Every finding on record at Frasier Meadows Health Care Center

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and one out of one satellite kitchen.Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated, and discarded within appropriate good-through timeframes.Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 6/9/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. (6-501.12) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11) The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment. (6-501.114)B. Observations The initial tour was completed on 6/1/26 at 9:25 a.m., and revealed the following:At 9:29 a.m., in the satellite kitchen dry storage area, food debris was observed beneath the storage shelving. There were several individual packages of peanut butter on the ground beneath the shelving. At 9:43 a.m., in the main kitchen, accumulations of food debris and crumbs were observed beneath a work table and adjacent shelving. Two cans of Sprite were observed on the floor underneath the shelving.At 9:45 a.m., in the main kitchen, there was a dark brown unidentified residue beneath the oven. Food debris, including small food particles and crumbs was also observed on the floor near the cooking equipment.A second observation of the kitchen was conducted on 6/3/26 at 1:14 p.m. The observations identified the same concerns as identified on 6/1/26 during the initial tour.C. Staff interviewsCook #1 was interviewed on 6/3/26 at 1:17 p.m. [NAME] #1 said it was the cook's responsibility to clean the floors. [NAME] #1 said he swept all areas daily after meal service, wiped counters from top to bottom, and mopped the floors when he finished his work. [NAME] #1 said he cleaned areas underneath equipment, shelving, and work tables daily.Cook #1 said he would clean up any food products, beverages, or food debris found underneath shelving or on the floor. [NAME] #1 said food debris could attract mice and rodents, was unsanitary, and could make residents sick.Cook #2 was interviewed on 6/3/26 at 1:31 p.m. [NAME] #2 said she used a cleaning checklist and completed some cleaning tasks herself while assigning other cleaning responsibilities to the other cooks. [NAME] #2 said areas underneath equipment, shelving, and work tables should be swept every day.Cook #2 said she would sweep up and discard any food products, spills, or food debris found underneath shelving or on the floor. [NAME] #3 was interviewed on 6/3/26 at 1:43 p.m. [NAME] #3 said he was responsible for overseeing the cleaning of areas underneath equipment, shelving, and work tables and delegated those responsibilities to the sous chef and cooks.The dietary manager (DM) was interviewed on 6/3/26 at 1:54 p.m. The DM said kitchen floors, shelves, work tables, and areas underneath equipment should be kept clean and free of food debris, residue, and improperly stored items. The DM said failure to keep these areas clean could lead to cross-contamination and sanitation concerns.II. Failure to properly label, cover, and discard expired food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 6/9/26, read in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location and, where it is not exposed to splash, dust, or other contamination. (3-305.11) Working containers holding food or food ingredients that are removed from their original packages for use in the food establishment shall be identified with the common name of the food. (3-302.12) Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. (3-501.17) A food specified in 3-501.17(A) or (B) shall be discarded if it exceeds the temperature and time combination specified, is in a container or package that does not bear a date or day, or is inappropriately marked with a date or day that exceeds the temperature and time combination. (3-501.18)B. Facility policy and procedure The Food and Supply Storage Policy, revised January 2026, was provided by the nursing home administrator (NHA) on 6/8/26 at 10:14 a.m. The policy revealed in pertinent part, Cover, label and date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections on an orange label. Products are good through the close of business on the date noted on the label. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. Foods that are stored on ladder/speed racks must be fully covered to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart or cover each tray individually.C. ObservationsThe initial tour of the kitchen was completed on 6/1/26 at 9:25 a.m., and revealed the following:At 9:36 a.m., in the satellite kitchen walk-in refrigerator, one package of Swiss cheese was observed with a 'today's date' of 5/21/26 and a good-through date of 5/26/26.At 9:47 a.m., in the main kitchen refrigerator, two pans containing hoisin sauce, pork sauce, and sun-dried tomato sauce were observed uncovered. There was accumulation of dust and lint on the fan guard inside the refrigerator.At 9:48 a.m., in the main kitchen walk-in refrigerator, a pan with salmon was observed covered with plastic wrap and did not have a date or label.-At 9:53 a.m., in the main kitchen walk-in refrigerator, a metal pan containing cut vegetables was observed. The vegetables included cabbage, onions, carrots, peppers, and peas. The pan was observed without a cover or date label.At 9:54 a.m., in the main kitchen walk-in refrigerator, a pan of beef was observed without cover. At 9:55 a.m., in the main kitchen walk-in refrigerator, a pan containing pork sauce was observed without a cover or wrap. At 9:57 a.m., a container of peeled sweet potatoes soaked in water was observed in the main kitchen walk-in refrigerator. The container did not have a label or a preparation date.A follow-up observation of the main kitchen refrigerator and walk-in refrigerator was conducted on 6/3/26 at 1:40 p.m. and 6/4/26 at 9:54 a.m. The observations identified the same concerns as identified on 6/1/26 during the initial tour.D. Staff interviewsCook #1 was interviewed on 6/3/26 at 1:17 p.m. [NAME] #1 said it was the cook's responsibility to ensure food items were properly covered and labeled. [NAME] #1 said he covered, labeled, and dated food items before storing them in the refrigerator and kept raw meat on the bottom shelf.Cook #1 said he would throw away any prepared food that was not dated, expired, or did not have a discard date. [NAME] #1 said he would also discard food stored uncovered in the refrigerator because he would not know how long it had been there.Cook #2 was interviewed on 6/3/26 at 1:31 p.m. [NAME] #2 said food should be labeled, dated, and covered before storage to ensure it was kept for the appropriate amount of time and discarded when required. [NAME] #2 said if she found food without a preparation date or discard date, she would ask the person who prepared it when it was made and check the temperature. [NAME] #2 said if she could not determine when it was prepared, she would discard it.Cook #2 said prepared food stored in the refrigerator should be labeled, dated, and covered in accordance with facility policy. [NAME] #2 said food should be stored properly to protect against contamination and to ensure it was kept for the appropriate amount of time.Cook #3 was interviewed on 6/3/26 at 1:43 p.m. [NAME] #3 said he conducted daily kitchen walk-throughs and delegated responsibility to the sous chef for ensuring food items were properly labeled, dated, and covered.Cook #3 said if he found prepared food without a date or discard date, he would ask when it was prepared. [NAME] #3 said if the preparation date could not be determined, he would discard the item.Cook #3 said prepared food items stored in the refrigerator should be labeled, dated, and covered in accordance with facility policy. [NAME] #3 said labels should indicate when the food was prepared and how long it was safe to use. [NAME] #3 said covering food helped prevent cross-contamination.The DM was interviewed on 6/3/26 at 1:54 p.m. The DM said he oversaw compliance with food storage, sanitation, and infection control requirements through routine monitoring of food receiving, food temperatures, food storage practices, and verification that food items were properly labeled, dated, and stored. The DM said the management team, including the executive chef, sous chef, and cooks, shared responsibility for monitoring compliance. The DM said they conducted daily kitchen rounds and they used a sanitation checklist to monitor compliance. The DM said the sous chef and the executive chef ensured they followed the sanitation checklist. The DM said dietary staff received ongoing training, including through daily stand-up meetings. The DM said prepared foods stored in the refrigerator should be labeled, dated, and covered to identify what the item was, when it was prepared, and to protect against contamination. The DM said food items should be removed from service and discarded when they exceeded their good-through date because expired food may no longer be safe for consumption.

Based on record review and interview, the facility failed to ensure residents' rights regarding arbitration were protected for three (#28, #36 and #39) of three residents reviewed for arbitration out of a sample size of 27. Specifically, the facility failed to inform the Resident #28, Resident #36, Resident #39 or their representative that they had the right to rescind or terminate the agreement within 30 calendar days of signing.Findings include:I. Facility admission agreement and policyThe admission Agreement and Binding Arbitration Agreement, revised January 2025, was provided by the nursing home administrator (NHA) on 6/1/26 at 11:52 a.m. Review of the agreement revealed it did not inform the resident or their representative of their right to revoke the agreement. The facility policy for arbitration agreement was requested on 6/4/26 at 1:38 p.m. and was not provided by the facility.II. Contract reviewA review of the binding arbitration agreement was completed on 6/4/26 at 10:41 a.m. Resident #28's representative signed the agreement on 10/22/25. Resident #36's representative signed the agreement on 7/31/25.Resident #39's representative signed the agreement on 12/20/24.Review of the agreement revealed it did not include, or inform the resident, or the resident's representative of their right to revoke the agreement within 30 days of signing. III. Staff interviewsThe director of nursing (DON) was interviewed on 06/04/2026 at 11:04 a.m. The DON said she was acting as the admission coordinator temporarily. The DON said that there were no additional documents regarding the arbitration agreements and confirmed that the revised date on the agreement was the most current agreement. The DON said she explained the arbitration agreement to the resident and the resident's representative upon admission to ensure residents knew what they were signing. The DON said if someone wanted to rescind the arbitration agreement, they would do so, but no one asked. The DON said she did not realize there was a 30-day stipulation that needed to be in the contract and the facility will be updating the agreement to reflect this.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training to ensure continued competence for five of five CNAs reviewed.Specifically, the facility failed to have a system in place to ensure CNAs including CNA #5, CNA #8, CNA #9, CNA #10 and CNA #11 received annual dementia training.Findings include:I. Training record review reviewA review of CNA training was completed on 6/4/26 at 10:10 a.m. CNA #5, hired on 11/27/23, last completed dementia specific training on 12/31/23.CNA #8, hired on 3/07/11, last completed dementia specific training on 10/17/24.CNA #9, hired on 2/14/06, last completed dementia specific training on 11/18/24.CNA #10, hired on 11/9/11, last completed dementia specific training on 6/21/24.CNA #11, hired on 11/23/11, last completed dementia specific training on 4/6/24.II. Staff interviewsCNA #12 was interviewed on 6/4/26 at 11:51 a.m. CNA #12 said she was trained on how to manage individuals with dementia, but did not remember the last time she completed the dementia specific training. During the interview CNA #12 opened her online training and revealed she completed dementia specific training in 2024.The nursing home administrator (NHA) was interviewed on 6/4/26 at 12:02 p.m. The NHA said she recognized training was needed for the facility and during quality assurance and performance improvement (QAPI) meetings. The NHA said they were needing to wait until their new fiscal year, in July 2026, in order to secure funding for training. She said they are getting this corrected as soon as possible. The NHA said it was her understanding dementia training was supposed to be two hours of training annually for CNAs and the training was needed for staff to ensure dementia residents were well taken care of. CNA #6 was interviewed on 6/4/26 at 1:46 p.m. CNA #6 said he did not remember when he last completed dementia training. CNA #5 was interviewed on 6/4/26 at 1:50 p.m. CNA #5 said she completed dementia specific training when she first started and completed it annually since then. She said she thought she completed it in September 2025 or December 2025, but was not sure. CNA #5 said education and training was necessary for resident safety. -However, documentation shows CNA #5 completed dementia training on 12/31/23.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of five residents reviewed for accidents out of 27 sample residents.Specifically, the facility failed to ensure:-Resident #4, who had a pressure ulcer, had physician's orders for the settings on his air mattress; and, -Ensure staff regularly checked on the functioning of Resident #4's air mattress. Findings include:I. Facility policy and procedureThe Bed Maintenance and Inspections policy, implemented 9/1/24, was provided by the nursing home administrator (NHA) on 6/4/26 at 9:44 a.m. It read in pertinent part, It is the policy of this facility to conduct regular inspections of all bed frames, mattresses in any bed rails that may be used as part of the regular maintenance program to identify and avoid areas of possible entrapment. The central supply coordinator or designee is responsible for keeping records of bed inspections and maintenance. A list of bed frames, mattresses and bed rails will be maintained including the manufacturer for each. The central supply coordinator shall be notified of any new equipment brought into the facility. The central supply coordinator or designee, shall review each manufacturer's recommendations and requirements for maintenance and bed inspections and shall establish a maintenance and inspection schedule accordingly. Bed frame mattresses and bedroom inspections will be conducted upon each item entering the facility and then placed on regularly scheduled inspections and maintenance cycles according to the manufacturer's recommendation to include manufacturers time frame recommendations.A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia, muscle wasting and atrophy hypertension, history of urinary tract infections and long-term use of anticoagulants.The 4/24/26 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status (BIMS) assessment. The facility indicated that the facility should not conduct a staff assessment for cognitive status. The resident was dependent on staff for rolling in bed left to right, chair-to-chair transfers, toileting hygiene, and lower body dressing. The MDS assessment indicated Resident #4 was at risk for developing pressure injuries. The MDS indicated the resident had one stage three pressure ulcer and did not have a pressure injury upon admission.The MDS indicated the resident had a pressure reducing device for his chair and bed. B. ObservationsOn 6/2/26 at 11:37 a.m., Resident #4 was in his bed lying on his back on his right side. He was lying on an air mattress. The air mattress indicated it was in the ON position. The air mattress was was set to alternate setting. -However, review of the electronic medical record (EMR) did not indicate the settings for the air mattress to be on (see record review below).C. Record reviewThe skin care plan, dated 10/26/25, revealed Resident #4 was at risk for skin breakdown due to weakness and possible friction and shearing with transfer and positioning. Pertinent interventions included assisting the resident with toileting per her plan (initiated 10/26/25), avoiding hot water, or scrubbing of skin, gently pat skin dry (initiated 10/26/25), encourage fluid intake outside of mealtimes (initiated 10/26/25), frequent turning and repositioning as appropriate (initiated 10/26/25), inspecting skin with cares, report any changes to skin (initiated 10/26/25), and keep linen dry and wrinkle free (initiated 10/26/26). -Review of the care plan failed to include the use of the air mattress as an implemented intervention or the settings of the air mattress. -Review of Resident #4's EMR, medication administration record (MAR) and treatment administration record (TAR) (4/1/26 to 6/4/26) did not reveal documentation indicating the facility regularly checked on the function or settings of Resident #4's air mattress.-Review of the June 2026 CPO did not reveal physician's orders for the settings of Resident #4's air mattress. A nursing long term care evaluation note, dated 4/7/26 at 4:09 p.m., revealed the resident had a new pressure injury to lower back related to air mattress failure.Review of Resident #4's EMR did not reveal documentation indicating the facility staff were checking on the resident every two hours on 4/7/26 when the air mattress failed. D. Staff interviews Registered nurse (RN) #1 was interviewed on 6/3/26 at 10:37 a.m. She said Resident #4 was using an air mattress before he developed his pressure injury, because he was at risk for skin breakdown. She said the air mattress helped with offloading of pressure on his buttocks. She said the pressure injury started as a dark spot on his skin. She said the nursing staff noticed the dark spot on his skin after his air mattress failed and stopped working. She said the nursing staff were supposed to check his air mattress, whenever they entered his room to ensure the air mattress was on and operating correctly. She said she did not know what setting the air mattress was supposed to be set to. She said she would expect there to be a physician's order for the settings for the air mattress and for it to be on the resident's care plan. -However, review of the June 2026 CPO and the care plan did not reveal the settings for the resident's air mattress.Certified nurse aide (CNA) #3 was interviewed on 6/3/26 at 10:50 a.m. She said if she noticed a resident's air mattress was flat, she would notify the nurse. She said the nurses were responsible for checking the air mattress and adjusting the settings if needed. She said there was no set schedule for checking the air mattress for Resident #4CNA #4 was interviewed on 6/3/26 at 10:58 a.m. She said the nurses were responsible for monitoring the settings on air mattresses. She said the nurses check the air mattress every day. She said she was not responsible for checking the air mattress, because she was not trained on how to operate the air mattress. The central supply coordinator was interviewed on 6/3/26 at 1:57 p.m. He said the air mattress were stored in the storage area when not in use. He said he set up the air mattress for a resident if he was notified by the nursing staff that it was needed. He said he would place the air mattress on the bed frame for a resident, plug in the device and check if it inflated. He said after he ensured the air mattress was operating, he did not monitor the air mattress on a continuous basis. He said the nursing staff were responsible for monitoring the air mattress functionality. He said he was unsure of the manufacturers recommendations regarding the length of life for the air mattress. The NHA and the director of nursing (DON) were interviewed together on 6/4/26 at 12:33 a.m. The NHA said she had worked at the facility for approximately four weeks. She said the facility should have followed the facility bed maintenance and inspection policy to ensure the air mattress for Resident #4 was monitored and maintained accordingly. She said according to their bed maintenance and inspections policy the air mattress should be checked on a regular basis. She said the central supply coordinator was responsible for initiating the routing schedule to monitor the functioning of the air mattress according to the manufacturer recommendations.The DON said the care plan and the physician's orders should include the use of the air mattress for Resident #4. She said she would obtain physician's orders and update the care plan immediately to ensure staff were aware of the plan of care for Resident #4. She said it was important for the nursing staff to clearly communicate any interventions and orders for Resident #4, because he was at risk for developing pressure injuries. The DON said the nursing placed Resident #4 in his bed after lunch. She said when the nursing staff went to check on the resident later that day and they noticed the air mattress was completely deflated. She said the cause of the air mattress deflating was due to normal wear and tear. She said she requested the central supply coordinator to remove and replace the air mattress immediately. She said she was unsure of the warranty, or the length of life for the air mattress.

