the staff was aware Resident 1 required supervision when in the common areas and would watch her carefully when in close proximity of the other residents. The DON stated staff should have provided extra supervision for Resident 1 in the dining room since she had an altercation earlier in the day. During a telephone interview on 1/14/25 at 10:51 p.m. with Registered Nurse (RN) 1, RN 1 stated she was the charge nurse on duty during both resident altercations on 12/25/24. RN 1 stated Resident 1 had walked in the dining room and Resident 4 stood up from her chair to readjust, Resident 1 tried to sit in the chair Resident 4 was standing in front of. RN 1 stated Resident 4 started to sit back down, and Resident 1 also tried to sit in the chair and bit Resident 4 on the left shoulder. RN 1 stated after the altercation between Residents 1 and 2, she placed the residents on every 15-minute checks. RN 1 stated Resident 1 moved quickly, and staff was unable to intervene and prevent the altercation. RN 1 was declined to state if Resident 1 had enough supervision to prevent the second altercation. During a telephone interview on 1/20/24 at 11:15 a.m. with CNA 6, CNA 6 stated she was present during both of Resident 1 ' s altercations. CNA 6 stated after the first altercation, Resident 1 went to her room and the staff were monitoring her every 15 minutes. CNA 6 stated close to dinner time Resident 1 came into the dining room and tried to sit in Resident 4 ' s chair and bit her on the shoulder. CNA 6 stated none of the staff had predicted she would have another altercation. CNA 6 stated Residents 1 and 4 had never had issues with each other before. During a review of the facility ' s policy and procedure (P&P) titled Freedom from Abuse, Neglect and Exploitation, dated 11/2017, the P&P indicated, . Purpose . keep residents free from abuse, neglect, and corporal punishment of any kind by any person . facility will provide a safe resident environment and protect residents from abuse . Definition of abuse . willful infliction of injury . When the facility has identified abuse, the facility should take appropriate steps . protect residents from additional abuse immediately. This includes but is not limited to . Take steps to prevent further potential abuse . Resident to resident abuse . Cognitive impairment or mental disorder does not preclude a resident from being abusive . Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions .

Based on interview and record review, the facility failed to provide rehabilitative services as determined by the comprehensive plan of care to attain, maintain, and restore the highest practicable level of physical well-being for one of three sampled residents (Resident 1) when Resident 1 did not receive physical therapy (PT) as ordered by the physician. This failure placed Resident 1 at risk for further decline and not meet rehabilitative goals. Findings: During an interview on 12/11/24 at 1:45 p.m. with the Physical Therapy Assistant (PTA), the PTA stated, the Physical Therapist determined the goals, amount of time and how many days a resident would require for rehabilitation based on the initial evaluation. During an interview on 12/11/24 at 2:13 p.m. with the PTA, the PTA stated, Resident 1 had physician's order to receive PT and Occupational Therapy (OT) five days a week. The PTA stated, Resident 1 was at the facility and receiving PT after she had a knee surgery. The PTA stated, Resident 1 worked with physical therapy to make progress with tolerance on mobility, weight bearing, transferring from bed to wheelchair and weight shifting. During an interview on 12/11/24 at 4:20 p.m. with the Administrator (ADM), the ADM stated, Resident 1 did not receive PT during the days of 10/19/24-10/25/24 while the PTA was out sick and there was no PT backup coverage to complete Resident 1's PT rehabilitation. During a concurrent interview and record review on 12/11/24 at 4:52 p.m. with Director of Nursing (DON), Service Log Matrix (SLM), dated 12/11/24, was reviewed. The SLM indicated, Resident 1 received PT on 10/4/24, 10/5/24, 10/7/24, 10/8/24, 10/9/24, 10/11/24, 10/12/24, 10/13/24, 10/16/24, 10/17/24, 10/18/24, 10/26/24, 10/27/24, 10/29/24, 10/30/24, 10/31/24 and 11/1/24. The DON stated, Resident 1 was admitted on [DATE] and was ordered to receive PT 5 times a week. The DON stated, Resident 1 did not receive PT during the days of 10/19/24 through 10/25/24 which caused her to miss 4 days of PT during this time. DON stated, it was important for Resident 1 to receive all her physician ordered days for PT due to her generalized muscle weakness. During a phone interview on 12/13/24 at 9:40 a.m. with the Regional Director of Rehabilitation (RDR), the RDR stated, Resident 1 was admitted to the facility on [DATE] after a left total knee revision surgery. The RDR stated, Resident 1 was ordered to have PT 5 days a week. The RDR stated, Resident 1 had PT to work on exercises involving bed mobility, transferring and wheelchair mobility. The RDR stated, Resident 1 did not receive PT during the days of 10/19/24-10/25/24 because the PTA was out sick for a week without backup coverage. The RDR stated, Resident 1 received PT on 10/18/24 but missed four days total of ordered PT during the week of 10/18/24-10/24/24. The RDR stated, Resident 1 was at risk for not fully recover from surgery which could lead to muscle weakness of the lower body from not receiving PT rehabilitation. During record review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 had diagnoses which included .AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY .MUSCLE WEAKNESS .DIFFICULTY IN WALKING . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/9/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a review of Resident 1's NSG Admission/Readmission Evaluation (NARE), dated 10/3/24, the NARE indicated, .Here for PT/OT and medication management .S/P [status post] Revision of total knee (surgery to revise a previous knee replacement surgery) .on the left with non-removable knee mobilizer (a brace that prevents the knee from bending or moving) in place . During a review of Resident 1's Order Summary Report (OSR), dated 10/4/24, the OSR indicated, .Physical therapy evaluation and treatment as indicated . During a review of Resident 1's Care Plan (CP), dated 10/4/24, the CP indicated, . [Resident 1] has limited physical mobility r/t [related to] Left Knee surgery .PT, OT referrals as ordered . During a review of the facility's policy and procedure (P&P) titled, SPECIALIZED REHABILITATION SERVICES dated 8/18, the P&P indicated, .Each resident receives the specialized rehabilitative services as determined by their comprehensive plan of care to assist them to attain, maintain or restore their highest practicable level of physical, mental, functional and psycho-social well-being .The facility will provide specialized rehabilitative services such as .physical therapy .The facility will employ directly or contract with an outside resource to engage the qualified personnel and support staff .

Based on observation, interview, and record review, the facility to ensure services provided met professional standards of practice for one of four sampled residents (Resident 1) when the facility staff failed to perform hourly monitoring of Resident 1 in accordance with the facility ' s policy and procedure (P&P) titled, Rounding Using the 4 P ' s Rounding Tool. This failure had the potential to result for Resident 1 to fall and suffer significant injury. Findings: During a review of Resident 1 ' s Admission Record, (AR) undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis including Type 2 diabetes mellitus with hyperglycemia (chronic condition that occurs when a person ' s blood sugar levels are consistently high and potentially dangerous), history of falling, difficulty in walking, dementia (impairment of brain function such as memory loss and judgement) and muscle weakness. During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 09 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 ' s cognition was moderately impaired. During a concurrent observation and interview on 9/17/24 at 9:27 a.m. with Resident 1, Resident 1 was lying in bed with a white sling on her left arm. Resident 1 stated she had fallen the previous week, hit her shoulder on the bathroom door and fractured her arm. During a concurrent interview and record review on 9/17/24 at 10:22 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a fall on 9/2/24. Resident 1 ' s fall care plan dated 9/2/24 was reviewed and indicated, . had an unwitnessed fall on 09/02/24 with fracture of left humerus . Interventions . Added on 4 ps [P ' s-pain, positioning, personal needs, personal items] monitoring . LVN 1 stated the 4 P ' s program was a rounding (practice where staff check on patients at regular intervals) tool and the staff would check on the residents in the program at a set time interval such as hourly to make sure all their needs were met. LVN 1 stated Resident 1 was started on the 4 P ' s program after her fall as an intervention to prevent falls. LVN 1 took out a binder titled 4 P ' s and opened it Resident 1 ' s logs. LVN 1 stated Resident 1 was supposed to have hourly rounds, but the log dated for 9/17/24 had not been signed off in the prior four hours. LVN 1 stated Resident 1 was scheduled for hourly rounds according to the 4 P ' s program and the log should have been signed off. Resident 1 ' s 4 P ' s logs were reviewed and found to have missing entries as follows: 9/10/24 eight entries - 7 a.m., 8 a.m., 9 a.m., 10 a.m., 11 a.m., 12 p.m., 1 p.m. and 2 p.m. 9/13/24 six entries - 7 a.m., 8 a.m., 9 a.m., 10 a.m., 11 a.m., 12 p.m. and 1 p.m. 9/14/24 three entries- 6 a.m., 7 a.m. and 8 a.m. 9/15/24 one entry - 7 a.m. 9/17/24 four entries-7 a.m., 8 a.m., 9 a.m. and 10 a.m. LVN 1 stated Resident 1 ' s care plan interventions and the 4 P ' s program were not followed to prevent falls. During a review of Resident 1 ' s IDT (Interdisciplinary Team-- group of professional doctors, nurse, and social workers working towards achieving resident healthcare goals) Note, dated 9/3/24 at 12:51 p.m., the IDT note indicated, . IDT met to review a fall occurring on 9/2/24 . Resident had an unwitnessed fall in her room as she turned to go to bathroom and tripped . IDT recommends . 4 Ps monitoring program . During a concurrent interview and record review on 9/17/24 at 10:46 a.m. with the Director of Nursing (DON), the facility ' s P&P titled, Rounding Using the 4 P ' s Rounding Tool, dated 4/2019 was reviewed. The P&P indicated, . Intent . The 4 Ps rounding system is designed to improve resident satisfaction, decrease falls, reduce skin breakdown, and improve staff satisfaction . Guideline . The 4Ps stand for Pain, Positioning, Personal Needs, Personal Items . Licensed and non-licensed staff will be expected to utilize the 4 Ps tool . Facility management will verify use of the 4 Ps with the residents while conducting daily rounding . If management identifies that staff is not utilizing the 4 P ' s system of rounding, retraining, coaching, and mentoring will be initiated by management . The DON stated the expectation for 4 P ' s program was for staff to check on the residents at the scheduled time interval for each of the 4 P ' s-pain, position, personal needs, and personal items. The missing entries on Residents 1 ' s 4 P ' s logs were reviewed. The DON stated Resident 1 was started on the 4 P ' s program as an intervention to prevent falls and staff should have rounded on her every hour and documented in the log when done. The DON provided a document with the resident names who were on the 4 P ' s program, this document indicated, . 4 P ' s is a fall prevention program used as an IDT intervention . The DON stated it was her expectation for the staff to follow the 4 P ' s guidelines. The DON stated Resident 1 ' s care plan and 4 P ' s program had not been followed.