Based on observations, record review and interviews, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for two (#52 and #3) of five residents out of 27 sample residents. Specifically, the facility failed to:-Ensure to maintain, clean, sanitize and properly store Resident #52's bilevel positive airway pressure (BiPAP) machine (a type of non-invasive ventilation that helps people breathe by providing pressurized air through a mask or nasal plugs) and mask;- Ensure Resident #3's CPAP (continuous positive airway pressure) therapy was provided per physician's orders; and,-Ensure Resident #3 had a physician's order specifying the oxygen flow rate.Findings include:I. Facility policy and procedureThe Oxygen Administration policy, undated, was provided by the nursing home administrator (NHA) on 6/5/56 at 4:55 p.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Oxygen is administered under orders of a physician, except in the case of an emergency.The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, including the type of oxygen delivery system, when to administer, such as continuous or intermittent and/or when to discontinue, and equipment setting for the prescribed flow rates.Follow manufacturer recommendations for the frequency of cleaning equipment filters. Keep delivery devices covered in plastic bag when not in use. Cleaning and care of equipment shall be in accordance with facility policies for such equipment.II. Resident #52A. Resident statusResident #52, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure unspecified whether with hypoxia (low oxygen in the body) or hypercapnia (too much carbon dioxide in the blood), hypertension (high blood pressure), and amyotrophic lateral sclerosis (disease that causes muscle weakness).The 2/23/26 minimum data set (MDS) assessment revealed Resident #52 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff with eating, hygiene, toileting, bathing and dressing. The MDS assessment did not document that the resident used a BiPAP device. -However, Resident #52 used a BiPAP machine (see record review, observations and interviews below).B. Resident interview and observationsResident #52 was interviewed on 6/1/26 at 4:02 p.m. Resident #52 said he used a BiPAP machine each night. Resident #52 said his personal caregiver cleaned the BiPAP equipment every Friday and the facility staff did not clean it. Resident #52 said his personal caregiver washed the nasal mask with soap and water and allowed it to air dry. Resident #52 said there was no process for changing the hoses or tubing.Resident #52's BiPAP machine was on the nightstand in the resident's room during the interview. The BiPAP machine was connected to a nasal mask. The nasal mask was resting on a washcloth. There was hair on the washcloth and there was yellowish residue inside the nasal mask.Resident #52 was interviewed again on 6/2/26 at 10:44 a.m. Resident #52 said the staff had removed the nasal mask that morning (6/2/26) and placed it on the nightstand without cleaning it. During the interview, the the nasal mask still had yellowish residue inside it. There was moisture on the nightstand where the nasal mask was placed.C. Record reviewReview of Resident #52's June 2026 CPO revealed the following physician's orders related to the resident's BiPAP machine:-BiPAP on at bedtime and off in the morning, ordered 2/17/26.Review of Resident #52's comprehensive care plan, initiated 3/2/26, revealed the resident had a BiPAP for night use and had respiratory failure and utilized oxygen.-The care plan failed to include interventions related to cleaning, sanitizing, maintaining, and replacing tubing, or storing the resident's BiPAP equipment.Review of Resident #52's electronic medical record (EMR) did not reveal documentation indicating the facility was cleaning the resident's BiPAP. III. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 6/3/26 at 3:23 p.m. CNA #6 said Resident #52 asked staff to apply the BiPAP mask at bedtime and the CNAs assisted him with applying the mask. CNA #6 said CNAs were responsible for cleaning the BiPAP equipment daily. CNA #6 said the BiPAP mask should be cleaned in the morning after the resident got up.CNA #6 said staff removed the BiPAP mask from the tubing, cleaned it daily with alcohol or warm water, dried it, and placed it on a paper towel. CNA #6 said staff also cleaned the mask whenever residue, buildup, or soiling was observed.During the interview, CNA #6 looked at the BiPAP mask and said there was hair and residue on the mask and said the BiPAP mask should be sanitized for infection control purposes.CNA #7 was interviewed on 6/3/26 at 4:10 p.m. CNA #7 said BiPAP equipment should be cleaned once a week, but did not know when it was supposed to be cleaned. CNA #7 said the CNAs were responsible for cleaning the nasal mask and BiPAP equipment. CNA #7 said the equipment should be washed with warm water, air dried, and placed on a towel, countertop, or nightstand. CNA #7 said if residue, buildup, or soiling was observed on the nasal pillow, she would wash it. CNA #7 said the equipment should be cleaned and sanitized daily for infection control.The assistant director of nursing (ADON) was interviewed on 6/3/26 at 4:14 p.m. The ADON said Resident #52 had an order for BiPAP use at bedtime and removal in the morning. The ADON said there were no orders or tasks for cleaning and sanitizing the BiPAP equipment and said there should be a task for daily cleaning. The ADON said she would create a task for the CNAs to document the cleaning. The ADON said the CNAs were responsible for cleaning, disinfecting, and maintaining the equipment by washing it daily with warm water and allowing it to air dry. The ADON said the CNAs should monitor the cleanliness of the BiPAP machine and nasal pillow, clean it, and document it. The ADON said facility staff were responsible for maintaining the equipment and said private caregivers were not responsible. The ADON said failure to routinely clean the nasal pillow could result in an infection.The director of nursing (DON) was interviewed on 6/4/26 at 11:09 a.m. The DON said the facility's general process for cleaning BiPAP equipment was weekly cleaning unless the mask was visibly soiled, in which case it should be washed with warm water and allowed to air dry. The DON said nurses were responsible for applying CPAP and BiPAP equipment and were ultimately responsible for cleaning the nasal pillow. The DON said they could assign a morning task for the CNAs to clean the equipment.The DON said staff received training on cleaning and monitoring respiratory equipment through in-services provided by the ADON and DON. The DON said a resident's private caregiver could assist with cleaning the equipment if it was the resident's preference and this should be included on the resident's care plan.The DON said a nasal mask with visible residue buildup would indicate that it was either not cleaned that morning or was cleaned ineffectively. The DON said proper cleaning was important to reduce the resident's risk for infection.III. Resident #3A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included unsteadiness on feet, history of falling, and major depressive disorder.The 4/27/26 MDS assessment revealed Resident #3 was cognitively intact with a BIMS score of 13 out of 15. She required substantial assistance with eating and oral hygiene. She was dependent on staff for toileting, bathing and transferring. The MDS assessment did not document that the resident used a CPAP device or oxygen.-However, observations, record review and interviews revealed the resident used a CPAP (see below).B. Resident interview and observationsResident #3 was interviewed on 6/1/26 at 3:04 p.m. Resident #3 said she no longer used her CPAP machine because she was on oxygen at all times. Resident #3 said her physician had told her to stop using the CPAP. Resident #3 said she did not know whether staff cleaned the CPAP nasal cannula because she had not used it in a while.-However, Resident #3 had active physician's orders for the use of the CPAP at night (see record review below).Resident #3's CPAP machine was observed on the nightstand in the resident's room. The CPAP nasal cannula had visible dust buildup on the portion that inserted into the resident's nose.C. Record reviewThe 4/20/26 nursing progress note revealed the resident was to use oxygen while in bed, CPAP at night, and nasal cannula oxygen when resting during the day.A review of Resident #3's June 2026 CPO revealed the following physician's orders:Titrate supplemental oxygen to maintain oxygenation over 90%, every shift, ordered on 4/25/26. Oxygen: obtain SPO2 (oxygen saturation) every shift for hypoxia, ordered on 3/31/26. CPAP on at bedtime and off in the morning, ordered on 5/25/25.Fill CPAP chamber with distilled water at bedtime and empty water and clean chamber and mask in the morning, air dry mask, ordered on 6/21/25. -However, the physician's orders failed to specify Resident #3's oxygen flow rate.-Review of Resident #3's comprehensive care plan revealed no interventions related to the resident's oxygen flow rate or ensuring CPAP therapy was provided as ordered.A review of the April 2026 through June 2026 treatment administration record (TAR) revealed staff documented the CPAP was applied as ordered (see staff interviews below).D. Staff interviewsThe ADON was interviewed on 6/3/26 at 4:25 p.m. The ADON said Resident #3 had an active CPAP order and there was no physician's order to discontinue the CPAP. The ADON said oxygen use had not replaced the CPAP. The ADON said staff used whatever oxygen flow rate was needed to maintain the resident's oxygen saturation above 90 percent and said 2 liters per minute was typically sufficient.The ADON said the May 2026 medication administration record (MAR) revealed the CPAP was applied at bedtime. The ADON said there were some documented refusals on the May 2026 MAR related to filling the CPAP chamber with distilled water and cleaning the CPAP equipment. However, the ADON said there should be documentation of refusals when the CPAP itself was not used.Registered nurse (RN) #4 was interviewed on 6/3/26 at 4:35 p.m. RN #4 said Resident #3 had been refusing the CPAP. RN #4 said Resident #3 said she did not need the CPAP and only needed oxygen. RN #4 said she documented the refusals in the TAR. RN #4 said she verbally notified the physician of the resident's CPAP refusals but did not document the physician notification. RN #4 said she could not recall when she spoke with the physician.RN #3 was interviewed on 6/3/26 at 4:46 p.m. RN #3 said the resident had not been refusing the CPAP. RN #3 said the resident had concerns about her oxygen saturation levels and said that she wanted to continue using oxygen.RN #3 said she documented not applicable for the use of the CPAP in the progress notes until the resident's care plan was updated. RN #3 said that 2 liters per minute of oxygen was usually sufficient to maintain the resident's oxygen saturation above 90 percent.The DON was interviewed on 6/4/26 at 11:04 a.m. The DON said there should be a documented oxygen flow rate order. The DON said staff should contact the Nurse Practitioner (NP) to clarify the order when the flow rate was not specified. The DON said oxygen was a medication and the order should clearly indicate how much oxygen is to be administered. The DON said it was important to have a specific oxygen flow rate to determine how much oxygen was necessary to maintain appropriate oxygen levels. The DON said she would have the oxygen order revised to include a specified flow rate.The DON said it was unclear from the documentation whether the resident refused the CPAP or whether the CPAP was simply not used.Licensed practical nurse (LPN) #1 was interviewed on 6/4/26 at 12:58 p.m. LPN #1 said there should be a physician order in the resident's clinical record for oxygen use. LPN #1 said if a resident did not have an oxygen order, she would contact the physician. LPN #1 said if the resident had an order to titrate oxygen to maintain an oxygen saturation above 90 percent, she would typically start at 2 liters per minute (LPM) and adjust as needed to maintain the resident's oxygen saturation above 90 percent. LPN #1 said it was important to have a physician order for oxygen use to ensure resident safety. LPN #1 said excessive oxygen flow rates could be harmful to residents, particularly those with cardiac or pulmonary conditions.The NHA and the nurse practitioner (NP) were interviewed together on 6/4/26 at 1:43 p.m. The NHA shared concerns regarding the resident's oxygen administration and CPAP use. The NP said the resident should have used the CPAP machine as ordered and said the resident used the CPAP for anxiety-related reasons. The NP said if the resident refused to use the CPAP machine, staff should have offered oxygen whenever the resident was in bed sleeping or resting.The NP said she understood that the absence of a specified oxygen flow rate order for the resident could create confusion for staff. The NP said the intent was for staff to administer one to two LPM of oxygen and titrate as needed to maintain the resident's oxygen saturation above 90 percent. The NP said she would clarify the oxygen order and add a specific flow rate.