Based on interview and record review, the facility failed to ensure residents were free from an unnecessary physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; or cannot be removed easily by the resident; and or restricts the resident's freedom of movement or normal access to his/her body) for three of six sampled residents (Residents 2, 3 and 4) when Residents 2, 3 and 4 had wedge pillows (triangular pillow to elevate the body) intentionally placed under their mattresses, out of their reach, restricting the residents freedom of movement and prevented them from getting out of bed. This failure violated Resident 2, 3 and 4 ' s rights to be free from physical restraints and placed them at risk for a decline in physical functioning and falls. Findings: During an observation on 8/29/24 at 11:08 a.m. with Resident 2, Resident 2 was lying in bed, the left side of the bed up against the wall and the right side of the mattress had an object under the sheet which tilted the mattress to the left. Resident 2 ' s movement was restricted by the position of the mattress. During a concurrent observation and interview on 8/29/24 at 11:11 a.m. with CNA 1, in Resident 2 ' s room, CNA 1 pulled up Resident 2 ' s bed sheet and uncovered a black wedge pillow under the mattress causing the resident to roll to her left side. CNA 1 stated Resident 2 had a history of falling and the wedge pillow restricted her movement to prevent falls. CNA 1 stated the wedge was placed under the mattress so Resident 1 could not reach and remove it. During a review of Resident 2 ' s Admission Record, undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis of atherosclerotic heart disease (a sticky substance called plaque builds up in the arteries and limits blood flow to the heart), atrial fibrillation (irregular and often very rapid heartbeat), dementia (loss of memory, language, problem-solving and thinking abilities) and unsteadiness on feet. During a review of Residents 2 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 2 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 99 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates the resident was unable to complete the assessment). The BIMS assessment indicated Resident 2 was not cognitively able to participate in the assessment. During an observation on 8/29/24 at 11:30 a.m. in Resident 3 ' s room, Resident 3 was observed in bed, the bed was against the wall on one side. A black wedge pillow was placed under his mattress turning him to the left, restricting his ability to get out of bed. During a review of Resident 3 ' s Admission Record, undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis of epilepsy (chronic brain disorder causes recurrent seizures [sudden, uncontrolled burst of electrical activity in the brain]), contracture (permanent tightening of the muscles, tendons and skin causing the joints to become very stiff), difficulty in walking, and dementia. During a review of Residents 3 ' s Minimum Data Set assessment dated [DATE], indicated Resident 3 ' s Brief Interview of Mental status assessment scored 99. The BIMS assessment indicated Resident 3 was not cognitively able to participate in the assessment. During an observation on 8/29/24 at 11:34 a.m. in Resident 4 ' s room, Resident 4 was observed with two black wedge pillows under the right side of her mattress and causing the mattress to lean to the left. Resident 4 was attempting to sit up with her upper body off the mattress and tried to look out to the hallway which was to her right while calling out to staff in her native language. Resident 4 was unable to turn all the way to the right because the position of the mattress prevented her from getting out of bed. During a review of Resident 4 ' s Admission Record, undated, the admission record indicated, Resident 4 was admitted to the facility on [DATE] with diagnosis of Parkinson ' s Disease (movement disorder of the nervous system [nerve cells that controls the body ' s activities] that worsens over time), abnormalities of gait (manner of walking) and mobility, dementia, and difficulty in walking. During a review of Residents 4 ' s Minimum Data Set assessment dated [DATE], indicated Resident 4 ' s Brief Interview of Mental status assessment scored 99 The BIMS assessment indicated Resident 4 was cognitively not able to participate in the assessment. During a concurrent observation and interview on 8/29/24 at 11:37 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 2 ' s room, Resident 2 was lying in bed with a black wedge pillow under her mattress. LVN 1 walked into Resident 3 ' s room and Resident 3 was observed lying in bed with one wedge pillow under his mattress. LVN 1 walked into Resident 4 ' s room and two black wedge pillows were observed under the right side of the mattress. LVN 1 stated Residents 2, 3 and 4 had wedge pillows placed under their mattresses because they were high fall risks and the wedges kept them in bed to prevent falls. LVN 1 stated the staff put the wedge pillows under the mattress because they were out of the residents ' reach and prevented them from removing the pillow. LVN 1 stated the use of wedge pillows under the mattress could be considered restraints if the residents were unable to get out of bed. During a concurrent interview and record review on 8/29/24 at 11:50 a.m., Resident 2 ' s physician ' s orders for August 2024 were reviewed. LVN 1 stated she was unable to locate an order to place wedge pillows under the mattress for fall prevention. LVN 1 stated she was unable to locate a care plan intervention for the use of the wedge pillow under the mattress to prevent falls. LVN 1 reviewed Resident 3 ' s physician orders dated August 2024 and stated she was unable to locate an order to place wedge pillows under the mattress. Resident 3 ' s care plans were reviewed, LVN 1 stated she was unable to locate an intervention for the wedge pillow. LVN 1 reviewed Resident 4 ' s physician orders dated August 2024 and stated she was unable to locate an order for wedge pillows under the mattress. Resident 4 ' s care plans were reviewed and LVN 1 stated she was unable to locate any documentation for the wedge pillow as an intervention to prevent falls. LVN 1 stated the wedge pillows were being used as a fall prevention intervention, so they needed a physician ' s order and care plan. During an interview on 8/29/24 at 1:18 p.m. with Physical Therapy Assistant (PTA) 1, PTA 1 stated wedge pillows should not be placed under the mattress if the resident could not remove it themselves. PTA 1 stated a wedge pillow under the mattress increased a residents fall risk because the residents could try to climb over it and fall. PTA 1 stated the wedge pillows under the mattresses would take the residents freedom of mobility away and could be considered a restraint. During an interview on 8/29/24 at 1:30 p.m. with CNA 2, CNA 2 stated when the wedge pillows was placed directly under the resident, they could pull the wedge pillows out. CNA 2 stated the wedge pillows were placed under the mattress to prevent the resident from removing it and keep them in bed. CNA 2 stated the staff needed to keep the residents in bed, so they do not fall. During an interview on 8/29/24 at 1:43 p.m. with the Director of Nursing (DON), the DON stated wedge pillows should not be placed under the mattress because the residents could remove it. The DON stated if the residents were unable to move freely in bed it could be considered a restraint. During a review of the facility ' s policy and procedure (P&P) titled, Freedom from Abuse, Neglect and Exploitation Physical Restraint, dated 11/2017, the P&P indicated, . an environment that prohibits the use of physical restraints for convenience . or to inhibit a resident ' s freedom of movement . A physical restraint as any manual method, physical or mechanical device, equipment or material that meets all the following criteria . Is attached or adjacent to the resident ' s body . Cannot be removed easily by the resident . Restricts the resident ' s freedom of movement . the resident will be able to . remove the restraint or device intentionally . The review process will include assessment, monitoring, care planning by the IDT [Interdisciplinary Team- a team of healthcare providers who meet to plan resident care] . During a review of a professional reference found at https://canhr.org/restraint-free-care/ titled, Restraint-Free Care, dated 10/24/22, the reference indicated, . restraints are dangerous and often cause harm to nursing home residents . In most cases, nursing home use of restraints is a form of neglect or abuse . physical restraint is a device, item or practice that restricts a resident ' s freedom of movement . physical restraint as any manual method, physical or mechanical device . is attached or adjacent to the resident ' s body . Cannot be removed easily by the resident .Restricts the resident ' s freedom of movement . The way an item is used determines if it is considered a physical restraint . if they are used to restrict residents ' movement and residents cannot easily remove them . Other methods of restraint include moving a chair or bed against a wall so residents cannot get out . Restraints often cause incontinence, poor circulation, weak muscles . loss of mobility and increased illness . also diminish independence . Residents have the right to be free from involuntary seclusion and any physical restraint not required to treat the resident ' s medical symptoms .

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 1) was free from injury when his shoeless left foot fell off his wheelchair and scraped on the pavement while out of the facility for an appointment. This failure resulted in Resident 1 experiencing abrasions to four of his toes on his left foot which caused pain, daily dressing changes by nursing staff, and an increased risk for infection. Findings: During a review of the facility document titled, Facility Reported Event (FRE) dated 7/30/24, the FRE indicated, On July 25, 2024, [Resident 1] had an appointment at [a medical clinic]. Transportation was arranged for [Resident 1] . He was picked up in the lobby by the driver. He had a footrest on the left side of his wheelchair due to mobility and sensory impairment to his left side, and right foot out to support independent mobility while self-propelling per his baseline. [Resident 1] was then taken to the scheduled appointment by the . transport driver. Upon his return to the facility, the toe area of the sock on his left foot was worn off, and his toes were exposed. He had skin injuries to the top of four of his toes. There were skin injuries noted on four toes on [Resident 1 ' s] left foot. Upon return the left sock was completely worn down, exposing all his toes. Sometime during the transport from the facility to his physician ' s office, his foot must have dragged under the wheelchair without being noticed by the transport employee causing the sock to wear down and the skin injuries to his foot. During a review of Resident 1 ' s Admission Record (AR), dated 8/16/24, the AR indicated he was admitted to the facility with diagnoses that included hemiplegia (a severe or complete loss of strength on one side of the body) and diabetes (inability to regulate blood sugar, which can lead to many different complications, such as risk for infection and delayed wound healing, especially to the feet and toes). During a concurrent observation and interview on 8/16/24, at 10:55 AM, with Resident 1, in his room, a bandage was noted to his left foot. The bandage was dated 8/16/24, and covered his lower foot, with the ends of his toes visible. Resident 1 stated he recalled the incident on 7/25/24, and, Once at the appointment, the driver started pushing me, after unloading me from the van, the ground was cement, you know? I felt a bump, like a big bump, and my foot had slipped off of my right leg. Little did I know, my left leg got caught under my wheelchair. I guessing the driver was not aware of this happening. We were kind of in a hurry, we had trouble finding the place, finding the right address, we were kind of in a hurry, trying to make the appointment on time. I have a little bit of sensation in my left leg, but I felt it when the wheel of my wheelchair rolled over my left foot. I felt the sensation all the way up into my abdomen. I got loaded back up into the van, returned to the facility. Once back at the facility, a nurse said to me: ' Your sock is all ripped and bloody. ' I saw my foot and it was all bloody. During a review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive, standardize assessment tool), dated 7/17/24, the MDS indicated at question C500, Brief Interview for Mental Status, of score of 14 out of a possible 15, which indicated he was cognitively intact. During a review of Resident 1 ' s Progress Notes (PN), dated 7/25/24, at 7:28 PM, the PN indicated, [Resident 1] in the hallway coming back from his appointment with abrasions noted on his 4 toes. [Resident 1] noted no shoes during transport and only sock is on both feet. [Resident 1] refusing taking meds and [blood glucose] check because is upset. The PN dated 7/26/24, at 4:07 PM, the PN indicated a nurse performed a dressing change to Resident 1 ' s left foot. The PN indicated Resident 1 was able to feel some discomfort during wound care. When ask if he can feel the pain to toes, he said ' yes. ' Acetaminophen, a pain reliever, was given for pain. The PN dated 7/26/24, at 8:34 PM, indicated Resident 1 complained of pain, rated at a 3 out of a 10 (with 10 being worst pain). The PN dated 8/6/24, at 11:48 AM, indicated, Resident was noted complaining that his current pain medication is not working. Verbalized discomfort with the left [upper part] foot, and that a new order was obtained for Norco [a strong, narcotic-based pain reliever] to be given routinely twice a day for pain. The PN dated 8/15/24, at 10:45 AM, indicated, [Resident 1] continues on enhanced barrier precautions [an infection control measure used to reduce the spread of disease-causing organisms] related to open wound, gloves and gown used by staff during high contact activities. The PN was written by the Infection Prevention nurse. During a review of Resident 1 ' s Care Plan (CP), dated 7/25/23, the CP indicated Resident 1 has a Skin injury skin abrasion of the left foot 2nd, 3rd, 4th 5th[toes] has diagnoses of [diabetes]. The CP indicated that in intervention is to provide shoes when going out for appointment. During a review of Resident 1 ' s Wound Evaluation (WE), dated 7/25/24, the WE indicated Resident 1 had an abrasion to the left foot that measured 8.36 centimeters in length by 2.99 centimeters in width. During an interview on 8/22/24, at 1:25 PM, with the Director of Occupational Therapy (DOT), the DOT stated she was with Resident 1 when he was being assisted into the transport van for his appointment on 7/25/24. The DOT stated that she noticed he had left the building without his left wheelchair legrest, but she applied it before he entered the transport van. The DOT stated he did not have shoes on and was wearing only socks on his feet and stated, I don ' t know why he had only socks on. During an interview on 9/3/24, at 11:30 AM, with the Director of Nursing (DON), the DON stated it would be her expectation that residents wear shoes when leaving the facility for appointments. The DON stated she would also expect the transportation staff to be attentive to residents in wheelchairs and notice when a resident ' s leg falls off of the wheelchair leg rest and to replace it safely. During an interview on 9/3/24, at 11:55 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was familiar with Resident 1 and the wounds to his toes, and has performed treatments to them. LVN 1 stated when leaving the facility for appointments, I would expect all residents to on have socks, shoes, and leg rests. LVN 1 stated she would expect the transportation drivers to be attentive to the needs of the resident and ensure they remain safely in the wheelchair and notice if a resident ' s leg fell off of the leg rest and to replace it safely.

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of nine sampled residents (Resident 1), when Resident 1 was diagnosed with dementia (a chronic or persistent disorder of the mental processes marked by memory disorder, personality changes, and impaired reasoning), and a known history of poor safety awareness and muscle weakness and contracture (shortening of muscular or connective tissue that results in deformity) of left hand; and was not supervised while she drank hot tea on 2/16/22, in accordance with comprehensive care plan which indicated Resident 1 was totally dependent on staff to eat and drink. This failure resulted in Resident 1 spilling hot tea onto her chest, suffering avoidable second-degree burns (a burn to the skin characterized by injury to the outer and middle layers of the skin), causing pain and required routine acetaminophen (pain medication) twice daily for pain management, an assessment by the Would Consultant Physician (WCP), and daily dressing changes. Findings: During a review of Resident 1 ' s Admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain), clostridium difficile (a germ that causes diarrhea and inflammation of the colon [large intestine]), protein-calorie malnutrition (inadequate intake of food), dementia, transient ischemic attack (TIA- a brief episode of weakness, vision problems, slurred speech resulting from an interruption in the blood supply to the brain), hemiplegia (weakness or partial paralysis on one side of the body) and contracture of muscle left upper arm (fixed tightening of a joint preventing normal movement of the body part). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to memory and judgement] and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental Status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 04 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had severe cognitive impairment. The MDS assessment section G (functional status) dated 1/23/22 indicated Resident 1 required the support of one-person physical assistance for eating. During a review of Resident 1 ' s progress notes written by the WCP, dated 2/16/22, the notes indicated, . 2 [second degree] burn chest . consistent with hot water . Wound Location . Chest . Type . Trauma . Burn . L x W x D [length by width by depth-measurements] 18 [cm-unit of measurement] x 40 [cm] x 0.2 [cm] . Wound cleanser . silvasorb [wound dressing for partial thickness (outer and middle layer of skin) burns]/alg [alginate-treatment for wound healing] . D [daily] . During a review of Resident 1 ' s Order Summary Report, (OSR-physician orders) dated 2/2022, the OSR indicated, . Cleanse chest with wound cleanser pat dry apply silvasorb gel and leave open to air one time a day related to BURN OF SECOND DEGREE . [brand name] Tablet 325 MG [milligrams-unit of measurement] (Acetaminophen) Give 2 tablet[s] by mouth two times a day related to BURN OF SECOND DEGREE . During a review of Resident 1 ' s IDT Note (Interdisciplinary Team-a group of different healthcare disciplines to plan, coordinate and deliver personalized care) dated 2/17/24 at 2:21 p.m., the IDT note indicated, . IDT met to review redness noted to [Resident 1 ' s] chest on 2/16/22 . Chest injury measurement is 18 [cm] x 40 [cm] x 0.2 [cm] with scant [small amount] drainage . Wound doctor, [WCP ' s name] notified and came in to evaluate [Resident 1] . [WCP] stated the site is a 2nd degree superficial [situated on the skin or immediately beneath it] burn . [Resident 1] stated she spilled tea on her chest . [Resident 1] is also at risk due to fragile skin and a contracture to her left hand . [physician (PHY) 1 ' s name] notified of event and ordered routine pain medication [brand name for acetaminophen] 325 mg 2 tabs PO [by mouth] BID [twice daily] for pain management . During a concurrent interview and record review on 4/2/24 at 1:29 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s medical diagnoses were reviewed. LVN 1 stated Resident 1 ' s diagnoses included cerebral infarction with hemiplegia, weakness and dementia which could affect Resident 1 ' s ability to safely feed herself. Resident 1 ' s ADL [activities of daily living- includes eating, dressing, bathing] care plan dated 1/21/22 was reviewed, the care plan indicated, . [Resident 1] has an ADL self-care performance deficit . Eating: [Resident 1] is totally dependent on (1) staff for eating . The resident has contractures of the left hand . LVN 1 stated the care plan indicated Resident 1 needed a staff member to physically feed her, which would include holding a cup. LVN 1 stated, probably nobody assisted her that day [when Resident 1 was burned]. A color photo of Resident 1 ' s chest dated 2/16/22 at 1:54 p.m., was reviewed. The photo revealed multiple reddened areas on the right upper chest, right breast, mid-chest, and the left inner breast with a few scattered darkened areas. LVN 1 stated the darkened areas in the photo appeared to be scabs (dry protective crust that forms over wounds) which were deeper burns to the skin. During a telephone interview on 4/11/24 at 6:31 a.m. with LVN 2, LVN 2 stated she was the day shift charge nurse on 2/16/22. LVN 2 stated at approximately 1:00 p.m., the Director of Nursing (DON) had called for her to Resident 1 ' s room. LVN 2 stated when she entered Resident 1 ' s room, she observed redness across Resident 1 ' s chest area. LVN 2 stated Resident 1 reported she had spilled hot tea on herself. LVN 2 stated Resident 1 complained she had a burning pain of eight out of 10 on the numeric pain scale (1-3 no pain to mild pain, 4-6 moderate pain, 7-10 severe pain). LVN 2 stated Resident 1 was assessed by the WCP who was in the facility at the time of the incident. LVN 2 stated the WCP indicated Resident 1 had 2nd degree burns to her chest and ordered wound care. LVN 2 stated Resident 1 ' s PHY 1 ordered acetaminophen 325 mg two tablets twice daily for pain management. Resident 1 ' s ADL care plan was reviewed, LVN 1 stated the care plan indicated Resident 1 was totally dependent on one staff member for eating. LVN 2 stated totally dependent meant Resident 1 required a staff member to provide physical assistance to eat and drink. During an interview on 4/17/24 at 10:15 a.m. with CNA 5, CNA 5 stated if a resident required assistance to eat, they were not safe to handle a hot beverage without assistance. CNA 5 stated, they could burn themselves. During a concurrent interview and record review on 4/17/24 at 10:42 a.m. with LVN 3, Resident 1 ' s NSG [nursing] Hot Beverage Safety Evaluation (HBSE- an assessment to determine the level of supervision needed for safe consumption of hot beverages) dated 1/21/22 was reviewed. The HBSE indicated, . score 3 [out of 5] . May require set up assistance . A. Resident demonstrates impaired orientation . yes . B. Resident has a diagnosis of Neuropathy [disease of the peripheral nerves causing numbness or weakness] or other neurological impairment . yes . C. Resident demonstrated one or more of the following cognitive impairments: Poor safety awareness, Impaired short term memory, Impulsiveness . Yes . score . 1-3 points: Resident may require set up assistance while consuming hot beverages . 4-5 points . Resident is unable to consume hot beverages safely independently. Resident requires supervision while consuming hot beverages . LVN 3 stated the HBSE indicated Resident 1 may require set up assistance with hot beverages but did not indicate she needed supervision. LVN 3 stated Resident 1 ' s diagnoses of cerebral infarction, dementia and weakness should be considered when evaluating if Resident 1 was safe to drink hot beverages independently. LVN 3 stated, I would question the results [of the HBSE]. LVN 3 stated Resident 1 ' s diagnoses placed her at a higher risk of burning herself if left unsupervised with a hot beverage. During a concurrent interview and record review on 4/17/24 at 11:23 a.m. with the DOR (Director of Rehabilitation), Resident 1 ' s Occupational Therapy OT Evaluation & Plan of Treatment, dated 1/24/22 was reviewed. The evaluation indicated, . Musculoskeletal System [bones, muscles and joints] Assessment . RUE [right upper extremity (arm)] Strength = Impaired [weakened or damaged] . LUE [left upper extremity] Strength = Impaired . General RUE Strength = 3/5; Shoulder = Impaired . Elbow/Forearm = Impaired . Wrist = Impaired . LUE Strength = 2+/5; Shoulder = Impaired . Elbow/Forearm = Impaired . Wrist = Impaired . Self Feeding=Patient requires assistance . Evaluation Summary . Physical/Cognitive/Psychosocial [evaluation of mental health and social well-being] Performance . presents with impairments in balance, dexterity [performing tasks with hands], fine motor coordination [small exact movements], gross motor coordination [large movements], mobility [movement], strength . limitations and/or participation restrictions in the areas of general tasks and demands . The DOR stated the evaluation indicated Resident 1 had an impairment in the strength and mobility to both arms. The DOR stated the evaluation indicated Resident 1 ' s daughter assisted with all care and mobility needs before facility admission. During a concurrent interview and record review on 4/17/24 at 12:14 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1 ' s MDS Section G dated 1/23/22, was reviewed. The MDS indicated, . H. Eating-how resident eats and drinks, regardless of skill . ADL Support Provided . code 2 [One-person physical assistance] . The MDSC stated the MDS indicated Resident 1 needed one person to physically assist her to eat. The MDSC reviewed Resident 1 ' s ADL care plan and stated the care plan indicated she was totally dependent on staff to eat. The MDSC stated it was unsafe for Resident 1 to drink a hot beverage without assistance. During a concurrent interview and record review on 4/17/24 at 12:45 p.m. with the Director of Staff Development (DSD), the DSD stated she remembered Resident 1. The DSD stated she was not working the day Resident 1 had a burn incident but had seen Resident 1 ' s wound after the incident. The DSD stated an HBSE was done for all residents on admission, quarterly and if there was an incident. The DSD reviewed Resident 1 ' s HBSE dated 2/16/22 and stated it indicated there was a cognitive impairment, poor safety awareness, impaired short-term memory, and impulsiveness. The DSD reviewed Resident 1 ' s ADL care plan and stated one person should have stayed with her the entire time she was drinking the hot beverage. The DSD stated Resident 1 was not safe to drink hot tea unsupervised. During a concurrent interview and record review on 4/17/24 at 1:10 p.m. with the DON, the DON stated on 2/16/22 at approximately 1:00 p.m. she answered Resident 1 ' s call light. The DON stated she noticed Resident 1 ' s neck was wet and there was redness across her chest. The DON stated called for the charge nurse. The DON stated she asked Resident 1 what had happened, and Resident 1 told her she spilled tea on herself. The DON stated the WCP was in the facility and assessed Resident 1. The DON stated the WCP diagnosed Resident 1 with 2nd degree burns to her chest. Resident 1 ' s ADL care plan dated 1/21/22 was reviewed, and the DON stated the care plan indicated Resident 1 was totally dependent on staff for eating. The DON stated totally dependent meant staff would set up meals, cut the food and feed the resident. The DON stated care plans were important because they provided individualized care for the residents. The DON stated Resident 1 ' s MDS Section G dated 1/23/22 indicated Resident 1 was assessed as needing one-person physical assistance to eat. The DON stated somebody should have stayed with Resident 1 while drinking hot tea. The facility ' s policy and procedure (P&P) titled Quality of Care, dated 7/2018 was reviewed. The P&P indicated, . provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents . Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment . The DON stated Resident 1 ' s individualized care plan was not followed according to P&P, and it may have prevented the accident from occurring. During a review of Resident 1 ' s NSG [nursing] Admission/Readmission Evaluation, dated 1/21/22, at 5:24 p.m., the evaluation indicated, .ADLs . Eating . The resident has an ADL self-care performance deficit . [box checked] Eating: the resident is dependent on (1) staff for eating . Impairments . [box checked] cognitive . Forgetfulness and confusion noted . During a review of Resident 1 ' s History and Physical, (H&P-complete assessment), dated 1/23/22, at 6:13 p.m., written by Physician (PHY) 1, the H&P indicated, . past medical history significant for generalized weakness, Dementia, CVA [Cerebrovascular Accident-loss of blood flow to part of the brain] with left sided weakness and left hand contracture . Dementia; Monitor behavior and help with ADL . During a review of the facility ' s policy and procedure (P&P), titled Quality of Care, dated 7/2018, the P&P indicated, . provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents . Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Interventions will be modified when necessary . Individualized interventions will be developed to reduce the potential for accidents .Interventions will be consistent with professional standards . Resident specific interventions will be reflected in the resident ' s person-centered, individualized care plan . Monitoring and modification process may include . verifying that interventions are implemented . evaluating the effectiveness of interventions . The facility may use supervision as an intervention to mitigate accident risk . Risks and Environmental Hazards . In order to be considered hazardous, a potentially hazardous item or situation must be accessible to a vulnerable resident . Hot water may reach temperatures that are hazardous for residents, putting them at risk for burns caused by scalding [injury from hot liquid or steam] . During a review of a professional reference retrieved from https://nursinghomesabuse.org/nursing-home-injuries/burns/ titled Burn Injuries in Nursing Homes, dated 4/30/23, the reference indicated, . Burn injuries are a common occurrence in nursing homes, with elderly residents being at higher risk due to factors such as decreased mobility, sensory deficits [loss, absence, or marked impairment of vision, hearing taste, touch or smell] and cognitive impairment . Burn injuries can be cause by hot surfaces, scalding liquids . are often preventable with proper staff training and safety protocols . following factors make elderly individuals more vulnerable to scalds . Impaired sensation that prevents elders from reacting quickly to heat . Thinner skin, which burns to its full depth more readily . Nursing home residents could come into contract with hot liquids if the nursing home fails to take protective measures . Hot coffee and the steam from hot foods can cause painful and severe burns. Health conditions common to the elderly . can increase the risk of elders spilling coffee on themselves . Nursing homes should always ensure food and coffee are served at safe temperatures, and that coffee is served in cups with secured lids . older adults with the following characteristics face the highest risks of experiencing burns . limited mobility Slow reaction times . Sensory impairment . Decreased coordination . Cognitive decline . When nursing homes accept patients, they accept responsibility for any harm that comes to patients while under their care . has the duty to provide a safe, hospitable environment for residents . Their duties include . protect patients . supervise patients . Take proactive measures to prevent injuries .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were free from physical abuse when Resident 2 who had a known behavior of aggression and history of altercation pushed Resident 1 down to the ground on 1/25/2024. This failure resulted in Resident 1 to sustain a laceration to her elbow, skin tear to her forehead, and bruising to her face. Findings: During a review of the Facility Reported Event, dated 1/5/24, the document indicated, At approximately 2:00 PM on 01/05/2024, [Resident 2] was wandering in the hall of Life Journey ' s Care memory care unit [a locked unit that specializes in the care of residents with memory issues]. [Resident 1] walked past [Resident 2] and [Resident 2] reached both of his hands out toward [Resident 1] making contact with her back. [Resident 1] fell on the ground upon contact, causing a laceration to her head, and a skin tear to her right elbow. Staff then redirected [Resident 2] from the area. [Resident 1] was ordered sent to [local general acute care hospital] for further evaluation. Orders were received for the laceration to her forehead and skin tear of the right elbow. She returned from the hospital at 5:00 AM on 01/06/24. During a review of Resident 1 ' s Admission Record, dated 1/5/24, the document indicated Resident 1 was an [AGE] year-old female. Her diagnoses included Alzheimer ' s Disease & dementia (progressive mental disorders affecting mood, judgement, and memory), anxiety (a mental disorder causing excessive worry and feelings of fear, dread, and uneasiness), and unsteadiness on feet. During a review of Resident 2 ' s Admission Record, dated 1/5/24, the document indicated Resident 2 was a [AGE] year-old male. His diagnoses included dementia (a progressive mental disorder affecting mood, judgement, and memory) psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (feelings of distress or sadness, or symptoms of depression and anxiety) and anxiety (a mental disorder causing excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 2 ' s Weights/Vitals, dated 1/28/24, it indicated he weighed 197 pounds and was six feet and one inch tall. During a review of the local General Acute Care Hospital ' s Emergency Documentation for Resident 1, dated 1/5/24, at 3:57 PM, the document indicated Resident 1 had been brought in by ambulance for a fall after being pushed by another resident. The document indicated Resident 1 looks comfortable. Moving arms and legs spontaneous. Resident 1 received a CT scan (a computer assisted X-ray) of her head and neck, which were negative for injury. Resident 1 was returned to the facility on [DATE]. During a review of Progress Notes, for Resident 1, dated 1/5/24, at 11 PM, the Progress Notes indicated Spoke with [local acute care hospital ' s emergency room physician] who informed that CT scan came back normal with no injuries noted. Resident has bruising to forehead and small skin tear but overall is doing well and at normal baseline. They will be sending resident back to facility at this time. During a review of Resident 1 ' s Care Plan dated 1/5/24, the Care Plan, the care plan indicated Resident 1 received physical aggression from male patient. She was pushed in the hallway and landed facedown sustained laceration to forehead and skin tear to right elbow. During a review of Resident 1 ' Progress Notes, dated 1/6/24, at 5:47 AM, the Progress Notes indicated Resident 1 is monitor for witnessed fall bump to forehead, skin tear to R[ight] elbow, laceration to forehead, denies pain or discomfort noted. Able to move upper and lower extremities are stable. No change with [level of consciousness]. During an interview on 1/30/24, at 2:25 PM, with the Director of Nursing (DON), the DON stated Resident 2 had a previous altercation with another resident in the memory care unit back on 12/2023 and is now being observed on a one-to-one basis, 24 hours a day since the incident with Resident 1 occurring on 1/5/24. The DON stated the facility is working with Resident 2 ' s family to find a more appropriate clinical setting for Resident 2. During a concurrent observation and interview, on 1/30/24, at 3:10 PM, with Certified Nursing Assistant (CNA) 1, in Resident 2 ' s room, Resident 2 was resting in his bed peacefully with his eyes closed. CNA 1 stated I ' m watching Resident 2 on a one-on-one basis now. CNA stated, Resident 2 has a history of getting agitated. I was here during the incident with [Resident 1]. It happened in the middle of the hallway, he had been trying to get into another resident ' s bedroom, and that resident was telling him to get out of here. This agitated him. Then I heard another CNA say to him, No, and I turned and saw [Resident 1] on the floor on her face. [Resident 2] had pushed her. [Resident 2] stated, she was laughing at me, and she was, but she has dementia. But he was agitated. During a concurrent observation and interview, on 1/30/24, at 3:27 PM, with CNA 2, in Resident 2 ' s room, Resident 2 remained resting in his bed peacefully with his eyes closed. CNA 2 stated he has taken over from CNA 1 and is now performing one-on-one observation with Resident 2. CNA 2 stated, I ' m watching [Resident 2] because of his behaviors. He does get agitated. He ' ll quickly jolt up out of bed. As long as he ' s escorted with a one-on-one, the other residents are safe. During an interview with the Administrator (ADM)- on 1/30/24, at 4:35 PM, the ADM stated, In hindsight, [Resident 2 ' s admission to the facility] wasn ' t the best admission. The ADM stated prior to admission to the facility, Resident 2 did not display any aggression, but did wander. The Administrator stated, I believe the loudness and the yelling in our Memory Care Unit overwhelms him and causes him to display aggressive behavior. During a review of the facility ' s policy and procedure (P&P) titled, Freedom from Abuse, Neglect, and Exploitation, dated 9/13/22, the P&P indicated, in part, Purpose: To keep residents free from abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility ' s policy is to prohibit and prevent abuse.