Based on observations, record review and interviews the facility failed to ensure one (#31) of three residents reviewed for pressure-related skin conditions out of 19 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #31, who was at risk for developing pressure injuries due to a recent surgery to replace his left hip joint, was admitted to the facility on [DATE]. According to the facility's assessment of the resident's skin on 3/8/24, the resident was admitted without any pressure injuries. The facility implemented a pressure reducing mattress upon the resident's admission, however, there were no interventions implemented for offloading the resident's heels, which were at an increased risk for skin breakdown due to the resident's decrease in mobility following the left hip surgery. On 3/11/24, a left heel blister was observed to the resident's left heel and a right heel blister developed later that same day. The facility did begin appropriate treatment of the wounds and implemented further interventions to address offloading the resident's heels after the wounds were identified, however, they failed to implement appropriate interventions of heel booties or an air mattress overlay until after the wounds developed. Despite providing treatment to the wounds after they developed and implementing further interventions, Resident #31's wounds continued to worsen. The resident was discharged to the hospital on 3/27/24 for further treatment of the wounds. Once at the hospital, Resident #31's heel wounds required surgical debridement down to the bone. Due to the facility's failures to identify upon admission that Resident #31 was at risk for pressure injuries related to his recent hip surgery and the facility's failure to implement timely interventions to offload and protect the resident's heels, Resident #31 developed pressure wounds to both of his heels within three days of his admission which resulted in his discharge to the hospital 16 days after the wounds developed for further wound treatment. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: (2019), retrieved from https://www.internationalguideline.com/guideline on 4/17/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedures The Pressure Injuries policy, revised on 1/9/24, was provided by the director of nursing (DON) on 4/11/24 at 5:42 p.m. The policy revealed the purpose of the policy was to assure that all residents received an accurate assessment of pressure injuries, and the appropriate documentation was completed. The compliance guidelines revealed skin assessments would be completed by a licensed nurse upon admission and weekly thereafter. The information provided by the initial comprehensive assessment, established baseline data for the ongoing assessment of the resident's skin status. Accurate assessments that addressed each resident's skin status would be conducted by qualified staff and correctly documented in the medical record. A qualified health professional would correctly document the presence, number, size and stage of any pressure injury on the wound documentation form in the medical record. The nurse completing the skin section of the minimum data set (MDS) assessment would record the appropriate number and stage of pressure injuries as reflected in the pressure injury documentation. A licensed nurse would conduct or coordinate each assessment with the appropriate participation of health professionals. The director of nursing (DON) would be notified of any pressure injury. If it was determined a consultation was necessary, the wound nurse would be notified. If the wound nurse was notified, the DON, or designee, would be present during his/her visit. A Weekly Wound Evaluation would be completed and added to the pressure injury log. Education regarding pressure injuries would be provided to the nurses at least annually. Dressing treatments would be determined based on recommendations from the wound nurse, ordering physician, or best practice. The care plan would be updated indicating the presence of a pressure injury, the goal, and appropriate interventions. The physician would be informed of the presence of a pressure injury and treatment orders would be obtained. III. Resident #31 A. Resident status Resident #31, age 82, was admitted on [DATE] and was discharged to the hospital on 3/27/24. According to the March 2024 computerized physician orders (CPO), diagnoses included aftercare following joint replacement, left artificial hip joint, chronic atrial fibrillation, cardiomyopathies and chronic kidney disease. The 3/11/24 MDS assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required substantial/maximal staff assistance for upper and lower body dressing. He also required substantial/maximal staff assistance for putting on/taking off footwear. The resident was at risk for the development of a pressure ulcer. The resident did not have any pressure, venous or arterial ulcers upon admission. C. Record review A care plan, initiated 3/8/24, revealed Resident #31 was at risk for a pressure ulcer related to a recent fracture. The goal was for the resident's skin to remain intact with no new open areas caused by pressure or friction throughout his stay in the facility. Interventions included a skin risk assessment Braden Scale would be completed upon admission, quarterly and with a significant change in condition. The resident would use a pressure reducing mattress when in bed (start 3/8/24). A new recliner was ordered to try a different pressure relieving technique (start 3/8/24). The resident would allow staff to float his heels while in bed (start 3/11/24). On 3/18/24, a new boot for his heels was ordered according to physician recommendations. The care plan (started 3/11/24) further revealed the resident had a blister to his left heel and the resident was to wear booties when in bed. On 3/11/24, the resident's room recliner was replaced with a new recliner. On 3/13/24, the new recliner was not comfortable for the resident and another one was ordered by central supply. The staff were to provide treatment as ordered as necessary. An air mattress was placed on the resident's bed. The resident started on a nutritional supplement twice a day. The care plan (started 3/15/24) further revealed the resident had a blister on his right heel. A new air mattress was placed on his bed(start 3/15/24). The staff were to provide treatment as ordered as necessary. An air mattress was placed on the resident's bed. The resident started on a nutritional supplement twice a day (start 3/15/24). A Skin Evaluation Form, dated 3/8/24 at 2.16 p.m. by a registered nurse (RN) did not reveal any pressure injuries to the resident's heels. The Braden Scale assessment for predicting pressure sore risk, dated 3/8/24 at 1:33 p.m., documented Resident #31 was not at risk for the development of pressure ulcer/injury development. A Skin Evaluation Form dated 3/11/24 at 11:35 a.m. by a RN revealed a pressure injury to the left heel with an onset date of 3/11/24. The left heel pressure injury measured 3.8 centimeters (cm) by 2.2 cm by 0.0 cm depth. The wound was an unstageable unopened blister that was purple in color. The wound bed was not visible and there was no exudate. A nurse note dated 3/11/24 at 11:54 a.m. by a registered nurse (RN) revealed the resident complained of pain in his bilateral heels that morning in occupational therapy. The nurse assessed the resident and found a purple blister to the left heel and the wound bed was not visible. The right heel was pink with a blanchable (skin turns white when pressed then returns to pink when pressure is removed) surface. Booties for his heels were requested from supply. An addendum to the 3/11/24 nurse note, documented at 3:24 p.m., revealed during the day the resident developed an unstageable blister to the right heel. The nurse practitioner (NP) assessed and agreed to use the same treatment for both heels. The recommended treatment was skin prep (a skin barrier wipe which creates a thin film on the skin to protect skin by reducing friction) with optifoam (gauze pad) and protective booties while in bed. A Skin Evaluation Form dated 3/11/24 at 3:26 p.m. by a RN revealed a pressure injury to the right heel with an onset date of 3/11/24. The wound was an unstageable blister that measured 3.0 cm by 3.0 cm by 0.0 depth. A nurse note dated 3/12/24 at 2:07 p.m. by a licensed practical nurse (LPN) revealed the resident wore bunny boots (heel protection cushions) to his bilateral feet. The resident had slight edema to his bilateral lower extremities and was also wearing thigh high compression stockings. -The facility failed to implement protective heel booties until after Resident #55 developed the blisters on his heels. A nurse note dated 3/13/24 at 10:56 a.m. by a LPN revealed large fluid filled blisters were noted to bilateral heels that appeared to be from the middle to the lateral (outer) side. The resident had bunny boots to be worn when not working with therapy. The optifoam was removed, skin prep was applied and new optifoam was applied. Facility supply was working on getting a new recliner for the resident so he could elevate his legs. A nurse note dated 3/15/24 at 11:44 a.m. by a RN revealed large blisters on both heels. Skin prep and a dressing were applied. The resident had booties on with compression hose. An air mattress overlay was placed on his bed to help prevent skin breakdown. A recliner was ordered so that the resident could recline with his feet up. -The facility failed to implement the mattress overlay until four days after the blisters on the resident's heels were first noted. A nurse note dated 3/16/24 at 9:29 a.m. by a RN revealed the resident had slight edema to his legs and compression stockings were in place. The dressings to his heels were clean, dry and intact. The resident had booties in place and an air mattress (overlay) on his bed to help prevent skin breakdown. A nurse note dated 3/17/24 at 3:20 p.m. by a RN revealed a right heel blister had opened with drainage on a pillowcase. The left heel blister was intact. The dressings were changed as ordered and the resident was concerned about the blisters/wounds on his heels. The right foot looked swollen and the compression stockings were not on. A nurse note dated 3/18/24 at 10:54 a.m. by a RN revealed no edema was noted to the resident's legs and his legs were elevated on a stack of pillows and the heels were floated. The dressings were clean, dry and intact to bilateral heel blisters. The bunny boots were off due to bruising to the tops of his feet. His bed had an air overlay in place to relieve pressure. A nurse note dated 3/18/24 at 10:48 p.m. by a RN revealed the bandage to the left heel was replaced and a seeping (slow leak) of pink fluid was observed from the site. An absorbent pad was placed under his feet and the resident requested his socks be applied before the placement of the bunny boots. A nurse note dated 3/19/24 at 10:01 a.m. by a RN revealed open blisters to bilateral heels and the dressings were changed. A physician assessed the wounds and new booties were ordered. A new recliner for the resident had arrived and needed to be placed in his room. The resident had low albumin levels and the physician ordered a protein shake in addition to a nutritional supplement. A nurse note dated 3/21/24 at 2:37 p.m. by a LPN revealed the resident's left heel was hurting during a walk to the bathroom with therapy staff. The dressings to his heels were removed and saturated with drainage. The heel wounds were slightly macerated (soft with breaking down of skin due to prolonged exposure to moisture). The heels were cleaned and dried. Skin prep was applied to the periwound and to the wound areas. Calcium alginate was applied to the wound bed and covered with optifoam. Two optifoams were used on the left heel because the wound was too big. Larger heel dressings and blue offloading air boots were requested from facility supply. The resident had a low protein level on his last set of labs and he was now on a nutritional supplement. A nurse note dated 3/21/24 at 11:49 a.m. by a LPN revealed requested offloading blue air boots from supply, as well as bigger heel dressings. A nurse note dated 3/22/24 at 5:11 p.m. by a RN revealed physician orders for vitamin C chewable 500 milligrams tablets twice a day and zinc 220 milligrams, 50 capsules twice a day for 14 days. Wound care orders were to cover the wound bed and periwound with zinc barrier cream and apply calcium alginate with the alginate cut to fit the wound bed. Cover with silicone bordered foam dressing, wrap with kerlix (gauze) and Coban (wrapping material) to keep in place. The dressings were to be changed twice a week. The resident was to avoid walking until further notice. It was okay for the resident to use the Nu step machine (exercise machine) and use a bike. A nurse note dated 3/22/24 at 10:56 a.m. by a RN revealed wound rounds were completed. The right heel measured 5.6 cm by 6.5 cm by 0.2 cm depth. The left heel measured 6.0 cm by 8.0 cm by 0.2 cm depth. Large serous (pale yellow watery fluid) drainage from both heels that were boggy (soft and watery). Both heels were debrided (removal of dead or unhealthy tissue) and the dressings were to be changed three times a week. The resident was to remain off his heels as much as possible. A Skin Evaluation Form dated 3/22/24 at 11:06 a.m. by a RN revealed a pressure injury to the right heel with an onset date of 3/11/24. The right heel measured 5.6 cm by 6.5 cm by 0.2 cm depth. The wound was an unstageable opened blister that was boggy. There was a large amount of serous exudate and the wound tissue was 50% slough (yellow/white material of dead cells in a wound bed). A Skin Evaluation Form dated 3/22/24 at 11:12 a.m. by a RN revealed a pressure injury to the left heel with an onset date of 3/11/24. The left heel measured 6.0 cm by 8.0 cm by 0.2 cm depth. The wound was an unstageable opened blister that was boggy. There was serous exudate and the wound tissue was slough. A nurse note dated 3/23/24 at 12:37 p.m. by a RN revealed dressings were clean, dry and intact to bilateral feet. No edema was noted in the resident's ankles but he had slight edema in his feet below the Coban wrapping. The resident said, I am off the heels. A nurse note dated 3/25/24 at 4:29 p.m. by a RN revealed the resident sat in a recliner in his room with his feet off the end of the recliner footpad with booties on his heels. The resident said just in case I forget to put my feet up. The dressings were changed to his bilateral heels and a small amount of drainage was observed to the dressings when removed. The dressings for both heels required rolled gauze around the feet so there was a cushion from the protective bootstraps. A nurse note dated 3/26/24 at 3:54 p.m. by a LPN revealed the resident continued to have wounds to his bilateral heels. The resident was seated in a recliner with his feet elevated and floated off the edge of the recliner. He had bunny boots on both feet and his feet were warm with normal color. The resident was accepting the protein shakes and nutritional supplement. The resident said his heels did hurt at times. No edema was observed. A nurse note dated 3/27/24 at 11:40 a.m. by a RN revealed no edema was observed. The resident reported pain in his heels. Wound care was completed. The wounds were smelly with black necrotic (dead cells) tissue on both heels. The right heel measured 4.5 cm by 5.5 cm by 0.1 cm depth. The left heel measured 4.9 cm x 5.0 cm by 0.3 cm depth. There was a new order for skin prep, silver alginate, optifoam with silver and rolled gauze with kerlix to be changed daily. A referral was made to (physician's name) for possible surgical debridement. The referred provider wanted the resident to have restrictions on walking on his heels. A Skin Evaluation Form dated 3/27/24 at 11:54 a.m. by a RN revealed a pressure injury to the left heel with an onset date of 3/11/24. The left heel measured 4.9 cm by 5.0 cm by 0.3 cm depth. The wound was unstageable with black tissue. There was serous exudate and the wound tissue was necrotic/eschar (dry dead tissue in a wound). A Skin Evaluation Form dated 3/27/24 at 11:56 a.m. by a RN revealed a pressure injury to the right heel with an onset date of 3/11/24. The right heel measured 4.5 cm by 5.5 cm by 0.1 cm depth. The wound was unstageable with black necrotic tissue. There was serous exudate and the wound tissue was 100% eschar. A nurse note dated 3/27/24 at 4:18 p.m. by a RN revealed the writer received physician's orders to send the resident out to the hospital for deep tissue concerns to the bilateral heels. The resident was sent out by a transport service at 3:58 p.m. via stretcher to the hospital. A physician's assistant (PA) note dated 3/27/24 at 8:12 p.m. revealed a deep tissue injury (unstageable) to the right heel measuring 4.5 cm by 5.0 cm by 0.1 cm depth. There was no undermining (space that occurs under the wound's edges as tissue erodes) or tunneling (a channel that has opened underneath the skin). There was a large amount of sero-serosanguinous exudate with slough and a foul odor. There was 90% firmly adherent slough and dark purple necrotic tissue with 10% granulated tissue. Last week's measurement was 5.6 cm by 6.5 cm by 0.2 cm depth. The left heel was a deep tissue injury (unstageable) with no undermining or tunneling. There was a large amount of sero-serosanguinous exudate with slough and a foul odor. There was 80% firmly adherent slough with 20% beefy red granulation tissue. The previous week's measurement was 5.0 cm by 8.0 cm by 0.2 cm depth. Both heels were debrided on 3/22/24. The resident was very edematous when the wounds were started and now the edema was controlled. The procedures performed were Sharps debridement (use of forceps, scissors or scalpel to remove devitalized tissue, foreign material or debris from a wound) attempted to remove slough, but nearly all was firmly adhered. An attempt was made to probe to find viable tissue, but the necrosis was too deep and extensive. The resident was in pain and did not tolerate the procedure very well. Very little of the slough was removed due to the resident's pain and the severity of the tissue necrosis. A Hospital History and Physical dated 3/27/24 at 7:20 p.m. revealed a chief complaint of bilateral heel pain. The resident presented with bilateral pressure injuries on his heels. The wounds present with eschar and necrosis. The wounds would need Sharp debridement in the morning. The resident also presented with severe life threatening conditions including pressure injuries that required close monitoring and complex decision-making. It appeared the resident had very limited mobility since his most recent surgery and despite attempts to be more mobile and offloading his heels, the resident had developed bilateral heel wounds associated with significant pain. A Hospital Assessment and Plan dated 4/1/24 at 9:39 p.m. revealed full thickness necrotic pressure ulcers of bilateral heels due to pressure injuries suffered after a hip fracture and fixation (surgical repair). It did not appear there was any arterial compromise to the wounds to complicate the healing, and there was significant tissue space to recover. The relevant laboratory findings, dated 3/28/24, revealed 3+ Proteus mirabilis (A) and Rare Staphylococcus aureus (A). The Proteus isolates (bacterial organisms) from the debrided necrotic tissue did not guarantee or clearly imply direct pathogenicity. The local isolates would be considered when choosing the covering antibiotics during the preoperative and post-operative period. The resident complained of heel pain when his legs were moved dependently. The wounds initially came from pressure ulcerations after he had a hip fracture that required hospitalization and surgical stabilization. He had significant debridement of both necrotic heels on 3/28/24 (during hospitalization ) that required debridement down to the bone. The resident was currently tolerating the ampicillin/sulbactam (antibiotics). IV. Staff interviews The DON and the assistant director of nursing (ADON) were interviewed on 4/15/24 at 3:30 p.m. The DON said the resident was admitted to the facility on [DATE] and the admission skin assessment did not reveal the resident had any skin issues with his heels. The DON said the resident was ambulatory and liked to wear slippers. She said during the last two days in the facility, the resident only walked to the bathroom. The DON said on 3/11/24 (after the resident developed the wounds) an air mattress overlay was placed on the resident's mattress. The DON said the 3/11/24 nurse note revealed the resident had a blister to his right heel and a purple blister to his left heel. From 3/11/24 at 11:54 a.m. to 3:30 p.m. the right heel went from a blister to an unstageable (fluid filled) pressure ulcer. The DON said bunny boots were put in place on 3/11/24. His heels were also floated on pillows at times. They agreed on measurements in the clinical record that were taken by a physician assistant (PA) that had wound certifications. They said the resident never refused any treatments, never refused to offload his heels and was compliant with interventions such as wearing the bunny boots. The DON said the facility thought the resident's heel pressure ulcers might be due to the resident digging his heels into the carpet to engage his chair recliner into the reclining position. The facility purchased a new electric recliner to remedy the action and to help him to be able to elevate his feet easier. She said the facility ordered the resident a special set of boots (more padding past the ankle and up to the calf) for the resident two days before he left the facility. The resident was provided with protein smoothies and a nutritional supplement. The DON said the resident was sent to the hospital on 3/27/24 at 4:00 p.m. using non-emergent transportation due to the fast progression of his bilateral heel pressure ulcers. The PA at the facility had recommended the resident be assessed by a wound physician, however the next available appointment was not until 4/17/24. The resident's family was okay with waiting until that date, but the PA spoke with the family and the resident's son, who was a physician, and they were in agreement to send the resident to the hospital. The PA called the hospital and provided a detailed report on the resident's wounds. The DON and registered nurse (RN) #2 were interviewed on 4/16/243 at 9:00 a.m. RN #2 said she did the resident's admission assessment and he had no skin issues on his heels. The DON and RN #2 agreed the resident was observed, on 3/11/24, to have blisters on his heels. RN #2 said a PA assessed and measured the resident's bilateral heel wounds on three separate dates. RN #2 said on 3/11/24 (after the development of the wounds) the resident had facility bunny boots applied to both heels. The facility ordered a specialty set of bunny boots on 3/19/24 and they arrived at the facility on 3/26/24. RN #2 said the resident's room recliner was too short for him and the facility purchased a new recliner for the resident. The new recliner was electric and kept the resident from digging his heels into the floor to push back in the recliner. She said the resident had a standard mattress and an air overlay was placed on his mattress. She said he did ambulate in the facility while wearing his own shoes. She said the only time he did not ambulate was when the PA did not want him to make his heel worse by walking. She said the PA debrided both heels only once at the facility and he was not seen by another wound physician. She said that he was sent to the hospital because the PA wanted the heels to be debrided better. She said the pressure wounds were unstageable and had a foul odor when he went to the hospital. They both said they were unsure how the pressure ulcers started. V. Physician letter The facility sent a typed/signed physician letter dated 4/16/24 at 5:11 p.m. (after the survey exit date). The letter revealed the resident had bilateral heel blisters with acute and rapid onset due to comorbidities of poor cardiac perfusion, and frailty, recent hip fracture with surgical repair and malnutrition per labs. The blisters escalated to pressure wounds quickly despite close monitoring, intervention with wound care and nutritional supplementation. This was unavoidable despite close monitoring, and rapid and appropriate interventions including wound care by a wound specialist, off-loading, and nutritional supplementation. -However, the facility failed to implement appropriate interventions, such as heel booties or a specialty mattress to offload Resident #31's heels, until after Resident #31 developed the bilateral heel wounds. -Additionally, the facility failed to have the physician document the wounds were unavoidable until after the survey exit.

Based on observations, record review and interviews, the facility failed to implement timely interventions for falls and for falls with injury for three (#5, #26 and #54) of six out of 17 sample residents reviewed. Resident #5 had diagnoses of dementia, normal pressure hydrocephalus (a condition in which fluid accumulates in the brain) and history of repeated falls prior to admission 6/30/22. The facility failed to develop a person centered plan of care to promote safety and prevent repeated falls with injury. Resident #5 had falls on 8/15/22, 9/7/22 and 12/29/22, the resident suffered a skin tear, bruising and a head laceration (see record review). On 9/7/22 Resident #5 suffered a laceration to her head she was hospitalized and received five staples to her head. The facility failed to conduct an interdisciplinary team (IDT) review of Resident #5's repeated fall and implement further interventions. Additionally, the facility failed to develop person centered plans of care to prevent repeated falls for Resident #26 and #54. Findings include: I. Facility policy The Fall policy, revised 2/23/22, was received from the director of nursing (DON) on 1/5/23 at 10:41 a.m. It read in pertinent part: Every resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground and can occur anywhere. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The resident will be placed on the facilities fall prevention program. The level of fall risk will be placed on the resident's care plan. A fall risk assessment should be completed for the resident every 90 days and as indicated when the resident's condition changes. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify the physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. II. Resident #5 A. Resident status Resident #5, age 94, was admitted on [DATE]. According to the January 2023 computerized physicians orders (CPO), diagnoses included unsteadiness on feet, unspecified dementia, normal pressure hydrocephalus (abnormal build up fluid within the brain) and repeated falls. The 9/7/22 minimum data set (MDS) assessment was reviewed and revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. The resident required limited assistance with toilet use, personal hygiene, dressing, walking on the unit and transferring. The MDS assessment revealed the resident had two or more falls since admission with injury. B. Observations Resident #5 was observed on 1/4/22 at 11:30 a.m. She was sitting in her wheelchair in the dining room. The left side of her face around her eye was bruised and swollen. The physical therapist (PT) was sitting beside her. The PT said Resident #5 had fallen on 12/29/22 in her room. C. Record review 1. Care plan The fall history risk, dated 12/6/22 included interventions for falls: -Provide the resident with a safety device (walker or wheelchair), call pendant, and remind the resident to call for assistance; -Keep the call light within reach at all times and obtain physical therapy as needed; and, Keep all personal items within reach. The resident had fallen on 8/15/22, 9/2/22 and 12/29/22. The falls were not listed in the care plan. The care plan was not updated with any interventions to prevent repeated falls with injury until after 12/29/22 when the last fall occurred. 2. Incidents The 8/15/22: Fall incident report on 8/15/22 at 2:45 p.m. revealed the following: At 2:45 p.m.the certified nurse aide (CNA) on duty heard the resident fall from the hallway outside her room. The resident was found in her bathroom sitting up against the wall. The resident was covered in fecal matter and the floor was wet with urine. The resident reported back pain and hand pain. Registered nurse (RN) #3 called the resident's physician and primary contact person. Pain medications were ordered for Resident #5. The visual injury noted was a skin tear on the right hand. The contributing environmental factors section of this report was not filled out. -There were no post injury interventions for this fall. Fall incident report on 9/7/22 at 10:00 p.m. revealed the following: The resident was found on the floor in her bedroom with her back to her bed. The staff noted blood on the floor. RN #3 on duty assessed the resident's wounds which included a laceration on the back of her head, right shoulder pain from a previous fall and lower back pain. The resident required three people to assist her to bed and the head wound was cleaned and dressed. The resident stated she was going to the bathroom and fell . The physician on call was contacted and she instructed the staff to send the resident to the hospital. -There were no new post injury interventions listed in the medical record after this fall. The hospital notes dated 9/7/22 at 11:15 p.m. revealed the following: At 11:15 p.m., Resident #5 was brought to the emergency room by ambulance. The notes indicated the resident had a laceration on the back of her scalp due to a fall. The resident experienced pain in the thoracic spinal area. A computerized tomography (CT) scan was performed at the hospital for Resident #5 head. No fractures or other acute injuries were found. According to the notes no brain bleed was found. The aftercare to the wound included cleansing the wound with a sterile solution and applying a local anesthetic of lidocaine 1% to the scalp. An application of five staples was applied to the wound for closure. The wound was then cleaned with a sterile saline solution and a gauze bandage was applied to the wound. The resident was discharged home with outpatient care as needed. A nursing note was entered on 9/21/22 at 11:56 a.m. The note indicated the resident loved spending time with group activities outside of her room. She also liked one-on-one activities. The contributing environmental factors section of the incident report was not filled out. The Fall incident report on 12/29/22 at 10:50 a.m. revealed the following: The resident was found on the floor in her room facing a downward (prone) position with her head near the recliner. The resident was assisted to bed with the gait belt two person assistance. The neurological checks were initiated and the vitals were within normal limits.The neurological checks the facility sent were for another resident. There was bruising noted to the left forehead and the resident complained of pain in that area. Registered nurse (RN) #3 administered one Hydrocodone 5 mg-Acetaminophen 325 mg tablet for the residents' pain. The report form was signed by the director of nursing (DON) on 12/29/22. The notifications on the form were not filled out. The contributing environmental factors to this fall were not listed. Follow up information provided by the DON indicated the resident was a high fall risk and was on isolation precautions for COVID-19 at the time of this report. The staff were supposed to provide frequent checks on the resident and provide education to the resident. -There was no evidence that frequent checks and education was provided to the resident after this fall. -Further review of Resident #5's clinical record including (progress notes, medication administration record, treatment administration records, CPO and physician notes) revealed there was no follow-up after the residents' falls, there was no implementation of interventions monitoring and no updates documented on the resident's plan of care. D. Interviews The restorative certified nurse aide (RCNA) was interviewed on 1/10/23 at 1:51 p.m. She said she had been working on restorative therapy with Resident #5 for a few months. She said they worked on transferring, sitting to stand, leg and arm exercises and ambulating. The therapy was going well until the resident fell and then got COVID-19. When the resident got out of isolation she fell again. Intervention was working on getting the resident to ambulate. She said she thought the resident tried to get out of the wheelchair when she was in the room by herself and that may have contributed to her fall. The DON was interviewed on 1/10/23 at 12:17 p.m. She said the interventions used to prevent falls for Resident #5 were using her walker, staying around common areas, and using a wheelchair. If a resident fell and the CNA found them they checked the resident for comfort and would notify the nurse to assess the resident. The resident's power of attorney (POA) and the physician were to be notified even if there was no injury. The DON said she did not know why the incident reports were missing information. She said the facility had been using the forms for the six years she had been working there. The DON said the fall committee group decided Resident #5 could be let out of isolation early if she passed the rapid COVID test on her sixth day of isolation. She did pass the test and was allowed out of her room early. Resident #5 fell after she was released from isolation which resulted in an injury on the left side of her face. She said the interventions put into place after each fall was to monitor the resident more closely and not isolate the resident and place them in a common area, and keep the resident involved in activities. The DON said the facility would develop a sheet of list of residents and information about how often the resident was checked on by the CNAs. 42840 III. Resident #26 A. Resident status Resident #26, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia, abnormalities of gait and mobility, difficulty in walking, and lack of coordination. The 11/20/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. He required one-person extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. He required two-person extensive assistance for dressing. The Fall History on Admission/Entry or Reentry section of the MDS assessment was not completed. B. Observations On 1/4/23 at 1:27 p.m., Resident #26 was lying in bed with his eyes closed. There was a thick padded fall mat on the floor beside the bed. On 1/9/23 at 9:26 a.m., Resident #26 was in his room seated in his wheelchair. His wife was present in the room. The fall mat was folded up and leaning against the wall at the end of the bed. On 1/10/23 at 2:16 p.m., Resident #26 was seated in his recliner in his room. His wife was sitting on the resident's bed talking to him. C. Record review Review of Resident #26's electronic medical record (EMR) revealed the resident had sustained 13 falls since his initial admission on 6/28/22. -Of the 13 falls sustained by Resident #26, six of the falls occurred after the resident's readmission to the facility on [DATE]. Review of Resident #26's fall care plan, initiated 10/31/22 and revised 11/16/22, revealed that the resident was at risk for falling related to seizures, weakness, and Parkinson's disease. Pertinent interventions included frequent checks of the resident, putting the resident's bed in the lowest position while in bed and a mat next to the bed for safety, obtaining physical therapy consult as needed and following therapy recommendations, providing the resident an environment free of clutter, keeping the call light in reach at all times, and keeping personal items and frequently used items within reach of the resident. The Fall Risk assessment dated [DATE] revealed Resident #26 was at significant risk for falls. Review of the incident reports for Resident #26's falls revealed the following: 7/4/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 7/4/22 at 8:15 p.m. The incident report for the fall read in pertinent part: Nurse went into the resident's room to give medication and found the resident sitting on the floor with back against the bed and wheelchair in front of him. Resident stated 'I got up to get undressed and could not make it back to bed. 