Based on observation, interview and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, wheno ne of three License Nurses (Licensed Vocational Nurse 1) did not know how to set up a suction machine and did not receive training on suctioning. This failure placed residents at risk for respiratory distress which could lead to death. Findings: During an interview on 8/31/23, at 1:00 p.m. with LVN 1, LVN 1 stated training on suction was part of a competency check off list at the facility. LVN 1 stated she had not performed suctioning at the facility. During a concurrent observation and interview on 8/31/23, at 1:24 p.m. with LVN 1 in the Ice Room, 2 crash carts were against the wall, both crash carts had a suction machine on top of them. LVN 1 pulled bag valve mask (a handheld tool that is used to deliver air to someone not breathing well) out of a plastic bag. LVN 1 stated, she would connect the bag valve mask to the suction tubing and turn the suction on. LVN 1 attached the bag valve mask bag to an oxygen masks tubing. LVN 1 stated, I don't know if this is for suction. During a concurrent observation and interview, on 8/31/23, at 1:15 p.m. with LVN 1, in the Ice Room there were 2 covered crash carts. LVN 1 removed both covers off of the crash carts. LVN 1 stated there was suction on top of both crash carts. LVN 1 stated, she could not set up the suction. LVN 1 stated she had not received training on setting up the suction. LVN 1 stated she had not demonstrated how to put suction together at the facility. During an interview on 8/31/23, at 4:20 p.m. with the Director of Nursing (DON), the DON stated LVN 1 had missed the annual competency training due to being on leave when annual competency training was held during the month of May at the facility. During an interview on 9/20/23, at 10:31 a.m. with the Director of Staff Development (DSD) the DSD stated, The Licensed Nurses competencies were done in May. The DSD stated she kept track of when the Licensed Nurses (LN) were on leave and when they returned from leave. The DSD she or the DON would schedule a time for a LN's to complete their competency if they missed it while on leave. The DSD stated the LN's clinical competencies should be competed as soon as possible upon return to work at the facility. During an interview on 9/20/23, at 10:46 a.m. with the DON, the DON stated, when LN's are hired the orientation process starts with the DSD. The DON stated, the LN's annual competency skills training was usually done in May. The DON stated, when the LN's annual competency training is missed the LN will get an orientation when they return from leave and then the DON or DSD will schedule a one on one to complete the LN's annual competency skills training. The DON stated, she did not complete the orientation with LVN 1 after her leave due to her being on vacation when LVN 1 returned. The DON stated, LVN'1 orientation was completed by the Unit Manager Registered Nurse (UMRN) or the DSD. The DON stated, it is within the scope of practice for LVN's to administer oropharyngeal suctioning (a procedure used to remove secretions that can block normal airflow that can lead to someone not getting enough oxygen). The DON stated, it was her expectation that all LVN's at the facility would know how to set up suction. The DON stated, setting up suction was part of the Licensed Nurses annual competency training. The DON stated, training on suction was not included in LVN 1's Nursing Orientation Checklist. The DON stated, training on suction was part of LVN 1's Licensed Nurse Core Clinical Competency. The DON stated, it was important for LN's to know how to set up suction for the residents safety at the facility. The DON stated, knowing how to set up suction was important for emergent situations, to clear a resident's airway to assist with breathing. During a review of Job Description Licensed Vocational Nurse , dated 2022, the Job Description Licensed Vocational Nurse indicated, . Delivers Resident Care: Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . Continuing Education: Participate in facility/department in-services and quality improvement activities . Safety: Demonstrates proper use of equipment . During a concurrent interview and record review, on 9/20/23, at 3:33 p.m. with the DSD, LVN's Nursing Orientation Checklist (NOC), dated 3/21/23, was reviewed. The NOC indicated, . Skill/Task Observed /Completed . Location of Oxygen Crash Cart . Additional Training [blank area] . Comment [blank area] . Initials of Trainer [blank area] . The DSD stated, she went over and initialed the NOC for LVN 1. The DSD stated there was no skill or task for suctioning listed on the NOC . The DSD stated, she went over LVN 1's training on suctioning when training her on the section for the location of the crash cart (a wheeled container carrying medicine and equipment for use in emergencies). The DSD stated, she did not put her initials on the initials of trainer section of LVN 1's NOC for Location of crash cart. The DSD stated the initials of trainer section of the NOC for location of crash cart was blank. The DSD stated LVN 1 went on leave on 4/24/23 and returned to the facility on [DATE]. The DSD stated, she had not scheduled the one on one competency training for LVN'1 since she had returned to work at the facility. During an interview on 9/22/23 @ 4:47 p.m. with the UMRN, the UMRN stated, she remembered doing LVN 1's nursing core competency. THE UMRN stated, when she documents discussion on the Nursing Core Competency that meant that her and LVN 1 discussed the procedure but did not perform the procedure. The UMRN stated, LN's get practice hooking up suction during the annual skills competency training in May. The UMRN stated, if a LN's annual skills competency training, the DON and DSD would set up a date to go over the skills fair. The UMRN stated, the annual skills competency training should be reviewed with the returning LN within a week of their return to the facility. The UMRN stated, it was important for nurses to receive skills training to ensure they were competent (having the necessary ability, knowledge, or skill to do something successfully) as a nurse at the facility. During a review of JOB DESCRIPTION UNIT MANAGER - REGISTERED NURSE , dated 2022, the JOB DESCRIPTION UNIT MANAGER - REGISTERED NURSE indicated, . Administrative Functions: . Assure all new staff to unit receive appropriate orientation job as per job description . Assess all staff ability to perform their job tasks by . staff evaluation process . provide in-service to nursing staff as needed . During a review of LVN 1's Licensed Nurse Core Clinical Competencies dated 7/7/23, the Licensed Nurse Core Clinical Competencies indicated, . Employee to be observed completing the following: . Oropharyngeal suctioning . Date 7/7 . Observer initials [UMC] . Comments . Discussion . During a concurrent interview and record review on 9/27/23, at 10:04 a.m. with the DON, Licensed Nurse Core Clinical Competencies [undated] was reviewed. The Licensed Nurse Core Clinical Competencies indicated . Procedure . Employee to be observed completing the following: . Oropharyngeal Suctioning . The DON stated, it was her expectation there would be a nurse trainer discussing the oropharyngeal suctioning and the nurse being trained would do a return demonstration (an educational technique where a skill first observed then practiced in mock or real situations). The DON stated, if a resident required suctioning and a licensed nurse did not know how to set up the suction machine, there was a potential for the resident to have further respiratory decline.

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of three sampled residents (Resident 1) when Licensed Nurses did not accurately document Resident 1's tube feeding and water flush totals accurately in Resident 1's Medication Administration Record (MAR). This failure had the potential for Resident 1 to be administered more fluids (tube feeding and water flushes) than ordered. Findings: During a review of Resident 1's Admission Record (AR), dated 8/31/23, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Moderate Protein - Calorie Malnutrition (lack of proper nutrition) and Gastrostomy Status (an opening into the stomach made surgically for food). During a concurrent interview and record review, on 9/7/23, at 3:27 p.m. with License Vocational Nurse (LVN) 4, Resident 1's Medication Administration Record (MAR), dated 8/2023 was reviewed. The MAR indicated, Resident 1 had a doctor's order for Jevity (a supplemental nutrition used for tube feedings) 60 milliliters (mls [standard of measurement]) an hour for 20 hours to be turned off from 8:00 a.m. to 10:00 a.m. and 4:00 p.m. to 6:00 p.m., with a total of 360 mls to be administered for AM shift and PM shift and a total of 480 mls to be administered for NOC shift. LVN 4 stated, Resident 1's MAR had documentation that Resident 1 was administered 480 mls on 8/6/23, 8/7/23 and 652 mls on 8/8/23 on the AM shift and 480 mls on 8/5/23, 8/6/23, and 8/7/23 on the PM shift. LVN 4 stated, the mls documented for AM shift on 8/6/23, 8/7/23, 8/8/23 were not accurate. LVN 4 stated, the mls documented for PM shift on 8/5/23, 8/6/23 and 8/7/23 in Resident 1's MAR was not accurate. LVN 4 stated, Resident 1 should have had 360 mls documented on 8/6/23, 8/7/23 and 8/8/23 for the AM shift and 360 mls documented on 8/5/23, 8/6/23, 8/7/23 for the PM shift. During a concurrent interview and record review, on 9/7/23, at 3:53 p.m. with LVN 4, Resident 1's Medication Administration Record (MAR), dated 8/2023 was reviewed. The MAR indicated, Resident 1 had a doctor's order for water flushes three times a day of 175 mls every 8 hours, with a total free water of 525 mls a day. LVN 4 stated, Resident 1's MAR indicated Resident 1 was administered 200 mls of water flush at 4:00 a.m. on 8/5/23, 8/6/23, 8/7/23, and 8/8/23. LVN 4 stated Resident 1's MAR indicated Resident 1 was administered 200 mls of water flush at 10:00 a.m. on 8/5/23, 8/6/23, 8/7/23 and 8/8/23. LVN 4 stated Resident 1's MAR indicated Resident 1 was administered 200 mls of water flush at 6:00 p.m. on 8/4/23, 8/5/23, 8/6/23 and 8/7/23. LVN 4 stated, all the water flushes should have been documented as 175 mls. LVN 4 stated, all of the water flushes documented as 200 mls were incorrect. LVN 4 stated, he had documented giving 200 mls on Resident 1's MAR at 6:00 p.m. on 8/6/23 and 8/7/23. LVN 4 stated his documentation was incorrect. LVN 4 stated, documentation in Resident 1's MAR should have been accurate. During a concurrent interview and record review, on 9/8/23, at 11:33 a.m. with LVN 5, Resident 1's MAR , dated 8/2023 was reviewed. The MAR indicated, Resident 1 had an doctor's order for Jevity 60 milliliters (mls [standard of measurement]) an hour for 20 hours to be turned off from 8:00 a.m. to 10:00 a.m. and 4:00 p.m. to 6:00 p.m., with a total of 360 mls to be administered for AM shift and PM shift and a total of 480 mls to be administered for NOC shift. LVN 5 stated, she documented administering 652 mls of Jevity on 8/8/23 for the AM shift in Resident 1's MAR . LVN 5 stated she did not thoroughly read the doctors order and her documentation was not accurate. LVN 5 stated, documentation in Resident 1's MAR should have been accurate. During an interview on 9/20/23, at 10:46 a.m. with the Director of Nursing (DON), the DON stated, the Licensed Nurses at the facility had incorrectly documented the mls in Resident 1's MAR for the doctor's order for Jevity and water flushes. The DON stated, it was her expectation that the Licensed Nurses documented correctly. The DON stated the Licensed Nurses had made a documentation error. The DON stated, it was important for Licensed Nurses to document correctly because it was a standard of practice and part of the rights of medication administration for nursing (right patient, right drug, right dose, right time, right route, right reason, right documentation). During an interview on 9/27/23, at 4:49 p.m. with the DON, the DON stated, it was important to accurately documents tube feedings to ensure the right calorie intake. The DON stated, it too much fluids were given there was a potential for a resident to experience fluid overload (too much fluid volume in the body). During a review of Professional Reference from https://www.cms.gov, titled, Nursing Home Staff Competency Assessment for Registered Nurse and Licensed Vocational Nurse, undated, indicated, . Competency Assessments are an important tool . which leads to higher quality of care and life for residents . Follows safe medication administration practices, such as adhering to accepted processes around medication use and documentation .