'When asked about pain and injury he stated he had no pain or injury. Assessed for injury, two people assisted to bed, started neuro (neurological) assessments/frequent checks, instructed the resident to use call light for help. -The Quality Indicators section of the incident report was not completed. -There was no fall investigation/follow-up by the interdisciplinary team (IDT) documented on the incident report. 7/6/22 fall Review of Resident #26's EMR revealed the resident sustained a witnessed fall on 7/6/22 at 5:00 p.m. The incident report for the fall read in pertinent part: Resident sitting on shower chair. When he was ready to transfer to wheelchair with certified nurse aide (CNA) assisting, he pushed up using his arm rests and slid to the left side. His left thigh was wedged between the cushion on the chair. Staff was able to unwedge his leg and return him to his wheelchair. Left thigh reddened with bruising, no swelling noted. Complained of slight discomfort. Physician faxed. Resident's wife to be notified in a.m. (morning) -There were no immediate fall interventions documented on the incident report. -The Quality Indicators section of the incident report was not completed. 7/24/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 7/24/22 at 5:20 p.m. The incident report for the fall read in pertinent part: Resident was found on both knees, kneeled down in front of recliner. Resident stated 'I did not fall. I went from the bed to the chair and kind of crumbled.' No injury. CNA found the resident and reported it to the nurse. Vital signs stable. Nurse assessed. Notified provider and next of kin. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 8/2/22 at 9:42 a.m., nine days after the incident occurred. -The IDT investigation did not reveal any new fall interventions put into place to prevent further falls for Resident #26. 9/14/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 9/14/22 at 6:25 p.m. The incident report for the fall read in pertinent part: CNA reported to the nurse that she found Resident #26 in his bathroom by his wheelchair. CNA said that she told him if he needed help he should use the call light, but he tried to go to the bathroom by himself and lost his balance and fell . No injury. Resident assessed by the nurse for any injury. Neuro assessments and vital signs all checked and all within normal limits. He did not complain of pain or signs of discomfort. No skin issues noted except old bruise to his right arm. It is important to prevent this kind of fall, check the resident more often after dinner because after dinner the resident might need to go to the bathroom. -The intervention to check on the resident after dinner and take him to the bathroom was not added to Resident #26's fall care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 9/21/22 at 11:54 a.m., seven days after the incident occurred. The note documented an intervention to remind the resident to use his call light. -The fall intervention to remind Resident #26 to use his call light was not updated on the care plan. 9/21/22 fall Review of Resident #26's EMR revealed the resident sustained a witnessed fall on 9/21/22 at 8:45 p.m. The incident report for the fall read in pertinent part: CNA was assisting resident to bed when he became unstable and started falling backwards. CNA assisted the resident to the floor on his knees. Resident sustained a 4 centimeter (cm) by 1 cm abrasion to the left shin and a 1 cm by 0.5 cm skin tear to the right knee. Staff assisted the resident to bed with a gait belt, assessed for injury. Cleaned shin and knee applied triple antibiotic ointment and bandaid to right knee and dressing to left shin. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -There was no fall investigation/follow-up by the interdisciplinary team (IDT) documented on the incident report. 10/5/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 10/5/22 at 8:00 p.m. The incident report for the fall read in pertinent part: CNA found the resident laying flat on floor by bed between window and bed. The resident sustained a 2 cm by 1 cm skin tear to the right shin. Assessed resident for injury, reported no pain or injury, three persons assisted with gait belt, resident able to lift hips to get gait belt around him, assist to sitting, then to sitting on bed, started neuro assessments. Later while getting the resident undressed for bed, found skin tear to right shin, cleaned and steri-stripped. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/8/22 at 8:35 a.m., 34 days after the incident occurred. -The IDT note documented an intervention to remind the resident to use his call light, the same intervention the facility documented after the resident's previous fall. -The fall intervention to remind Resident #26 to use his call light was again not updated on the care plan. 10/14/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 10/14/22 at 8:40 p.m. The incident report for the fall read in pertinent part: Resident found on floor face down between bed and recliner. Assessed resident for pain or injury, moved recliner away, rolled resident to back, asked resident if anything hurt. He stated 'My pride.' Three-person assisted with gait belt to bed, assessed skin and found abrasion from rug burn on right knee, cleaned and left open to air. Started neuro assessments. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/8/22 at 8:34 a.m., 25 days after the incident occurred. The note documented an intervention that staff was educated to check the resident's floor for objects when leaving the resident's room. -The fall intervention to check Resident #26's floor for objects when leaving the resident's room was not updated on the care plan. 11/13/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/13/22 at 5:30 p.m. The incident report for the fall read in pertinent part: Resident found on the right side of his bed positioned on his right side. He sustained multiple skin abrasions. Resident stated he wanted to stand up and stretch. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The IDT note, dated 11/16/22 at 8:54 a.m., documented an intervention to remind the resident to use his call light, the same intervention the facility documented for two previous falls. -There were no new interventions updated on Resident #26's care plan. 11/18/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/18/22 at 8:00 a.m. The incident report for the fall read in pertinent part: At 8:00 a.m., resident sitting on the fall mat perpendicular to the bed, no new injury, pain, or discomfort noted on assessment, resident denied pain. Two people assisted the resident up on the chair, assessed for pain, injury, neuro assessments, pupil reaction, vital signs, and mobility. Wife, hospice, and nurse practitioner notified. Neuro assessments initiated. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/29/22 at 8:30 a.m., 11 days after the incident occurred. -The IDT note documented an intervention that the resident had a low bed with a fall mat, which was not a new intervention. -There were no new interventions updated on Resident #26's care plan. 11/20/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/20/22 at 7:45 p.m. The incident report for the fall read in pertinent part: CNA found resident on mat with back against bed, perpendicular to bed. Assessed resident for injuries, three people assisted to bed, started neuro assessments. Resident was still restless and kept trying to get out of bed when checking him for neuro assessments. Frequent checks and CNA one on one in the room until the resident was more calm. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/29/22 at 8:29 a.m., nine days after the incident occurred. -The IDT note documented an intervention that the resident had a low bed with a fall mat and that the resident was reminded to use his call light, which were not new interventions. -There were no new interventions updated on Resident #26's care plan. 11/22/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/22/22 at 6:40 a.m. The incident report for the fall read in pertinent part: CNA found the resident lying on the floor mattress. He said that he put himself on the mattress. He was covered with a blanket. He looked comfortable. No new bodily injuries noted. Neuro assessments within normal limits. Vital signs stable. Assisted back to wheelchair with two person assist. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/29/22 at 8:23 a.m., seven days after the incident occurred. -The IDT note did not document any new fall interventions for Resident #26. -There were no new interventions updated on Resident #26's care plan. 11/26/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/26/22 at 11:30 a.m. The incident report for the fall read in pertinent part: CNA reported resident on floor on his knees at 11.30am (11:30 a.m.). This writer observed the resident on his knees between bed and recliner. Per resident, he was trying to get up out of his recliner to say thank you to choir singers, and he slid off his chair. Denies hitting his head, no injury noted. Neuro assessments initiated. Resident assisted to bed with a gait belt and two person assist. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT note, dated 11/29/22 at 8:26 a.m., documented an intervention to remind the resident to use his call light, the same intervention the facility documented for several previous falls. -There were no new interventions updated on Resident #26's care plan. 1/1/23 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 1/1/23 at 11:40 a.m. The incident report for the fall read in pertinent part: At 11:40 a.m., the resident was found on the floor lying facing down next to bed in front of his recliner in his room. Resident was conscious and alert, explained he transferred himself and fell on his left buttock, denied hitting head. Left buttock had a 4 cm by 4 cm bruise on skin assessment, mobility of extremities is intact with mild pain on his left shoulder. Assessed pupil reaction, mobility, skin, and injuries. Three staff assisted the resident into his wheelchair, gave education to call and wait for staff. Neuro assessments and vital signs initiated. Wife, physician, and hospice were notified. -There were no immediate fall interventions documented on the incident report other than education to resident to call and wait for staff. -The Quality Indicators section of the incident report was not completed. -The IDT note, dated 1/5/23 at 12:21 p.m., documented the resident had a low bed with mat, wife and staff have educated the resident to call for assistance and not to transfer by himself. Staff provides frequent checks and wife visits with resident daily. -The fall interventions documented in the IDT follow up note were interventions previously implemented. There were no new fall interventions documented in the note or updated on the Resident #26's fall care plan. -Review of the January 2023 CPO revealed the facility did not obtain a physician's order for Resident #26 to receive a physical therapy evaluation for restorative therapy as an intervention for the resident's falls until 1/3/23, after the resident had sustained six falls between 10/31/22 and 1/1/23. D. Staff interviews Registered nurse (RN) #2 was interviewed on 1/10/23 at 11:05 a.m. RN #2 said when a resident had a fall, the nurse was to assess the resident for injury. She said if the fall was unwitnessed or the resident was witnessed hitting their head, neurological assessments were to be initiated. RN #2 said the nurse was to investigate the fall to determine what had occurred to cause the fall. She said the fall incident report was to be filled out by the nurse. She said she did not think the nurse was supposed to fill out the Quality Indicators section of the incident report. RN #2 said management determined the fall interventions to put in place for the residents. She said Resident #26 had lots of falls and staff tried to do frequent checks on him to prevent falls. She said it was difficult to monitor residents. RN #2 said staff provided repeat education to Resident #26 to use his call light to get help from staff. CNA #3 was interviewed on 1/10/23 at 2:04 p.m. CNA #3 said Resident #26 had had several falls. He said the resident had a low bed with a fall mat. CNA #3 said he did not know if there were any other fall interventions in place for Resident #26. IV. Resident #54 A. Resident status Resident #54, age 79, was admitted on [DATE]. According to the January 2023 CPO, diagnoses included Parkinson's disease, weakness, and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down that can cause dizziness, lightheadedness and possibly fainting.) The 12/6/22 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He had a history of falls in the six months prior to admission, and had had one fall without injury since admission to the facility. B. Observations and resident interview On 1/4/23 at 12:25 p.m., Resident #54 was seated in his wheelchair in his room. There was a walker folded up and propped against the wall under the television (TV). Resident #54 had a thick purple scab on his left temple just above his left eyebrow. He had a large purple bruise that encompassed the upper left side of his face and left eye and extended around the bottom portion of his left eye. He said he fell out of his chair recently while he was reaching for something. He said he had had several falls at the facility. Resident #54 said staff reminded him to wait for help to do things like go to the bathroom. On 1/5/23 at 2:41 p.m., Resident #54 was seated in his wheelchair in his room watching TV. His bedside table was in front of him and he had his feet resting across the bar on the bottom of the table. His walker was folded up and propped against the wall under the TV. On 1/9/23 at 9:35 a.m., the privacy curtain in Resident #54's room was observed to be pulled halfway across the entrance to the room, and the resident could not be seen from the doorway of his room. Upon entry into the room, the resident was observed seated in his wheelchair watching TV. The resident's walker was folded up and propped against the wall under the TV. On 1/10/23, Resident #54 was observed from 10:35 a.m. to 10:53 a.m. The resident could not be seen from the doorway of his room. Upon entering the room, Resident #54 was observed seated in his wheelchair on the side of the bed closest to the bathroom. The resident was facing the head of the bed with his back to the wall containing the TV. The resident was observed leaning way over to the right side of his wheelchair reaching toward the floor. He said he was trying to get his TV remote. The TV remote was on his bedside table on the opposite side of the bed. There was nothing on the floor. The resident's call light was on the floor at the head of the bed. His walker was folded up and leaning against the dresser under the TV. Resident #54 stopped leaning to the right side of his wheelchair, however he continued to lean forward in the wheelchair. No staff came to check on the resident during the continuous observation. At 10:53 a.m., registered nurse (RN) #1 was notified Resident #54 was leaning forward in his wheelchair and the RN went down to the resident's room to check on him. C. Record review Review of Resident #54's EMR revealed the resident had sustained four falls since his admission on 11/25/22. Review of Resident #54's fall care plan, initiated 11/25/22, revealed that the resident was at risk for falling related to being very weak and having close calls for falls in the prior two weeks. Pertinent interventions included frequent checks of the resident, obtaining physical therapy consultation as needed and following therapy recommendations, providing the resident an environment free of clutter, keeping the call light in reach at all times, and keeping personal items and frequently used items within reach of the resident. Further review of Resident #54's care plan revealed he had impaired functional status with bed mobility, transfers, walking, toileting, eating, grooming, and bathing. Pertinent interventions included leaving the resident's walker or wheelchair near the resident for safety when he was in his room due to the resident's high fall risk. The Fall Risk assessment dated [DATE] revealed Resident #54 was at moderate risk for falls. Review of the incident reports for Resident #54's falls revealed the following: 11/29/22[TRUNCATED]

Based on record review and interviews, the facility failed to inform the physician and/or the resident's legal representative in a timely manner that the residents had a fall in the facility for two (#26 and #54) of six residents reviewed for falls out of 17 sample residents. Specifically, the facility failed to: -Ensure Resident #26's physician was notified on one occasion following the resident sustaining a fall in the facility; -Ensure the legal representative for Resident #26 was notified in a timely manner on six different occasions following the resident sustaining falls in the facility; and, -Ensure the legal representative for Resident #54 was notified in a timely manner on two different occasions following the resident sustaining falls in the facility. Findings include: I. Facility policy and procedure The Notification of Changes policy, last revised 11/9/22, was provided by the nursing home administrator (NHA) on 1/10/23 at 3:26 p.m. It read in pertinent part: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's medical power of attorney (MPOA)/Guardian when there is a change requiring notification. Circumstances requiring notification include accidents/incidents. II. Resident #26 A. Resident status Resident #26, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia, abnormalities of gait and mobility, difficulty in walking, and lack of coordination. The 11/20/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. He required one-person extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. He required two-person extensive assistance for dressing. The Fall History on Admission/Entry or Reentry section of the MDS assessment was not completed. B. Record review 1. 7/6/22 fall Review of Resident #26's electronic medical record (EMR) revealed the resident sustained a witnessed fall on 7/6/22 at 5:00 p.m. The incident report for the fall read in pertinent part: Resident sitting on shower chair. When he was ready to transfer to wheelchair with certified nurse aide (CNA) assisting, he pushed up using his arm rests and slid to the left side. His left thigh was wedged between the cushion on the chair. Staff was able to unwedge his leg and return him to his wheelchair. Left thigh reddened with bruising, no swelling noted. Complained of slight discomfort. Physician faxed. Resident's wife to be notified in a.m. (morning) The incident report further documented that the resident's wife was notified on 7/7/22 at 10:20 a.m. -Despite the fall occurring at 5:00 p.m., the resident's wife was not notified until 17 hours after the incident. 2. 7/24/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 7/24/22 at 5:20 p.m. The incident report for the fall read in pertinent part: Resident was found on both knees, kneeled down in front of recliner. Resident stated ' I did not fall. I went from the bed to the chair and kind of crumbled. -The incident report did not document that the physician or the resident's wife were notified of the fall. 3. 9/14/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 9/14/22 at 6:25 p.m. The incident report for the fall read in pertinent part: CNA reported to the nurse that she found Resident #26 in his bathroom by his wheelchair. CNA said that she told him if he needed help he should use the call light, but he tried to go to the bathroom by himself and lost his balance and fell . -The incident report did not document that the resident's wife was notified of the fall. 4. 9/21/22 fall Review of Resident #26's EMR revealed the resident sustained a witnessed fall on 9/21/22 at 8:45 p.m. The incident report for the fall read in pertinent part: CNA was assisting resident to bed when he became unstable and started falling backwards. CNA assisted the resident to the floor on his knees. Resident sustained a 4 centimeter (cm) by 1 cm abrasion to the left shin and a 1 cm by 0.5 cm skin tear to the right knee. -The incident report documented the resident's wife was notified of the fall with injury on 9/22/22 at 9:20 a.m., more than 12 hours after the resident's fall. 5. 10/5/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 10/5/22 at 8:00 p.m. The incident report for the fall read in pertinent part: CNA found the resident laying flat on floor by bed between window and bed. The resident sustained a 2 cm by 1 cm skin tear to the right shin. -The incident report did not document that the resident's wife was notified of the fall with injury. 6. 11/22/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/22/22 at 6:40 a.m. The incident report for the fall read in pertinent part: CNA found the resident lying on the floor mattress. He said that he put himself on the mattress. He was covered with a blanket. He looked comfortable. -The incident report did not document that the resident's wife was notified of the fall. III. Resident #54 A. Resident status Resident #54, age 79, was admitted on [DATE]. According to the January 2023 CPO, diagnoses included Parkinson's disease, weakness, and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down that can cause dizziness, lightheadedness and possibly fainting). The 12/6/22 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He had a history of falls in the six months prior to admission, and had had one fall without injury since admission to the facility. B. Record review 1. 11/29/22 fall Review of Resident #54's EMR revealed the resident sustained an unwitnessed fall on 11/29/22 at 6:30 p.m. The incident report for the fall read in pertinent part: Resident was found lying on his right side in front of the recliner next to the bed. Further review of the incident report revealed the nurse called the resident's wife on 11/29/22 at 7:00 p.m. to inform her of the fall, however the resident's wife did not answer and the nurse documented she was unable to leave a message. -There was no documentation in the EMR to indicate further attempts were made by the facility to notify the resident's wife of the fall until she came into the facility on [DATE]. -The incident report documented that the resident's wife was notified of the fall in person on 11/30/22 at 11:20 p.m., almost 17 hours after the incident. 2. 12/28/22 fall Review of Resident #54's EMR revealed the resident sustained an unwitnessed fall on 12/28/22 at 11:15 p.m. The incident report for the fall read in pertinent part: Resident was found on floor in front of recliner next to wheelchair. -The incident report documented that the resident's wife was notified of the fall on 12/29/22 at 3:30 p.m., 16 hours after the incident. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 1/10/23 at 11:05 a.m. RN #2 said when a resident sustained a fall, the nurse should notify the resident's physician and the legal representative as soon as possible after the resident has been assessed. Notification to the physician and the representative should occur even if the resident did not sustain an injury. The director of nursing (DON) was interviewed on 1/10/23 at 12:18 p.m. The DON said the resident's physician and legal representative should be notified after every fall, even if there was no injury to the resident. She said notification should occur as soon as possible, but at least by the end of the shift if the resident did not sustain an injury. The DON said if the resident sustained an injury, notification should occur as soon as the resident was assessed by the nurse and the injuries were attended to. She said notifications of the physician and the legal representative should be documented in the incident report and in a progress note in the resident's EMR. RN #1 was interviewed on 1/10/23 at 1:54 p.m. RN #1 said nurses should notify the resident's physician and legal representative for every fall. She said notification should occur even if the resident did not sustain an injury. RN #1 said notification should occur as soon as possible after the resident was assessed and comfortable. She said notification of the physician and the legal representative was documented by the nurse on the incident report.

Based on record review and interviews the facility failed to thoroughly investigate allegations of abuse for one of two (#191) of 44 residents reviewed. Specifically the facility failed to: -Provide an investigation of the incident from the Independent living unit where the incident occured; and, -Investigate bruising documented on Resident #191's arm. Findings include: I. Facility policy The Abuse policy, revised on 5/10/18, was received from the nursing home administrator (NHA) on 9/15/21 at 10:30 a.m. It read in pertinent part: When abuse is suspected or reported an investigation is immediately warranted. Components of the investigation include: 1. Identify the staff doing the investigation 2. Use caution in handling any evidence found during the investigation 3. Identify and interview all involved persons including the alleged perpetrator and alleged victim, witnesses and others who may have knowledge of the allegations. 4. Provide complete a thorough documentation of the investigations The facility will make efforts to ensure all residents are protected from physical harm during and after the investigation. Examples include but are not limited to : Respond immediately to protect the alleged victim and integrity of the investigation. Provide increased supervision of alleged victims and residents, and temporary one on one supervision of a resident. II. Resident #191 A. Resident status Resident #191 age 86, was admitted on [DATE]. According to the September 2021 computerized physicians orders (CPO) the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/28/21 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with no brief interview for mental status (BIMS) conducted. The resident could not be understood or understand others.The resident required extensive two person assistance with grooming, bathing, dressing, bathing and one person assistance with mobility and eating. III. Record review Abuse investigation notes dated 8/27/21 at 3:30 p.m. The summary of the notes indicated that a private caregiver working in the independent living unit was a witness to the alleged abuse. The report revealed Resident #191 was observed in the elevator with the alleged abuser. The resident was observed trying to stand up from her wheelchair and the witness observed the alleged abuser continuously push the resident in the stomach back into the wheelchair. The witness said she went to the nursing side of the facility and reported the incident to a nurse who then contacted the NHA. The police were contacted as the incident occured in the independent living community. The NHA contacted [NAME] care independent living facility and asked the staff to check the condition of the alleged victim who was in apartment 492 with the alleged abuser. The staff member reported that Resident #191 was not in any distress. Interdisciplinary (IDT) note dated 8/31/21 at 10:04 a.m. Two bruises noted on Resident #191 left forearm. Resident was resistant with care and became anxious and combative. Refused care and brief change. IDT note dated 8/31/21 at 8:47 p.m. Resident left for a visit with her husband and returned at 6:30 p.m. Bruising to left forearm remained unchanged. Skin evaluation forms provided were dated 8/5/21, 8/11/21, 8/20/21, 8/26/21, 9/2/21 and 9/9/21. The evaluation forms all indicated there were no new issues for Resident #191, however the 8/31/21 IDT note indicated two bruises on the resident's left forearm. -The facility failed to provide documentation of a thorough investigation for the two bruises that were found on Resident #191's left forearm. IV. Interviews The NHA was interviewed on 9/14/21 at 9:00 a.m. She said the independent living facility did not do an investigation regarding Resident #191 and the alleged abuse. She could not give a reason why that did not happen. The NHA was interviewed again on 9/15/21 at 10:35 a.m. She said the case with Resident #191 was still an open investigation. She said adult protective services (APS) came to the facility on [DATE] and interviewed the alleged perpetrator. She said APS told her to re-educate him on how to reach the staff in case of emergency and offer redirection techniques should the resident try to get out the chair again. She said they did not recommend keeping them separated or have any ongoing supervised visitation. She said she took the advice of APS and allowed the couple to keep seeing each other. The NHA said she visited the alleged abuser on 8/30/21 at 2:45 p.m. in his apartment at the independent living community. She said she asked him if he struck the resident to which he replied of course not. She said he told her that he was devastated that anyone thought he would intentionally harm Resident #191. The NHA said she reminded the alleged abuser that he could get help from the staff by simply pushing the resident's pendant and the staff would respond to his exact location. She said she provide education to the alleged abuser on redirecting unsafe behaviors from Resident #191. She said she told him to hold the resident's hand or point to a distraction to look at. She said she did not do an investigation or an incident report about the bruising that occured on Resident#191 arm to determine the cause. She said she felt the bruises did not look like grab marks to her and she instructed the nurse to document the bruises in the resident's medical record. Detective #1 was interviewed on 9/16/21 at 9:10 a.m. He said he had not investigated the case yet regarding Resident #191. He said this was an open investigation. He included that many of these cases were substantiated but he did not know that yet. He said the officer that initially reported this case said it was alleged that the perpetrator struck Resident #191 in the stomach with the back of his hand. He said the resident had bruises on her arm two days after the reported incident and he would check into that. He said that sometimes he would ask the district attorney to look at these cases to help with decision making on how to proceed with the case. Witness was interviewed on 9/19/21 at 10:35 a.m. She said the incident occurred on 8/27/21 at approximately 3:30 p.m. She said she was standing by the elevator on the 5th floor with her client. She said the elevator doors opened and she saw Resident #191 with her husband on the elevator. She said the resident was trying to get out of her wheelchair and the husband was pushing her back into the wheelchair aggressively with his left hand. She said she offered her help to the husband and he refused. She said she asked the husband to stop doing that to the resident and he replied to her that I can do what I want. She said she then took her client back to her apartment and went to the nursing side of the facility and reported the incident to one of the nurses on the unit. She said the alleged abuser appeared to be frustrated with the situation and that he did not have control. She said that every time he pushed the resident into the chair she made a loud grunting noise. She said he did this several times until he was able to get the elevator going again and they both left the area.