Based on observation, interview, and record review, the facility failed to ensure the safety and protect one of three sampled residents (Resident 1) from sexual abuse when Resident 2 had a known history of inappropriate behavior towards Resident 1 and effective interventions were not in place to prevent Resident 2 from touching Resident 1's penis. This failure resulted in Resident 1 to manifest physical signs of emotional distress. Findings: During an interview on 5/30/23, at 9:20 a.m., with the Administrator (ADM), the ADM stated Resident 2 grabbed Resident 1's penis on 5/29/23. During a review of Resident 2's Interdisciplinary Team (IDT) note, dated 5/29/23, at 6:57 p.m., the IDT note indicated, .IDT met via phone conference to review an event of sexual contact [Resident 2] was involved. Staff observed her touching the genitals of a male peer whom [Resident 1] states she is in a relationship with. [Resident 1] quickly removed her hands once she saw staff approaching . During a review of Resident 1's clinical record titled, Admission Record (document containing resident personal information), dated 5/20/23, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with early onset (progressive mental deterioration affecting memory and other mental functions with onset prior to age 65), severe dementia (progressive loss of thinking, remembering and reasoning), and major depressive disorder (mental health disorder characterized by depressed moods). During a review of the Resident 1's Minimum Data Set (MDS -a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 99 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 1 was unable to complete the assessment. During a review of Resident 1's Interdisciplinary Team (IDT) note, dated 5/4/23, at 2:51 p.m., the IDT note indicated, .IDT met with the family of [Resident 1's name] to discuss a friendship he has developed with a female peer . The family states that when he is feeling uncomfortable, he will begin shaking or taping [tapping] a leg . Staff will be made aware of family's observation and provide redirection of the peer when [Resident 1] is feeling uncomfortable . During a review of Resident 1's progress note titled, Nursing Note, dated 5/29/23, at 12:18 p.m., written by LVN 2, the note indicated, .AM [day shift] CNA informed this writer that she was standing in the hallway between the dining room and the sunroom . CNA stated that as soon as she turned around she witnessed [Resident 2] reaching her arm over her seat into the personal space of [Resident 1] . [Resident 2] was noted moving her hands off of him quickly as CNA got closer [Resident 1] was sitting with his arms on the arm rest with his genitalia hallway exposed over his sweatpants . During a review of Resident 2's clinical record titled, Admission Record (document containing resident personal information), dated 5/30/23, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included severe dementia, agitation (unpleasant stated of extreme arousal), generalized anxiety disorder (mental health disorder of persistent worry and anxiety), and mild cognitive impairment (memory and thinking impairment). During a review of the Resident 2's MDS assessment dated [DATE], indicated Resident 2's BIMS assessment score was 03 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 2 had a severe cognitive deficit. During a review of Resident 2's progress note titled Nursing Note, dated 5/29/23, at 10:32 a.m., the note indicated, .Today 5/29/23 @ [at] 0830 [8:30 a.m.] [Name of Resident 2] was witnessed by staff sexually inappropriately touching a male resident . During a review of Resident 2's care plan dated 5/29/23, the care plan indicated, . [Resident 2] has a behavior of being sexually inappropriate toward a male per on 5/29/23 r/t [related to] Dementia . Goal . [Resident 2] will have no further evidence of behavior issues . Interventions . If reasonable discuss the residents behavior. Explain/reinforces why behavior is inappropriate and/or unacceptable to the resident . Intervene as necessary to protect the rights and safety of others . Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed . Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes . Provide a program of activities that is of interest and accommodates residents status . Q [every] 15 minute behavior monitoring . During an observation on 5/30/23, at 9:43 a.m., Resident 2 was in a wheelchair in the memory care unit hallway shouting curse words at staff as they passed by. Resident 2's body language was tense with her body leaning forward and eyebrows furrowed. A staff member sat next to the resident attempting to distract and calm her. During an interview on 5/30/23, at 10:00 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Residents 1 and 2. CNA 1 stated staff were aware Resident 2 was possessive over Resident 1. CNA 1 stated, [Resident 2] has a fit when you try to separate her from [Resident 1], she is attached to him. CNA 1 stated Resident 1 was unable to verbalize his feelings and the staff would closely monitor him for physical signs to indicate if he was uncomfortable around Resident 2. During an observation on 5/30/23, at 10:08 a.m., with Resident 1, Resident 1 was lying dressed, on top of his bed. Resident 1 was unable to verbally answer questions. During an interview on 5/30/23, at 10:10 a.m., with CNA 2, outside of Resident 1's doorway, CNA 2 stated she was assigned to supervise Resident 1 and keep him safe from Resident 2. CNA 2 stated, I do not feel like it's fair to him [Resident 1], that he has to have a one to one [supervision by staff] because of her [Resident 2's] behaviors. CNA 2 stated, [Resident 2] is obsessive toward [Resident 1], thinks he is her man. CNA 2 stated Resident 2 had a history of inappropriate behavior towards Resident 1 and she had witnessed Resident 2 attempting to kiss Resident 1 in the past and had to separate them. CNA 2 stated Resident 1 was unable to complain verbally but would show outward signs of discomfort such as bouncing his leg or shaking his head and hand. During an interview on 5/30/23, at 10:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the charge nurse for the memory care unit. LVN 1 stated she was not at the facility when Resident 2 had touched Resident 1's penis. LVN 1 stated she had been concerned about Resident 2's behavior towards Resident 1 prior to the incident and would try to keep them separated but was told by SS the residents were friends and should not be separated. LVN 1 stated the Administrator (ADM) and Social Services (SS) had made guidelines for Resident 2 to follow with Resident 1. LVN 1 pointed at a sign hanging on the nurse's station door which indicated, . [name of Residents 1 and 2] visiting guidelines . Visits with Resident 1 are done in the TV room or dining room . No entering Resident 1's bedroom . do not interrupt when nurses take Resident 1 for care . no visiting with Resident 1 during his family visits . no visiting during mealtimes. Resident 1 will sit as a different table . No visiting if Resident 1 is sleeping . No physical contact beyond touching hands . No leading Resident 1 around . If the above is not followed, staff will separate Resident 1 from your visit. A meeting will be scheduled with the administrator . LVN 1 stated the ADM and SS reviewed the guidelines with Resident 2. LVN 1 stated the staff were instructed to follow the guidelines. LVN 1 stated the guidelines did not keep Resident 1 safe and were ineffective. During a concurrent interview and record review on 5/30/23, at 10:55 a.m., Resident 2's care plan, dated 5/4/23, was reviewed. The care plan indicated, . Focus . [Resident 2] has formed a mutual relationship with a male peer. [Resident 2's] meaningful relationship includes occasional intimacy of hand holding . [Resident 2] will have no further evidence of behavior issues . [Resident 2] will engage in a relationship without sexual contact . Offer socialization in public areas of the unit . provide frequent checks to ensure that contact does not become sexual or that the affection does not become unwanted . LVN 1 stated the care plan interventions were not appropriate because Resident 2 could not be redirected would become agitated when Resident 1 was moved away from her. LVN 1 stated Resident 1 was rarely verbal but showed physical signs when he was nervous or uncomfortable such as his face would turn red and bounce his leg. During an interview on 5/30/23, at 11:30 a.m., with CNA 3, CNA 3 stated, she witnessed the incident between Residents 1 and 2 on 5/29/23. CNA 3 stated she was supervising the dining room and sunroom from the hallway. CNA 3 stated she taken a few steps away out of eyesight for a couple of seconds . CNA 3 stated, when I came around the corner [Resident 2] had [Resident 1] sitting next to her and was grabbing his private parts [penis] which were exposed. CNA 3 stated, When [Resident 2] saw me she quickly pulled her hand away. CNA 3 stated Resident 1's face was red, he stared straight ahead, and his leg was bouncing which he usually did if he was nervous or uncomfortable. CNA 3 stated she had removed Resident 1 from the room immediately which caused Resident 2 to become agitated and verbally aggressive. CNA 3 stated Resident 2 had a history of interfering with Resident 1's care and the administration made rules for her to follow when visiting with Resident 1, but the rules did not work because Resident 2 would not follow them. During an interview on 5/30/23, at 12:13 p.m., with the DON, the DON stated she was told a CNA had witnessed Resident 2 touch Resident 1's genitals. The DON stated prior to the incident, the facility administrative staff had made up a program and created interventions and guidelines for Residents 1 and 2's visitation. The DON stated Resident 2 was difficult to redirect away from Resident 1. During a concurrent interview on 5/30/23, at 12:22 p.m., with the ADM and DON, the ADM stated he was the abuse coordinator. The ADM stated he, the DON and social services had made a program with visitation guidelines for Residents 1 and 2. The ADM stated, the programs are not working great. The ADM stated Resident 2 was very difficult to redirect. The DON stated Resident 1 was placed on a one to one to keep him safe from Resident 2. During a phone interview on 5/31/23, at 12:51 p.m., with Family Member (FM) 1, FM 1 stated the family was notified of the incident on 5/29/23. FM 1 stated the family had ongoing concerns regarding Resident 2's attention toward Resident 1 prior to this incident and had last discussed their concerns with the administration on 5/22/23. FM 1 stated the family was assured Residents 1 and 2 would be supervised when together, but now it had crossed a line. FM 1 stated Resident 1 had tells when he was nervous or uncomfortable, he would stare straight ahead, face turned red and would bounce his leg. During a phone interview on 5/31/23, at 2:20 p.m., with LVN 2, LVN 2 stated she was the charge nurse at the time of the incident between Residents 1 and 2. LVN 2 stated a CNA had witnessed Resident 2 touching Resident 1's genitals (penis and/or testicles). LVN 2 stated Resident 2 was obsessed with Resident 1 and would try to control him which interfered with his care. LVN 2 stated Resident 1 appeared uncomfortable around Resident 2 and prior to the incident, she tried to keep the residents apart because she was concerned for Resident 1. LVN 2 stated when she had discussed her concerns with the administration, she was told the residents had a right to be friends and to follow the visitation guidelines put into place. LVN 2 stated Resident 2 was much calmer when she was with Resident 1 and stated, I feel like we are using him [Resident 1] to make her [Resident 2] happy. LVN 2 stated it was not fair to Resident 1. LVN 2 reviewed Resident 2's relationship care plan and stated the interventions were not effective because Resident 2 was difficult to redirect and had sexually assaulted (intentionally touch another person without consent) Resident 1. During a phone interview on 6/1/23, at 9:33 a.m., with Social Services (SS), SS stated she was aware Resident 2 had fondled Resident 1 on 5/29/23. SS stated Residents 1 and 2 developed a friendship a few months ago and would sit together for activities. SS stated Resident 2's feelings toward Resident 1 had evolved and Resident 1 stated Resident 2 was her boyfriend. SS stated there was an occasion prior to the incident on 5/29/23 where Resident 2 had taken Resident 1 by the arm and directed him down the hallway towards his room which prompted her and the ADM to make visitation guidelines for Resident 2. SS stated she and the ADM discussed the guidelines with Resident 2 and she appeared to understand the guidelines. SS stated Resident 1 was not capable of understanding the guidelines, so she and the ADM discussed them with his family. SS stated the memory care staff tried to keep the residents separated because they believed Resident 1 was uncomfortable with Resident 2 which would cause Resident 2 to become agitated and yell. SS stated she had informed the memory care staff the residents had a right to be friends and could sit together if Resident 2 did not lead Resident 1 around or interfere with his care. SS stated Resident 1's family was fine with their friendship if they were supervised. SS stated the lack of supervision caused the incident between Residents 1 and 2. SS stated, we failed by staff walking away, supervision lapsed for a few moments. During a review of the facility's policy and procedure titled Freedom from Abuse, Neglect and Exploitation, dated 11/2017, the P&P indicated, .keep residents free from abuse, neglect, and corporal punishment of any kind by any person . The facility will provide a safe resident environment and protect residents from abuse . This includes freedom from verbal, mental, sexual, or physical abuse . Definition of Sexual Abuse: Non-consensual sexual contact of any type with a resident . When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately . Take steps to prevent further potential abuse . Revise the resident care plan if indicated . Resident to resident abuse . Cognitive impairment or mental disorder does not preclude a resident from being abusive . Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g., physical, sexual .) . Sexual abuse . Non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent or a resident who does not want the contact to occur . Investigations of an allegation of sexual abuse will start with a determination of whether the sexual activity was consensual or not, taking into consideration the cognitive ability of the resident to consent . Residents without the cognitive ability to consent will not engage in sexual activity . Resident outcomes that will be considered in instances of sexual abuse may include but not limited to . Anxiety . Reasonable Person Concept for Evaluation of the Severity of Psychosocial Outcomes . To apply the reasonable person concept, the facility should assess the psychosocial outcome or potential outcome the abuse may have on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in the residents similar situation to suffer as a result of the abuse) .

Based on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current Covid-19 (an infectious disease caused by the SARS-CoV-2) virus status for seven of 62 sampled residents (Residents 6, 16, 23, 25, 31, 58, and 59 and) when: 1. Resident 6's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 6 did not have an active COVID-19 diagnosis. 2. Resident 16's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 16 did not have an active COVID-19 diagnosis. 3. Resident 23's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 23 did not have an active COVID-19 diagnosis. 4. Resident 25's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 25 did not have an active COVID-19 diagnosis. 5. Resident 31's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 31 did not have an active COVID-19 diagnosis. 6. Resident 58's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 58 did not have an active COVID-19 diagnosis. 7. Resident 59's COVID-19 status was inaccurately coded in the MDS assessment as currently having active COVID-19 and Resident 59 did not have an active COVID-19 diagnosis. These failures resulted in an inaccurate assessment of Residents 6, 16, 23, 25, 31, 58 and 59's MDS assessment and had the potential for the residents to receive unnecessary Covid-19 treatment. Findings: During a review, on 11/28/22, at 3:00 p.m., of MDS Resident Matrix (a list of all current residents and their pertinent care categories), seven residents were listed as having active COVID-19 and it was reported by the Administrator (ADM) that there were currently no residents with active Covid-19 cases in the facility since August 2022. During a concurrent interview and record review, on 11/29/22, at 03:01 p.m., with the Resident Assessment Director (RAD), the MDS Resident Matrix, dated 11/28/22, was reviewed. The RAD indicated, Residents 6, 16, 23, 25, 31, 58 and 59's MDS assessment had been inaccurately coded with code U07.1 which indicated Residents 6, 16, 23, 25, 31, 58 and 59's had active Covid-19 cases. The RAD stated all MDS assessments should be accurately coded to reflect the residents' health status. During an interview with ADM and the Director of Nursing (DON), the DON stated the RAD should have done a full assessment of all residents as part of the MDS assessment process prior to documenting it in the MDS assessment, The ADM stated it was the RAD's responsibility to ensure MDS assessments were accurately coded for all residents. During a review of professional reference from CMS (Centers for Medicare and Medicaid Services) titled, Resident Assessment Instrument dated 10/18 (found at www.cms.gov) indicated, . Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplined are required to develop individualized care plans . The RAI helps nursing home staff to look at residents holistically as individuals for whom quality of life and quality of care are mutually significant and necessary .

Based on observation, interview, and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1 experienced severe pain level of seven to eight (pain scale- is a tool that measures pain intensity to help assess a person's pain) from 12/23/19 through 12/28/21 as a result of a fall on 12/21/21. Licensed Vocational Nurses (LVN) 1, 2, 3 and 4 did not use a consistent and appropriate tool to assess pain, did not accurately document shift pain assessments, and did not notify the physician when pain was severe in accordance with facility policy and procedure and professional standards of practice. These failures resulted in Resident 1 experiencing uncontrolled pain and suffering from 12/23/21 through 12/28/21 which led to her inability to sleep at night and make simple movements. Resident 1 was sent to the acute care hospital on 12/28/21 when an X-ray was performed revealing a left [CONDITION(S)] requiring surgical intervention and received [MEDICATION(S)] (controlled narcotic used to treat moderate to severe pain) for pain management at the acute care hospital. Findings: During a concurrent observation and interview on 1/3/21, at 10:54 a.m., with Resident 1, in Resident 1's room, Resident 1 was laid in bed. Resident 1 stated she was admitted to the facility because she had experienced multiple falls at home. Resident 1 stated, on 12/21/21 she pressed the call light (device used to signal professional staff for assistance) and staff did not respond promptly so she ambulated to the restroom independently and tripped over her oxygen tubing. Resident 1 stated, she fell on her left side and experienced seven to eight out of 10 pain and was sent to the acute care hospital for an X-ray (device used to picture inside the body) on 12/21/21. Resident 1 returned to the facility from the acute care hospital on 12/22/21, with no new medication orders and no fracture was detected from the fall. Resident 1 stated, when she returned, she continued to have severe pain to her left hip. Resident 1 stated, staff did not address her severe pain, LVN's would tell her that her pain medication was not due and that she had to wait until it was time for her pain medication. Resident 1 stated, LVNS's did not offer any other pain medication and the pain got worse because staff would move her and insisted that she should get up and walk when she had severe pain to her left hip. Resident 1 stated, the pain to her left hip was horrible aching sharp pain and she couldn't sleep. Resident 1 stated it took the facility six days to realize, I knew what I was talking about and ended up with a hip surgery. Resident 1 stated, she had to scream in pain until they got another X-ray on 12/28/21 which revealed a left [CONDITION(S)]. Resident 1 stated, she had pain before the fall which was located on her bottom from a pressure ulcer (skin injury) and after the fall the pain on her left hip was more severe than the pressure ulcer pain. Resident 1 stated, she declined to receive physical therapy (PT) and occupational therapy (OT) after the fall because she was unable to tolerate the pain. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 which indicated Resident 1 was cognitively intact. During a review of Resident 1's clinical record, the order summary report dated 12/13/21 indicated [MEDICATION(S)] (pain medication to treat moderate to severe pain) tablet 50 mg (milligrams-unit of measurement) give 1 tablet by mouth every 6 hours as needed for pain level 2-10 related to pain unspecified joint. During a review of Resident 1's Medication Administration Record (MAR), dated 12/1/21 - 12/31/21, the MAR indicated Resident 1 received [MEDICATION(S)] 15 times between 12/23/21 - 12/28/21 for pain ranging from 5-8/10 pain. During a concurrent interview and record review on 1/3/21, at 11:30 a.m., with Infection Preventionist (IP), Resident 1's Progress Notes (PN), dated 12/21/21 was reviewed. The PN indicated, .Nurse was standing at the medication cart doing medication pass, heard a loud bang and resident stating NO NO, heard glass/plastic break. Nurse immediately went to room to see what happened and resident was on the ground on right side stating her hip was broken. Water was all over the floor. Nurse immediately asked resident what hurt resident stated everywhere but mainly her hip and she thinks its broke. Resident had a laceration on right forearm and skin tear on forearm as well. Resident insisted on going to ER for evaluation, provider stated send her out . The IP stated she was covering the shift on 12/21/21 when Resident 1 fell . The IP stated Resident 1 was admitted to the facility on [DATE] for PT and OT due to multiple falls at home. IP stated when she entered Resident 1's room after the fall, Resident 1 grabbed her left hip and was in severe pain of more than 10 out of 10. The IP stated Resident 1 insisted on going to the acute hospital and did not want an X-ray at the facility. The IP stated she assisted Resident 1 off the floor onto her bed, Resident 1 held her left hip and screamed in pain. During a concurrent interview and record review on 1/3/21, at 4:01 p.m., with the IP, Resident 1's Pain Evaluation dated 12/21/21 was reviewed. The pain evaluation indicated, .Are you taking any pain medication now? No .Do you have pain now? No .Have you had pain in the last five (5) days? No .Do you have a history of pain or chronic pain? No .Pain score out of 10, where 1 is mild pain and 10 is worst pain possible. 10 .Does pain negatively impact: Sleep and rest: Yes .physical activity and mobility: Yes .Resident stated nothing is going to help she needs to go to the hospital that her hip is broke. Nurse [assessed] resident no bruising noted to hip, pain upon movement. Nurse and CNA assisted resident to bed, called provider received orders to send out to acute to be evaluated . The IP stated the pain evaluation form was completed on admission, after a fall or any change of condition. The IP stated the pain evaluation was inaccurate because Resident 1 was taking pain medication, experienced pain, and had taken pain medication in the past 5 days. The IP stated the pain evaluation form was also incomplete because the form was not completed to its entirety and had blank sections such as the location and description of the pain. The IP stated the inaccurate pain evaluation form was given to EMT [Emergency Medical Technician] when they transported Resident 1 to the acute care hospital on 12/21/21. The IP stated the pain evaluation form should be complete and accurate to reflect accurate current and prior history of pain. During a review of Resident 1's ED-[emergency department] Physician Notes, dated 12/21/21, the ED notes indicated, .chief complaint of left hip pain s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Pain exacerbates with movement left hip movement . Xrays negative for acute fractures or dislocation . Patient refusing to go back to SNF, doesn't feel like she is receiving appropriate care there .12/21/21 .[MEDICATION(S)] [narcotic medication for sever pain] .Pain Intensity: 8 .12/21/21 .[MEDICATION(S)] .Pain Intensity:9 During a review of Resident 1's Progress Notes, dated 12/22/21, the progress notes indicated, .Resident arrived back at facility .There was no fx [fracture] of the hip after the fall from yesterday. No new orders from the hospital . During a concurrent interview and record review on 1/3/21, at 12:24 p.m., with LVN 1, Resident 1's MAR dated 12/1/21 -12/31/21 was reviewed. The MAR indicated, .[MEDICATION(S)] tablet 50 mg (milligrams-unit of measurement) give 1 tablet by mouth every 6 hours as needed for pain level 2-10 related to pain unspecified joint . LVN 1 initials on the MAR indicated she administered [MEDICATION(S)] on the following days: 12/23/21 at 1205 for a pain level of 8 out of 10 12/24/21 at 1152 for a pain level of 7 out of 10 12/25/21 at 1027 for a pain level of 8 out of 10 LVN 1 reviewed the MAR and stated, [MEDICATION(S)] was the only pain medication Resident 1 had since admission. LVN 1 stated, Resident 1 would tell her that her pain was throbbing and stabbing pain to her left hip and would constantly ask for pain medication during her shift. LVN 1, stated she did not document the pain assessment and should have. LVN 1 stated, it was important to have a complete accurate pain assessment to include the level of pain, quality, region, severity, and time in order to have a trail to look back on and evaluate the underlying cause of the pain. If it's not documented, then it's not done. LVN 1 stated, Resident 1 would still complain of pain even after medicating her with pain medication after an hour of administration she would request more pain medication. LVN 1 stated, on 12/28/21 she called the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated she did not call the physician to obtain an X-ray or obtain other pain medications sooner and should have because Resident 1 continued to have left hip pain after her fall on 12/21/21. LVN 1 stated, a pain rating of 7-10/10 was considered severe pain and she would document the medication was effective, but it was only effective for about an hour. LVN 1 stated, the X-ray results came back on 12/28/21 indicating Resident 1 had a left [CONDITION(S)] and she was sent out to the acute care hospital. During a review of Resident 1's Progress Notes, dated 12/28/21, the progress notes indicated, .called MD [medical doctor] to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Per PT/OT she's unable to do therapy d/t pain .X-ray results received .Conclusion left femoral neck fracture [[CONDITION(S)]]. MD .notified .gave T.O [telephone order] to send to ER [emergency room ] for further eval and treatment . During a review of Resident 1's Radiology Report, dated 12/28/21, the report indicated, .Conclusion: Left femoral neck fracture . During a review of Resident 1's acute care hospital final report dated 12/31/21, the report indicated, .Reason for Admission L [left] [CONDITION(S)] .she tripped on oxygen tubing .she was found to have left femoral neck fracture. She went under left hip hemiarthroplasty [hip surgery] .12/28/21 .