Based on observations, record review and interviews, the facility failed to implement interventions to prevent falls for one (#192) of three out of 44 residents reviewed. Specifically the facility failed to provide appropriate person centered interventions and safety devices were implemented timely for Resident #192 who had multiple falls since admission. Findings include: I. Fall prevention policy The Fall Prevention policy, revised on 10/21/2020, was provided by the nursing home administrator (NHA) on 9/21/21 at 1:23 p.m. It read, in pertinent part: Each resident will be assessed for fall risk and will receive care and services in accordance with their level of risk for falls. A fall is an event in which a person unintentionally comes to rest on the ground,floor or other surface. Each resident ' s risk factors and environmental hazards will be evaluated when developing the resident ' s plan of care. Interventions will be monitored for effectiveness and the care plan will be revised as necessary. II. Resident status A.Resident #192 Resident #192 age 91 was admitted on [DATE]. The September 2021 computerized physician orders (CPO) revealed a diagnosis of advancing Alzheimer's disease and dementia with behavioral disturbances, falls, and [CONDITION(S)]. The 7/21/21 minimum data set revealed the resident was severely cognitively impaired with a brief interview of mental status (BIMS) score of four out of 15. He required extensive two person assistance with bathing, dressing, transferring ,personal hygiene and toilet use. The MDS indicated the resident had one fall since admission, however see the incident reports below. B. Observations 9/15/21 -At 10:00 a.m. the resident's room did not have a fall mat by the resident ' s bed. His wheelchair did not have any anti-rollback device on it. -At 3:56 p.m. Resident #192 was seated at a table in the dining room in his wheelchair. There was no staff present in the area. There were no anti-roll back devices on the back of his wheelchair. -At 3:58 p.m. the resident left the dining room in his wheelchair. -At 4:00 p.m. the resident took himself down the hall in his wheelchair. -At 4:02 p.m. the resident took himself in his wheelchair to a chair by a window in the hallway. -At 4:03 p.m. the resident proceeded to transfer himself from the wheelchair to the chair by the window. The wheelchair moved away from the resident due to the brakes not being engaged. -At 4:04 p.m. the activity assistant (AA) who was approximately six feet down the hall saw the resident and rushed up to him and grabbed the wheelchair to keep it from moving and helped the resident into the chair. The AA reminded the resident to ask for assistance before transferring. 9/16/21 -At 10:50 a.m. Resident # 192 was in the living room area, moving his wheelchair up to a sofa. The resident stood up from the wheelchair and transferred himself to the sofa. Certified nurse aide (CNA# 6) came up to the resident just as he was sitting down. The CNA placed the wheelchair directly in front of the resident and put the brakes on and walked away. She did not remind the resident to ask for help before transferring, or educate him on locking his brakes to reduce falls. -At 10:59 a.m. the resident stood up from the couch, took the brakes off the wheelchair and proceeded to push the wheelchair while walking behind it. There was no staff in the area. -At 11:03 a.m. Registered nurse (RN#2) entered the area and saw the resident pushing the wheelchair. She redirected the resident to a reclining chair and helped him sit down. She then raised up the feet on the chair and put a blanket over the resident and walked away. -At 11:05 a.m. the anti roll back devices were observed to be attached to the back of the resident ' s wheelchair. -At 2:00 p.m. Resident # 192 was observed in the hallway outside the dining room walking while holding on to his wheelchair. An unidentified staff member was observed pushing a cart coming down the hall towards the resident. She was approximately four feet away from him. She stopped in the hallway and assisted the resident back to his wheelchair. She reminded the resident he should not be walking by himself. -At 3:55 p.m. the resident was observed sitting at a table on the outside patio with his feet propped up on a chair. There was no staff with him. C. Record review Care plan for Resident #192 dated 7/8/21 indicated the resident would have a decreased risk of falls with injury. The interventions listed to prevent falls were: -Provide activities that minimize the potential for falls while providing diversion and distraction. -Remind resident to call for assistance with call button. -Remind the resident of safety awareness. There was no other mention of fall prevention in the care plan. Fall risk assessment dated [DATE] indicated Resident #192 had one fall in the last six months. The risk factors included in the assessment were mobility and resident required assistance and or supervision with transfers and ambulation, unsteady gait, lack of understanding of physical and cognitive limitations. The fall risk score was 22 with 13 or higher being a high fall risk. III. Incident reports for Resident #192: Incident report dated 7/18/21 at 2:15 p.m. The resident was heard calling for help and was found in his room sitting on the floor in front of his dresser. His walker was near the dresser. The resident said he got up from bed to grab the walker and fell . Neuro checks were noted at the resident's baseline and vitals were completed. The family and physician were notified. -No fall interventions were listed in this report. Incident report dated 7/26/21 at 4:50 a.m. RN# 4 heard a noise from the resident's bathroom and went in to investigate. The resident was sitting on the floor next to the toilet seat. His walker was at the bathroom door. He told the nurse he missed the seat. Two skin tears were noted on the resident ' s right hand. Neuro checks and vitals were performed all within normal limits. RN#4 placed a dressing on the resident ' s right hand. The RN reminded the resident to use his call light and not to transfer by himself. Incident report dated 8/13/21 at 1:30 p.m. the resident was found on the floor by his bed. The wheelchair was beside the bed. The resident said he tried to stand but slid to the floor. Resident was assessed for injury then assisted to his wheelchair. Vitals and neuro checks were completed and they were within normal range. The intervention noted was to check the resident frequently when he was in bed. Incident report dated 8/19/21 at 10:05 a.m. the resident was found on the floor in the dining room in front of his wheelchair. He was unable to state why he was on the floor. He did not complain of pain. The resident was assisted back to his wheelchair. The family was notified and neuro checks and vitals were completed. No interventions were noted in the report. A follow up screen was completed on 8/19/21 at 3:35 p.m. A cushion made of non-slip material was placed on the resident's wheelchair. Registered nurse (RN#5) put in a work order for an anti roll back device for further fall prevention. The work order was requested and not provided. Incident report dated 9/1/21 at 7:30 a.m. indicated the resident was found on the floor by his bed. He said he tried to get up but slipped and fell . No injuries noted. Nuero checks and vitals done. The fall intervention listed was to check the resident frequently in early am to see if he needed assistance. Incident report dated 9/15/21 at 8:00 a.m. indicated that the resident was found on the floor by his bed lying on his left side. Resident noted to have a skin tear over left eye and a small bruise to the right side of his nose.The resident reported he tried to get up but lost his balance. Neuro(logical) and vital checks were completed. This fall occurred during the survey. No new interventions were listed. -The anti roll back device was not observed on the resident's wheelchair until 9/16/21. The nurses notes indicated that Resident #192 experienced a fall on 7/18/21, 7/26/21, 8/13/21, 8/19/21, 9/1/21, and 9/15/21. Each fall report indicated that the resident got up by himself and was later found on the floor by staff. This was a total of six falls since the resident ' s admission on 7/8/21. The facility failed to ensure appropriate person centered interventions were implemented and the interventions that were recommended were implemented timely, to assist with the prevention of future falls. IV. Interviews The director of nursing (DON) was unavailable for an interview on 9/14/21, during the survey. The nursing home administrator (NHA) was interviewed on 9/15/21 at 10:00 a.m. She said Resident #192 was moved from the assisted living to the nursing unit because of the numerous falls he had in the assisted living. She said the resident fell this morning because he tried to get out of his wheelchair by himself. She said the interventions in place for the resident were consistent monitoring and reminding the resident to call for assistance. She said that maintenance was in charge of placing anti roll back devices on residents wheelchairs. There was no doctor order for this device.She stated that the DON was in charge of ensuring the fall interventions from the reports were followed and added to the care plan. RN#1 was interviewed on 9/15/21 at 1:02 p.m. She said Resident #192 has fallen many times since he moved to the nursing unit. She said he did not have an anti-roll back device on his wheelchair. She said that the staff were required to keep a close eye on the resident for fall prevention. CNA#8 and CNA#7 were interviewed on 9/15/21 at 4:18 p.m. CNA #8 said that Resident #192 was impulsive and stood up from his wheelchair without warning. CNA#7 said the resident tries to get out of the wheelchair by himself all the time. She said the staff can ' t always be with him due to other work duties. She said the resident had fallen many times since he came to the unit. CNA #6 was interviewed on 9/15/21 at 4:35 p.m. She said Resident #192 had an anti-rollback device on his wheelchair. She said the resident stands up from his wheelchair all the time. She said that one time she saw him slip out of the wheelchair before she could get to him. She said it was up to all the staff to keep an eye on the resident. She included Resident #192 does not think to use his call button to ask for help. Activity assistant (AA) was interviewed on 9/15/21 at 4:45 p.m. She said Resident #192 moved to the nursing unit from assisted living because he was falling a lot there. She said the resident stands up from his wheelchair all of the time without asking for help.

Based on observation, interviews and record review the facility failed to ensure that two (#23 and #13) out of three residents reviewed for oxygen, out of 44 total sample residents, received necessary respiratory care and services. Specifically, the facility failed to ensure: -Resident #23 was administered oxygen per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident #13 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy and procedure The Oxygen Administration policy, dated 5/20/21, was received from the nursing home administrator (NHA) on 9/15/21 at 11:35 a.m. The policy documented in pertinent part Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Personnel authorized to initiate oxygen therapy include physicians, RNs, and LPNs. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: The type of oxygen delivery system. When to administer, such as continuous or intermittent and/or when to discontinue. Equipment setting for the prescribed flow rates. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. Monitoring for complications associated with the use of oxygen. II. Resident #23 A. Resident status Resident #23, age 98, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/6/21 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. Resident #23 required limited one person assistance with bed mobility, transfers, and personal hygiene. She required extensive one person assistance with dressing and toileting. She was on supplemental oxygen. B. Record review The September 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation that the resident refused oxygen. The Pulmonary care plan dated 7/22/21 was reviewed. The care plan documented the resident had the potential for complications from [CONDITION(S)]. Interventions included administering medications and treatment per orders. Monitor oxygen saturation and administer oxygen per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Observations and interviews On 9/13/21 at 7:30 p.m., Resident #23 was in bed. She had an oxygen concentrator next to her bed. She did not have the oxygen on. The tubing was wrapped up and tucked in the top of the oxygen concentrator. On 9/14/21 at 10:42 a.m., Resident #23 was in bed. She had an oxygen concentrator next to her bed. She did not have the oxygen on. The tubing was again wrapped up and tucked in the top of the oxygen concentrator. On 9/15/21 at 9:13 a.m., Resident #23 was in bed. She had an oxygen concentrator next to her bed. The oxygen tubing was on the floor next to the bed. The oxygen concentrator was off. On 9/15/21 at 9:51 a.m., Resident #23 was still in bed. The oxygen tubing was still on the floor next to the bed. Certified nurse aide (CNA) #2 was informed of the concern and observed the tubing as mentioned above as well. He observed the resident without oxygen and said she only wears oxygen at night. He then said her oxygen saturation was 90% this morning, and she did not need to wear her oxygen. He removed the tubing from the floor and replaced it with new tubing. He placed the new tubing in a bag and hung it on the oxygen concentrator. -He did not place the oxygen on the resident. On 9/15/21 at 10:05 a.m., Resident #23 was observed with registered nurse (RN) #2. RN#2 said she did not know why Resident #23 did not have oxygen on. She said maybe she only wears it at night. RN #2 then went into the hall and asked CNA #2 why the resident did not have oxygen on. CNA #2 told her that the resident's oxygen saturation level was 91% , therefore he did not put her oxygen on. She checked the oxygen orders on her computer and said the resident had orders for oxygen at 2LPM continuously via nasal cannula. On 9/15/21 at 10:06 a.m., RN #2 was asked to check the residents oxygen saturation level. Her oxygen saturation level on room air was 84%. RN #2 placed the oxygen on the resident at 2LPM. The oxygen went up to 88% slowly after two minutes, and then to 90%. The resident did not remove the oxygen. CNA #2 said he was unsure how the CNAs knew what the residents oxygen orders were. He then went to a computer and pulled up the CNA care plan. He said the CNA care plan did not indicate she was on oxygen. RN #2 said CNA #2 should have known the resident wore oxygen at 2LPM by looking at the care plan. RN #2 and CNA #2 both then said the resident removes the oxygen. However, based on observations and interviews above the resident was not consistently offered the oxygen, and the staff were unaware of her oxygen orders. D. Additional staff interviews On 9/15/21 at 10:29 a.m., the director of nursing (DON) was out of the facility. The NHA said she did not know anything about oxygen, and to speak to the admission nurse (ADN). The ADN was interviewed on 9/15/21 at 10:31 a.m. She said oxygen orders should include the liter flow, the frequency, the route and diagnosis. She said the information is available to the CNA on the CNA care plan. She said, she, as the admission nurse, should make sure it is on the CNA care plan. The ADN said the CNA could not titrate the oxygen or decide to not administer the oxygen. She said CNA #2 should not have held the oxygen this morning. E. Facility follow-up On 9/15/21 at 11:19 a.m., the ADN provided a copy of the CNA care plan. It documented she is on two liters oxygen. The CNA care plan did not document the frequency of the oxygen. It did not document that she wore it at night or continuously as was documented in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] III. Resident #13 A. Resident status Resident #13, age 86, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/8/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She required limited assistance of one person with bed mobility, transfers and toileting. Extensive assistance with dressing of one person and supervision of one person for hygiene. No oxygen documented. B. Observations Resident #13 was observed on 9/14/21 at 3:30 p.m. laying in her bed. She had an oxygen concentrator on at two liters and the tubing layed on the floor next to her. Resident #13 was observed on 9/15/21 at 7:45 a.m. laying sideways on her bed. The oxygen concentrator was on at two liters and the oxygen tubing was around her neck. -At 9:45 a.m. the oxygen tubing was around her neck. C. Record review Interdisciplinary note for Resident #13 dated 9/6/21 at 6:54 a.m. revealed vital signs of oxygen reading 89 percent (%) on one liter of oxygen and turned up to two liters of oxygen. Interdisciplinary note for Resident #13 dated 9/7/21 at 6:24 a.m. revealed vital signs of oxygen reading 91% on two liters of oxygen. Interdisciplinary note for Resident #13 dated 9/9/21 at 6:37 a.m. revealed vital signs of oxygen reading 96% on two liters of oxygen. Record review of Resident #13 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13 care plan on 9/15/21 at 10:00 a.m. revealed no oxygen care plan. D. Interviews Registered nurse (RN) #1 was interviewed on 9/15/21 at 10:30 a.m. She said Resident #13 started on oxygen when she arrived back from the hospital on 9/5/21. She said the oxygen concentrator was delivered the evening she arrived at the facility. She said the resident did not always wear the oxygen and took it off herself. The RN did a record review and it revealed there were no oxygen orders. The nursing home administrator (NHA) was interviewed on 9/15/21 at 3:30 p.m. She said there was no oxygen orders for Resident #13. She said when a resident used oxygen she would expect an order to be written for nurses to follow. E. Follow-up Interdisciplinary note for Resident #13 dated 9/15/21 at 5:26 p.m. read in pertinent part; The daughter requested not to have oxygen on Resident #13. She requested the oxygen concentrator to be picked up. NHA wrote in a follow-up email on 9/16/21 at 9:30 a.m. that read in pertinent part; When the resident was discharged from the hospital (new hospice admission from the hospital), the hospice nurse ordered that oxygen be delivered. Unfortunately, they neglected to write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, record review and interviews the facility failed to follow an activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being for one resident (#28) of two out of 44 sample residents. Specifically, the facility failed to provide one on one activities with Resident #28. I. Facility policy The activity policy, revised on 1/23/21, was provided by the nursing home administrator (NHA) on 9/16/21 at 11:00 a.m., it read in pertinent part; It was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group or individual activities and independent activities will be designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, as well as, encourage both independance and interaction within the community. II. Resident status Resident #28, age 98, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/23/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for a mental status score of four out of 15. He required limited assistance with one person for bed mobility and transfers and extensive assistance of one person for dressing, hygiene, and toileting. No rejection of cares. III. Observations Resident #28 was observed on 9/14/21 at 2:15 p.m. sitting in the day room on the opposite hallway where his room was. The music activity person arrived to play some music and the resident said, That would be nice to listen to some music. The music person was setting up her equipment when she was escorted to the other hallway by Resident #28s room where she proceeded to play the music. Resident #28 did not attend the music activity; he remained seated in the day room. No one assisted or offered to have Resident #28 attend the activity to listen to the music. The daily charting log for 9/14/21 showed Resident #28 attended the music group activity. There were no observations of Resident #28 attending the activity. Continuous observations from 9:20 a.m. to 1:10 p.m. revealed Resident #28 was sitting in the day room asleep in a chair at 9:20 a.m. There were no other residents in the day room. -11:15 a.m. he continued to be asleep in the day room, -12:10 p.m. he had assistance to come have lunch at the dining room table, he sat by himself at lunch and afterwards he sat by the window of the day room, -1:10 p.m. he was asleep in a chair in the day room. IV. Record review Record review of the activity logs for Resident #28 on 9/16/21 at 11:00 a.m. revealed there was no one on one activities. The activity care plan for Resident #28, dated on 6/24/21 was provided by the NHA on 9/16/21 at 11:00 a.m., it read in pertinent part; Resident #28 enjoys walks outside when weather permits, happy hour several times a month and reading groups. He enjoys one on one visits in his room and having someone read the daily chronicle to him. It read he needed reminders for some daily activity choices, he enjoyed music programs, supper food presentations and sing-[MEDICATION(S)]. Resident #28 will accept and receive one on one visits. He attends one to four activities of interest per week. The psychosocial well being care plan for Resident #28, dated on 6/28/21 was provided by the NHA on 9/16/21 at 11:00 a.m., it read in pertinent part; Resident #28 psychosocial well being would be impaired by his loss of being physically active outdoors. He will maintain his current involvement in activities, exercises and friendships. He responds well to music activities. Invite him to activities of interest (music). Resident #28 annual activity assessment dated on 10/28/2019 was provided by the NHA on 9/16/21 at 11:00 a.m., it read in pertinent part; Resident #28s activity interests are reading, music, talking, conversation, aromatherapy and social activities. Care conference note dated 4/15/21 for Resident #28 read in pertinent part; Resident #28 will accept and receive one on one visits. Staff will provide support and encouragement through one on one visits. The interdisciplinary social services note for Resident #28 dated 7/1/21 was provided by the NHA on 9/16/21 at 11:00 a.m., it read in pertinent part; Resident #28 expressed satisfaction with the current activity schedule such as one on one visits, one to five times a week with a duration of five to 20 minutes per visit. Daily charting log for Resident #28 revealed the resident attended 12 group activities in July and 12 in August 2021 which were logged as a music activity. The September log revealed he attended four group activities of music. The log had all other activities charted as independent activities. The duration of the time of activity was PRN or as needed. V. Interviews Certified nurse aide (CNA) #3 was interviewed on 9/15/21 at 2:15 p.m. She said Resident #28 liked to attend music activities. She said he stayed in the dayroom a lot during the day or wandered around on the patio. The community life coordinator (CLC) was interviewed on 9/15/21 at 4:00 p.m. She said when a resident moved into the facility an assessment was completed on their likes and dislikes. She said Resident #28 attended music groups and loved to go outside. She said the care plan reflected the activity for each resident. She said a daily charting log was filled out so she assessed the residents' activity quarterly. She said she helped Resident #28 with activities to walk outside, she read to him and he enjoyed most of his time in the day room sitting in the sun. She said there were no one on one activity logs specific to one on one visits.