[MEDICATION(S)] .Pain intensity 8 During a telephone interview on 1/4/21, at 1:47 p.m., with LVN 2, LVN 2 stated, Resident was cognitively intact and would request pain medication. LVN 2 initials on the MAR indicated she administered [MEDICATION(S)] on the following days: 12/25/21 at 0420 for a pain level of 8 out of 10 12/28/21 at 0528 for a pain level of 7 out of 10 LVN 2 stated she did not document a full pain assessment such as the location of the pain and should have. LVN 2 stated, looking back at all the pain medication Resident 1 was receiving, she should have called the physician for breakthrough pain management to alleviate the pain and identify the source of the pain but didn't. LVN 2 stated, with her nursing judgment it was the LVN's responsibility to call the physician within 48 hours of constant use of pain medication. During a telephone interview on 1/13/21, at 10:35 a.m., with LVN 3, LVN 3 stated, she did not document a full pain assessment to include location, quality, and duration of pain. LVN 3 stated it was important to conduct and document a full pain assessment in order to have documentation to look back on the type of pain Resident 1 was experiencing and elaborate in the nurses' progress notes. LVN 3's initials on the MAR indicated she administered [MEDICATION(S)] on the following days: 12/24/21 at 0540 for a pain level of 5 out of 10 12/27/21 at 0319 for a pain level of 6 out of 10 LVN 3 stated she should have looked back at the MAR and seen that Resident 1 was constantly receiving pain medication. LVN 3 stated she should have notified Resident 1's physician for better pain management. During a telephone interview on 1/17/21, at 5:06 p.m., with LVN 4, LVN 4 stated, on 12/27/21 she worked double shift that day. LVN 4's initials on the MAR indicated she administered [MEDICATION(S)] on the following day: 12/27/21 at 11:23 a.m. for a pain level of 7 out of 10 12/27/21 at 10:01 p.m. for a pain level of 7 out of 10 LVN 4 stated, Resident 1 would constantly ask for [MEDICATION(S)] during her shift. LVN 4 stated, the therapy department had also told her that Resident 1 was in pain and was unable to work with them. LVN 4 stated, she looked at the MAR but couldn't give the medication because it was ordered for every 6 hours as needed. LVN 4 stated, when Resident 1 had consistent pain and was not working with therapy due to left hip pain, the physician should have been called but wasn't. LVN 4 stated, the purpose of notifying the physician would have been to obtain an X-ray or send her out to the acute care hospital to find the root cause of her left hip pain. LVN 4 stated, she did not document in the progress notes full pain assessment to include the location of the pain and quality of pain to have a record of the pain. LVN 4 stated, documentation was important because it provided a trend we can look back on and identify the root cause of the pain. During a telephone interview on 1/13/21, at 9:03 a.m., with the PT, the PT stated he frequently communicated to the nursing department regarding Resident 1's left hip pain and her inability to participate in therapy. The PT stated the nursing departments response to him was that they will administer pain medication when the it was time. The PT stated after Resident 1 had a fall between 12/21/21 - 12/28/21, he saw a decline which was related to her left hip pain and her inability to bear weight on her left side. During a review of Resident 1's Physical Therapy Treatment Encounter Notes, dated 12/23/21, the notes indicated, .Unable to bear weight on single leg stance on left, unable to ambulate at this time .PT additionally has pain with 90 degrees of passive hip flexion on left .Nursing staff educated to utilize WC [wheelchair] for transfers to bathroom to reduce weight bearing and ambulation until further clarity gained .due to clinical exam may require additional imaging for subsequent views or further inspection .Pt appears to have new limitations from left hip after fall. Imaging from hospital negative for fx [fracture] but clinical exam today indicates there may be underlying bone pathology limiting ability to ambulate or bear weight on left leg . During a review of Resident 1's Physical Therapy Treatment Encounter Notes, dated 12/24/21, the notes indicated, .Pt continues to lack sufficient weight bearing tolerance. Unable to perform steps with right foot due to poor weight bearing tolerance on left. Deferred further attempts due to pain and poor form .Continues to be limited in out of bed mobility due to weight bearing pain on left . During a review of Resident 1's Physical Therapy Treatment Encounter Notes, dated 12/25/21, the notes indicated, .Pain at rest .left hip . very painful .Pain with Movement .left hip . very painful .Pt declined to stand saying she was in too much pain . During a review of Resident 1's Physical Therapy Treatment Encounter Notes, dated 12/27/21, the notes indicated, .Pt reports she is feeling terribly and does not want to get out of bed .(Reports pain limiting activities today) .Unable to progress with weight bearing activities today due to pt refusal . During an interview on 12/3/21, at 12:55 p.m., with Occupational Therapy Assistant (OTA), the OTA stated Resident 1 would decline therapy because she had too much pain in her left hip. OTA stated she notified LVN's regarding Resident 1's refusal of therapy and reports of pain to left hip. The OTA stated the LVN's response to her would be that they would, look into it and check if she was due for pain medication. During a review of Resident 1's Occupational Therapy Treatment Encounter Notes, dated 12/27/21, the notes indicated, .nursing aware .(Pt AMB [ambulates] on [NAME] toes of LLE [left lower extremity] c/o [complain of] pain in hip) .Pt unable to progress with skilled interventions d/t [due to] pain . During a review of Resident 1's Occupational Therapy Treatment Encounter Notes, dated 12/28/21, the notes indicated, .reporting 10/10 pain to L hip despite premedicating .pt's progress and performance limited d/t reports of 10/10 pain in L hip with NSG [nursing] notified . During a review of Resident 1's Physical Therapy Treatment Encounter Notes, dated 12/28/21, the notes indicated, .PT [patient] reports feeling very poorly today due to 10/10 pain in left hip. States she cannot participate with PT today .may require further ortho [orthopedics-bone doctor] follow up due to clinical presentation of hip pain, limited ambulation, and poor weight bearing tolerance .What exacerbates pain?= Standing, Bending .Response to Session Interventions: Pt unable to participate in session due to significant hip pain. During a telephone interview on 1/13/21, at 8:28 a.m., with Medical Doctor (MD), the MD stated if Resident 1 was having consistent left hip pain and continued to refuse PT/OT then licensed nurses should have informed him and should not have waited 6 days to call him. During a concurrent interview and record review on 1/4/21, at 3:21 p.m., with the Director of Nurses (DON), the facility pain assessment tool titled PRN PAIN FLOW CHART, dated 10/2018 was reviewed. The flow chart indicated, .Ask resident to rate level of pain each shift and as needed .Resident acknowledges pain above a 3 .Gather information from resident related to location and type of pain .Note: if resident has an increase in pain or has received several PRN pain medications in 24, Notify MD regarding routine pain control regimen . The DON stated the flow sheet was an assessment algorithm used by icensed nurses when administering PRN pain medication. The DON stated after Resident 1 returned to the facility on [DATE] the MD was not notified until 12/28/21. The DON stated Licensed Nurses should have called the MD sooner for Resident 1's left hip pain. The DON stated Resident 1's continued refusal for therapy should have also triggered the licensed nurses to notify the MD. During a concurrent interview and record review on 1/25/21, at 10:26 a.m., with the DON, the facility policy and procedure titled Quality OF CARE Pain Management, dated 11/2017 was reviewed, the policy indicated, .Residents are assessed and evaluated to identify pain and manage pain/symptoms with appropriate non-pharmacologic and pharmacologic interventions to assist the resident to attain or maintain his/her highest practicable level of well-being .the facility coordinates care and treatment that are in accordance with evidence based standards of practice, the comprehensive person-centered care plan, the resident's choices as it relates to pain relief or pain management .While a facility completes regularly scheduled assessments .they also have a process for ongoing clinical assessment and identify changes in condition .The facility, to the extent possible: Evaluates the existing pain and the cause(s), and, Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .Expression of pain may be verbal or nonverbal. The facility will evaluate residents through complaints of pain .physical symptoms .or loss of function or ADLs [activities of daily living] .An evaluation of pain based on professional standards of practice may necessitate gathering the following information, as applicable to the resident .the evaluation may include: Characteristics of pain, such as: (intensity, pattern, location, frequency and duration); Impact of pain on quality of life (e.g., sleeping, functioning .Evaluate the potential underlying cause of pain to the extent possible assess the resident for potential for pain characteristic onset . The DON reviewed Resident 1's progress notes and stated, the LVN's were not following the facility policy and were not documenting the pain evaluation as indicated in the policy. The DON stated, the Licensed Nurses should have complete and accurate documentation and follow professional standards of practice for pain management. During a review of the facility guideline titled PAIN MANAGEMENT, dated 12/2020, the guideline indicated, .To identify pain and implement interventions to reduce or relieve pain, to the extent possible, thus enabling residents to achieve their highest practicable level of functioning and quality of life .If a resident is utilizing a PRN pain medication frequently, staff will notify the physician and facilitate a review of the pain management regimen for possible revision. The care plan will be updated to reflect any revisions . During a review of the facility document titled, Licensed Practical Nurse/Licensed Vocational Nurse JOB DESCRIPTION dated 6/2018 was reviewed, the Licensed Practical Nurse/Licensed Vocational Nurse JOB DESCRIPTION indicated, .Keep physician and/or other health care professionals .informed of resident's condition; and notify physician and/or other health care professionals immediately of significant changes of condition .Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices .Company, facility and departmental policies and procedures, and appropriately utilize nursing judgment .Ensure accurate documentation of all medical records and reporting forms . During a review of professional reference titled Pain Assessment and Management - Understanding the Requirements, dated 10/21/21 retrieved from https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/provision-of-care-treatment-and-services-pc/ 2161/ indicated, .A 'screening' is a process for evaluating the possible presence of a problem. An 'assessment' gathers more detailed information through collection of data, observation, and physical examination. Assessments are completed individuals deemed qualified through education, training, licensure, etc., to conduct such evaluations. Pain assessment tools are generally evidence-based and often include, at a minimum, an evaluation of pain intensity, location, quality, and associated symptoms. An accurate pain screening and assessment is the foundation on which an individualized, effective pain management plan is developed. For example, a pain 'screening' may be used to determine if the patient has pain or not. If the patient answers yes, a comprehensive pain assessment would be indicated . Organizations are responsible for ensuring that appropriate screening and assessment tools are readily available and used appropriately .

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent falls for one of three sampled residents (Resident 1) when Resident 1 was assessed as high risk for falls and the Interdisciplinary team (IDT) (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) did not conduct a timely update, revision and implementation of Resident 1's fall care plan interventions based on assessed and recommended needs following falls on 3/22/19 and 12/21/19. These failures resulted in Resident 1 having an avoidable fall on 12/21/19 which caused a laceration to the left eyebrow and a skin tear to the lip. The injuries to Resident 1 required transportation to the acute care hospital (ACH) emergency department (ED) and surgical repair. Resident 1 experienced pain and suffering as a result of the injuries. Findings: During an interview with the Director of Nursing (DON), on 1/8/2020, at 2:08 p.m., the DON stated Resident 1 leaned forward and fell on the floor in the facility lobby near the nurses' station while on her wheelchair on 12/21/19 and sustained a laceration above her left eyebrow. The DON stated Resident 1 was transferred to the acute care hospital on [DATE] at 1:51 p.m. for further evaluation and medical management. During a concurrent interview and record review with the DON, on 1/8/2020, at 2:08 p.m., the DON reviewed Resident 1's IDT notes dated 3/25/19 and stated Resident 1 had a history of [REDACTED]. The DON stated Resident 1 fell out from her wheelchair and sustained a hematoma (localized bleeding outside of blood vessels due to trauma) on her left brow area. The DON stated Resident 1 was assessed as high fall risk on 2/8/19 before the fall on 3/22/19 and on 9/22/19 (before the fall on 12/21/19). During a concurrent interview and record review with the DON, on 1/8/2020, at 2:08 p.m., the DON reviewed Resident 1's IDT note dated 3/25/19, which indicated, . Provide rest periods after meals . She stated the IDT recommendations on 3/22/19 did not specify where Resident 1 needed to take rest periods after every meal. The DON stated Resident 1's rest periods were not determined whether they needed to be taken in bed or in her wheelchair. The DON stated Resident 1 needed to take rest periods to prevent recurrent falls. During a review of Resident 1's face sheet (a document with demographic, personal and medical information) dated 1/8/2020, the record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 1, the Minimum Data Set (MDS) (assessment of healthcare and functional needs) dated 12/26/19, indicated Resident 1 had short and long term memory impairment. The MDS document indicated Resident 1 was severely impaired in decision making during activities of daily living, and on wheelchair with total dependence (full staff performance) and required two-person physical assistance with mobility and transfers. During a review of the clinical record for Resident 1, the initial, Fall Risk Observation/Assessment (a health assessment by licensed nurses to evaluate risk of fall) dated 9/22/19, indicated Resident 1's fall risk score was 12 (the document indicated a score of 10 or higher was considered high risk for falls) with a history of falls on 3/22/19. During an observation with Resident 1, on 1/8/2020, at 2:24 p.m., she laid on her bed with the reclining wheelchair on the foot of her bed and did not respond to questions. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 1/8/2020, at 2:36 p.m., she stated she was assigned to Resident 1 on the morning of 12/21/19 when she sat at the nurses' station and heard a loud noise. She stated she found Resident 1 on the floor and laid on her left side of the body with the left eyebrow bled profusely. LVN 1 reviewed Resident 1's IDT note dated 3/25/19 (previous fall on 3/22/19), which indicated, . IDT met to review a witnessed fall occurring on 3/22/19 at 1630 (4:30 p.m.). (Resident 1) was sitting in her WC (wheelchair) by the lobby when all of a sudden (Resident 1) slowly falling asleep on her chair hitting her face down on the floor . noted a golf ball size hematoma on top of her left brow bone . As per report from CNA (Certified Nursing Assistant) assigned to her (Resident 1) for the shift, (Resident 1) has been sitting on her WC since lunch time and she was noted sleepy prior to her fall . IDT recommendations . Provide rest periods after meals . LVN 1 stated Resident 1's care plan interventions were not updated by IDT based on assessed needs on 3/28/19 and was not specific to indicate whether the rest period for Resident 1 had to be in bed or in the wheelchair to implement and prevent Resident 1's recurrent falls. During an interview with LVN 1, on 1/8/2020, at 2:36 p.m., she stated Certified Nursing Assistants (CNAs) were used to placing Resident 1 by the nurses' station right after lunch meal and would put Resident 1 in bed after assisting all other residents after lunch meal. She stated she saw Resident 1 asleep in the wheelchair with eyes closed minutes before she fell on [DATE]. LVN 1 stated Resident 1 had a habit of rocking herself a lot and at times would fall asleep while in her wheelchair. She stated CNAs should have put Resident 1 in bed immediately after lunch meal to provide Resident 1 rest period. LVN 1 stated Resident 1 was dependent on staff for all activities of daily living and used the wheelchair for mobility with one staff assistance. During a review of the clinical record for Resident 1, the Progress Notes dated 12/21/19, at 1:55 p.m., indicated, . At 1315 (1:15 p.m.) writer (LVN 1) was sitting at nurses' station when a loud noise was heard . resident found on floor lying on L (left) side of body in lobby. She was last seen in WC (wheelchair) with arms crossed and eyes closed minutes before fall. Upon Observation laceration to L eyebrow significant bleeding present pressure applied and controlled. Resident also had small ST (skin tear) to lip Send to ER (emergency room ) for further eval. (evaluation) . Resident transferred out of facility at 1330 (1:30 p.m.) . During a review of acute care hospital records for Resident 1, the Emergency Department progress notes dated 12/21/19, at 2:36 p.m., indicated, . The patient presents following fall .The fall was described a lost balance, from wheelchair laceration to left side of forehead and pelvic pain . Procedure: Laceration repair . 3.5 cm (centimeters) in length. Left brow. Linear. Superficial. Skin closure: # 6 (number of staples) staples (used in surgery in place of sutures to close skin wounds) . During an interview with CNA 1, on 1/8/2020, at 2:59 p.m., she stated Resident 1 had similar falls on 3/22/19 and 12/21/19 when Resident 1 fell forward on her wheelchair in the facility lobby and sustained an injury. She stated Resident 1 often moved from side to side while sitting in her wheelchair and sometimes would lean on her one side while in wheelchair. CNA 1 stated Resident 1 used a standard wheelchair at the time of the falls on 3/22/19 and 12/21/19 where Resident 1 sits up and not considered as rest period for Resident 1. She stated Resident 1 should have been put into bed for rest after meals on 12/21/19 and was not. CNA 1 stated the fall on 12/21/19 could have been preventable if Resident 1 had a reclining back wheelchair (chair with adjustable backrest and/or footrest into a reclined position for users who sleep in chairs frequently) to rest. During an interview with CNA 2, on 1/8/2020, at 3:11 p.m., he stated he was assigned to Resident 1 on the morning of 12/21/19 (date of fall) when Resident 1 leaned forward and fell on the floor. CNA 2 stated he was not aware Resident 1 was done with her lunch meal and was placed by other CNA (unrecalled) in the nurses' station. He stated he was responsible to put Resident 1 back to bed after lunch meal and he did not. During a review of the clinical record for Resident 1, the IDT note dated 12/23/19, at 2:59 p.m., indicated, . IDT met to review fall that occurred on 12-21-19 at 1351 (1:51 p.m.), (Resident 1) was in her wheelchair, in lobby, after lunch. Two nurses were sitting at nurses' station when a loud noise was heard. Both nurses stood up and saw (Resident 1) lying on left side of her body. She (Resident 1) was last seen in wheelchair with arms crossed and eyes closed minutes before fall . (Resident 1) was found to have a laceration above her left eyebrow with significant bleeding . (Resident 1 also had a small skin tear to her lip . (Resident 1) transferred out of facility at 1330 (1:30 p.m.) . (Resident 1) returned to the facility . (Resident 1) noted to have 6 stitches on her left eyebrow . IDT recommendations: Encourage (Resident 1) to rest in bed after lunch . During a concurrent phone interview and record review with Minimum Data Set Coordinator (MDSC), on 1/9/20, at 9:49 a.m., she reviewed Resident 1's fall care plan dated 1/20 and stated Resident 1's care plan interventions of rest periods after meals was not in place from 3/22/19 (date of previous fall) to 12/21/19 (date of fall) in the management of fall prevention. MDSC 1 stated Resident 1's care plan was updated only after Resident 1's fall on 12/21/19. MDSC stated licensed nurses were responsible for updating the IDT recommendations to Resident 1's care plan. During a concurrent interview and record with DON, on 1/9/2020, at 10:21 a.m., she reviewed Resident 1's IDT note dated 3/25/19, indicated, . Provide rest periods after meals . and stated Resident 1's fall care plan was not updated by the IDT and did not indicate Resident 1's rest periods after meals had to be in bed or in wheelchair to address Resident 1's fall prevention. During a concurrent interview and record review with DON, on 1/9/2020, at 10:21 a.m., she reviewed Resident 1's IDT note dated 12/21/19 and indicated, . IDT recommendations: Encourage (Resident 1) to rest in bed after lunch . She stated IDT recommended a reclining back wheelchair for Resident 1's care interventions on 12/21/19 to prevent fall and the IDT should have documented the intervention (reclining back wheelchair) to Resident 1's current care plan and did not. During a review of the facility policy and procedure titled, Quality of Care - Accident Hazards/Supervision/Devices dated 7/18, indicated, . Falls . 2. When a resident experiences a fall, the facility will evaluate potential casual factors to aid in the development and implementation of relevant, consistent and individualized interventions to reduce the likelihood of future occurrences. 3. The facility will initiate and implement a comprehensive, resident-centered fall prevention plan for residents at risk for falls or with a history of falls . During a review of the facility policy and procedure titled, Comprehensive Care Plans dated 11/17, indicated, .1. The care plan will be comprehensive and person-centered . 3. The comprehensive care plan will be reviewed and revised by the IDT following both comprehensive and quarterly review assessments . During a review of the facility policy and procedure titled, Assessing Falls and Their Causes dated 10/10, indicated, . The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .1. Review the resident's care plan to assess for any special needs of the resident .4. Falling may be related to underlying clinical conditions and functional decline . During a review of a professional reference titled, The Basics of Reclining Wheelchairs, at http://www.eldercarelink.com/elder-mobility/basics-of-reclining-wheelchairs.htm, dated 2020 (updated), indicated, . Reclining backs and moving seats allow for the most comfort and ease of use .The reclining wheelchair is often larger than standard wheelchairs and might be more difficult to transport. Many reclining wheelchairs can lie flat, allowing the user to sleep in the wheelchair if necessary . is made much easier by a reclining wheelchair that tilts back to a full 90-degree angle .

Based on observation, staff interview, clinical record, administrative document and police report review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse when CNA 1 punched (struck with a closed fist) Resident 1 twice in the abdomen (belly) and once in the left thigh. This failure resulted in Resident 1's suffering emotional distress and physical bodily injury. Findings: On 9/7/16 at 8:15 a.m., during an interview in the Director of Nurses' (DON) office, the DON stated on 9/6/16 at 1:30 a.m., CNA 2 reported to the night shift nurse in charge, Registered Nurse (RN) 1, she witnessed CNA 1 punch Resident 1 twice in the abdomen and once on the left thigh. The DON stated there was no reason to suspect CNA 2's report was not accurate. The DON stated CNA 1 was immediately suspended pending an internal investigation and was subsequently terminated (fired) as a result of that investigation. The DON stated police were called and CNA 1 was arrested on charges of assault and battery (the crime of threatening a person together with the act of making physical contact with them). On 9/7/16 at 8:45 a.m., Resident 1 was observed sitting in a wheelchair in the facility's Life's Journey Hallway, a locked dementia (chronic disorder of mental processes marked by memory loss, personality changes, and impaired reasoning) care unit. Resident 1 looked frightened, and responded unintelligibly (impossible to understand) to questions. Review of Resident 1's clinical record titled Minimum Data Set (MDS) (an assessment of resident's level of function and health care needs) dated 8/29/16, indicated Resident 1 had moderate cognitive (pertaining to perception, reasoning, judgement and memory) impairment and required extensive staff assistance for mobility, dressing, eating, hygiene and bathing. On 9/7/16 at 9:05 a.m., during an interview on the Life's Journey Hallway, CNA 3 stated she was making her rounds on 9/6/16 at 6 a.m., when she entered Resident 1's room. CNA 3 stated, She (Resident 1) looked sad. CNA 3 stated she asked Resident 1, What's wrong? CNA 3 stated, She (Resident 1) started crying. She (Resident 1) always cries, but this time she looked scared. CNA 3 stated, at first, Resident 1 said nothing, but then said, crying in Spanish, The man, the man. On 9/28/16 at 2:48 p.m., during an interview, RN 1 stated on 9/6/16 at 1:30 a.m., CNA 2 reported to her (RN 1) she was taking care of a resident in room [ROOM NUMBER] and heard Resident 1 screaming so she went to see what was going on. RN 1 stated CNA 2 reported she saw CNA 1 punch Resident 1 twice in the stomach and once in the left leg. RN 1 stated CNA 2 reported she asked CNA 1 what he was doing and he said Resident 1 hit him first. RN 1 stated CNA 2 told CNA 1 to get out of Resident 1's room and she would finish providing care. RN 1 stated she went immediately to Resident 1's room to assess Resident 1's condition. RN 1 stated, (Resident 1) was bawling (crying) her eyes out. Would not make eye contact . RN 1 stated Resident 1 rubbed her left leg and cried, Scared of him. RN 1 stated, (Resident 1) stated she didn't know what she did wrong. She didn't want him around. RN 1 stated Resident 1 had previously expressed she did not want CNA 1 assigned to her care. RN 1 was unable to provide the timeframe for Resident 1's expressed request. RN 1 stated CNA 1 was still occasionally assigned to care for Resident 1. The Nurses Note, dated 9/6/16 at 6:48 a.m., indicated Staff member (CNA 2) approached CN (Clinical Nurse, RN 1, and author of the note) at approximately (1:30 a.m.) stating that she didn't know what to do about it, but she had heard (Resident 1) screaming and had entered her room to check on her and witnessed (CNA 1) strike resident twice in the abdomen and once on the left upper thigh. She stated that she yelled at (CNA 1) to stop and asked him what he was doing. He replied to her that resident had struck him first. She told CN that she told him to leave her (Resident 1) alone and leave the room and that she would finish up care for the resident. Resident noted crying when CN entered room to ask what had happened. She did not want to make eye contact or speak to writer. Asked LVN (Licensed Vocational Nurse, LVN 1) to talk to her (Resident 1) in Spanish and see if she would open up. (LVN 1) was able to get her talking and she told her that that man had hit her while rubbing her left thigh and crying. She also stated that she is scared because she doesn't want him to come back again .Spoke with resident to obtain her side of incident. Stayed with resident and ensured her she was safe and he would not come back until she calmed down. Informed (CNA 1) that I was sending him home for the night and that either the DON or Administrator would contact him in the morning. Performed head to toe physical assessment on resident . multiple spider veins to the left along with approximately 1.5 cm (centimeter - metric measurement) x 1.5 cm discoloration to thigh that is deep purple in color. Notified RP (Responsible Party) and he stated that he would be in as soon as work is over today. Paged (Resident 1's physician) to notify and ask for STAT (immediate) X-ray of left leg. Awaiting return call. The Nurses Note dated 9/6/16 at 8:16 a.m., written by the Social Services Director (SSD), indicated (Resident 1) is being monitored for emotional distress regarding staff witness abuse by staff member. (Resident 1) is not in her usual spirits today but did eat a portion of her breakfast . On 9/28/16 at 3:45 p.m., during an interview, CNA 2 stated, I was toileting another resident across the hall from (Resident 1's) room. (CNA 1) was with her (Resident 1). (Resident 1) was distressed and calling out. (Resident 1) yelled, Aye! Aye! Stop it! I went to go see what was going on. I walked across the hall to (Resident 1's) room. CNA 2 stated the curtain was closed, so CNA 1 did not see CNA 2 enter Resident 1's room. CNA 2 stated she saw CNA 1 and Resident 1 struggling. CNA 2 stated she saw Resident 1's hand swinging wildly, hit CNA 1's forearm. CNA 2 stated she saw CNA 1 punch Resident 1 with his right fist into her abdomen and left thigh. CNA 2 stated Resident 1 continued to flail (swing wildly), scrambling, to fight him off. CNA 2 stated she walked towards the bed and yelled, Stop it! Leave! Get away from her! CNA 2 stated she told CNA 1 to leave but CNA 1 stayed, looked angry, and stated, She (Resident 1) hit me first. CNA 2 stated she could not make CNA 1 leave. CNA 2 stated, She (Resident 1) was crying, sobbing with tears. I told her it's going to be okay. He's not supposed to do that. CNA 2 stated Resident 1 stated, I know. I know. On 10/20/16 at 2:15 p.m., during a telephone interview with the Director of Staff Development (DSD), the DSD stated Resident 1 did not go to an acute care emergency room for follow up after being punched on 9/6/16. The DSD stated the physician was phoned and an X-Ray of Resident 1's left thigh was obtained. The DSD stated the X-Ray of the thigh was ordered due to Resident 1 complaining of pain to her left thigh. The facility policy and procedure (P&P) titled, Right to Be Free of Abuse, dated 1/10, indicated Guidelines: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal (physical)punishment and involuntary seclusion. Residents must mot be subjected to abuse by anyone, including facility staff . Definitions of Abuse: 1. Abuse - The willful infliction of injury, .intimidation or punishment with resulting harm, pain,or mental anguish .This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, pain or mental anguish (pain or suffering) . 4. Physical Abuse - Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 5. Mental Abuse - Includes, but is not limited to: humiliation, harassment . The facility P&P titled, Prevention of Abuse, dated 1/10, indicated Policy: The facility must use all practicable means to prevent resident abuse . The facility P&P titled, Staff treatment of [REDACTED].the facility must not use .physical abuse, corporal punishment . Review of Local Police Department report indicated the following: (Address) POLICE DEPARTMENT Case Number: 2016- 648 613 Offenses Incident Type: ASSAULT/BATTERY Occurred From: 09/06/2016 01:40 (9/6/16, 1:40 a.m.) Occurred Thru: 09/06/2016 01:45 (9/6/16, 1:45 a.m.) Reported Date: 09/06/2016 05:33 (9/6/16, 5:33 a.m.) Description: ELDER OR DEPENDENT ADULT ABUSE RESULTING IN GREAT BODILY HARM . Offense Status: ARRESTED Suspect/Offender: (CNA 1) Victim: (Resident 1)