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Specifically, the facility failed to: -Provide hand hygiene opportunities for residents; -Ensure proper social distancing guidelines were followed. Findings include: I. Facility policies/education The Staff Hand Hygiene document from the facility's Covid-19 Manual was provided via email by the nursing home administrator (NHA) on 4/15/2020. It read in part, When you are assisting residents, remember to perform hand hygiene with the resident after toileting and before and after meals. A document titled Updates to Covid-19 Requirements dated 3/14/2020 was provided via email by the nursing home administrator (NHA) on 4/15/2020. It read in part, We are no longer able to have communal dining in the dining rooms, so the residents will be provided room trays beginning with dinner this evening. Residents who have swallowing problems or need to be assisted at meals, may eat in the dining room as long as there are not more than 5 residents. The residents should sit at least 6 feet apart and you may assist these residents in the dining room. A document titled Minutes from March's House Meeting held 3/17/2020 and 3/18/2020 was provided via email by the nursing home administrator (NHA) on 4/15/2020. It read in part, Wash your hands and our resident's hands often. Use hand sanitizer and remind everyone to keep their hands away from their face, mouth and nose. Residents and staff are asked to maintain social distancing. This means residents should remain in their room until further notice. II. Failure to provide hand hygiene opportunities for residents A. Observations On 4/15/2020 at 11:21 a.m. Resident #2 was brought to the dining room for lunch. The resident had been playing cards and dominoes prior to being brought to the dining room. The resident was not offered the opportunity to perform hand hygiene prior to being left at the table. After being served her lunch, Resident #2 was observed picking up a sweet potato with her fingers, eating it, and then licking her fingers. At 11:25 a.m. an unidentified resident, who had been looking out a window in the dining room, was brought over to a table for lunch. The resident was not offered the opportunity to perform hand hygiene prior to eating. At 11:28 a.m. certified nursing aide (CNA) #2 gave Resident #1 her meal and set her up to eat her lunch. The CNA did not offer the resident the opportunity to perform hand hygiene prior to eating. The resident was observed to pick up a piece of food with her fingers and eat it. At 11:37 a.m. CNA #1 assisted Resident #3 from a couch in the common area to a chair. The CNA placed an overbed table in front of the resident. Resident #6 was not offered the opportunity to perform hand hygiene prior to eating. The resident was observed eating grapes with her fingers. At 11:48 a.m. Resident #3 was served a salad. She was observed picking up some carrots out of the salad with her fingers, and then licking her finger. At approximately 12:00 p.m. CNA #1 brought Resident #4 her lunch meal. The CNA #1 did not offer the resident the opportunity to perform hand hygiene prior to eating. B. Interviews The director of nursing (DON) was interviewed on 4/15/2020 at 1:00 p.m. She said that all residents should be offered the opportunity to perform hand hygiene prior to eating. The DON was interviewed a second time on 4/21/2020 at 10:30 a.m. The DON said one on one training has been given to staff in regards to washing resident hands before the meals. III. Failure to ensure proper social distancing guidelines were followed A. Observations On 4/15/2020 at 10:52 a.m. three residents were observed in a common area. Two of the residents were not six feet apart. RN #1 also observed and was observed to assist one of the residents further away from the other. At 11:30 a.m. , two residents were observed eating lunch at a round table in the dining room on Gardenia Lane. A CNA and registered nurse (RN) #2 were observed in the dining room. RN #2 was sitting at the round table which was approximately 60 inch round table. The two residents at the round table were not seated six feet apart from one another. A square table was observed to have two residents sitting at the table, however, they were not six feet apart. RN #2 was notified and was observed to assist the residents to another open table. B. Interviews RN #1 was interviewed on 4/15/2020 at 10:52 a.m. She said that residents should be six feet apart from one another. The director of nurses (DON) was interviewed on 4/15/2020 at 1:00 p.m. The DON said She said that there was a large round table in the dining room that they were allowing residents to eat meals at. She said that education on social distancing had been given to staff, however not to specific tables.

Based on observations and interviews, the facility failed to properly store medications in two of four medication carts. Specifically, the facility failed to ensure multi-dose medications were labeled with the date of opening or the proper resident identifier. Findings include: I. Facility policies and procedures The Labeling of Medications and Biologicals policy, revised 2/28/18, was provided by the director of nursing (DON) on 8/6/19 at 2:00 p.m. It read in part, All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices .medication labels must be legible at all times .labels for medications designed for multiple administrations (such as inhalers, eye drops), will identify the specific resident for whom it was prescribed. II. Observations On 7/31/19 at 8:45 a.m., Unit [NAME] & F medication cart was inspected with registered nurse (RN) #1. The following were found inside the medication cart: -A [MEDICATION NAME] Propionate Nasal Spray 50 Mcg was not labeled with the resident's name or the open date. -A Refresh [MEDICATION NAME] eye drop was not labeled with the resident's name or the open date. -A Pain relieving cream was not labeled with the resident's name or the open date. On 7/31/19 at 9:15 a.m., the Unit G & H medication cart was inspected with license practical nurse (RN) #1. The following were found inside the medication cart: -An Ear Wax Remover was not labeled with the resident's name or the open date. -An Artificial tears for was not labeled with the resident's name or the open date. -A [MEDICATION NAME] 1% was not labeled with the resident's name or the open date. III. Staff interview RN #1 was interviewed on 7/31/19 8:50 a.m. She said she always labeled every new medication when opened. She said nurses were supposed to label all medications upon receipt from the pharmacy. The RN said, moving forward, she would ensure all medications would be properly labeled prior to use. The DON was interviewed on 7/31/19 at 11:51: a.m. She said it was the facility's expectation that staff labeled all medications with the resident's name, room number and the initial date of opening. She said all nurses would be in-serviced to ensure all medications in their carts were appropriately labeled.

Based on observations and resident and staff interviews, the facility failed to ensure the building was kept at comfortable and safe temperatures. Specifically the facility failed to maintain comfortable and safe temperature in the resident dining rooms and common areas. The findings included: Facility Policy: The facility Resident Environmental Quality policy, revised (MONTH) (YEAR), provided by the assistant nursing home administrator on 7/11/18 at approximately 1:30 p.m. did not specify the acceptable temperature range for the dining rooms and common areas in the facility. Observations On 7/9/18 at 11:30 a.m., during the initial dining observation, the dining room for EF unit felt warm and the dining room for GH unit felt cold. On 7/9/18 at 11:32 a.m., resident #29 and #34 were seated at the same table in the GH dining room. Both residents called out several times the dining room was too cold. Resident #34 said it is too cold in here, I cannot take it anymore. An unidentified staff member asked the residents if they needed a blanket, both residents stated they needed blankets. The staff member was observed to bring both residents two blankets. On 7/9/18 at 2:44 p.m. the temperature in common area of F unit was 82 degrees Fahrenheit (F). On 7/9/18 at 5:01 p.m. the temperature in the common area of F unit was 84 degrees F. On 7/10/18 air temperatures in the EF dining room were taken and documented as follows: --At 11:15 a.m., the air temperature in the EF dining room was 84 degrees F. --At 11:29 a.m., the air temperature in the EF dining room was 84 degrees F. --At 12:00 p.m. the air temperature in the EF dining room was 85 degrees F. --At 12:20 p.m., the air temperature in the EF dining room was 85 degrees F. On 7/11/18 at 9:00 a.m. the temperature in the GH dining room was observed at 64 degrees F. Registered nurse (RN) #2 confirmed the temperature, and said she had called the maintenance department to report the temperature, but had not seen them yet. Resident council meeting The resident council interview was held with six alert and oriented residents on 7/11/18 at 10:19 a.m. The residents were cold as the air conditioner outside of the conference room was blowing in the dining area as well as into the room. The resident's all said it was cold and the activities coordinator went to get blankets, she said she was going to ask someone from the maintenance department to turn that air off because it was very cold and she apologized for the cold temperature in the room before she left. Resident #46 said it often got hot on the side of the building (EF unit) she resided on. She said different areas of the facility were either too hot or too cold. The resident said she had heard other residents voiced concerns about the temperatures but staff told them there was not much they can do about it because of the construction. The resident said staff usually just move the fans from the cold area to the hot and vice versa. Resident #3 said when residents had brought it up (air temperature) in the resident council meeting they were told when it gets too hot the facility could provide fans and that it was due to the construction. Resident #24 said the temperature fluctuates from hot to cold every day. She said sometimes it was bothersome but there was not much the staff could do about it. Staff interviews The director of facility operations (DFO) was interviewed on 7/10/18 at 3:15 p.m. The DFO provided his thermometer and confirmed the temperatures in the various areas of the facility. The DFO said the temperature in the EF dining room was 82.5. The DFO said he was unsure why the common area air in F unit felt hot. He said the air coming out of the vents located at the ceiling should be cold air. The DFO checked the air temperature with his thermometer and confirmed the air coming out of the two vents were 92.3 degrees F and 93.2 degrees F. The DFO said there was a vent located in the hall of F unit and that vent should also be blowing cold air into the facility. The DFO checked the air temperature with his thermometer and confirmed the air coming out of the vent was 93.5. The DFO said neither he, nor his staff, monitored the temperatures in the building on a regular basis. He said he relies on staff in the facility to call his department and let them know if common areas are too hot or too cold. He said the facility was currently undergoing construction and the chiller for the facility had to be moved. He said there were air conditioner units for the dining room and the common areas, but they were getting air lock and not working correctly. He said he would contact an independent contractor to come out to the facility to look at the air conditioners and possibly fix the problem. The DFO was interviewed again on 7/10/18 at approximately 5:00 p.m. he said two of the units had air locked and were not functioning properly. He said the facility had been dealing with temperature problems since the chiller had been moved as part of the construction project. The facilities supervisor (FS) was interviewed on 7/11/18 at 9:10 a.m. he said the facility did not have a system to monitor the temperatures throughout the facility. He said they had air conditioning units located outside the facility that were being used because of the construction. The units were located outside and had large vents that provided cold air in the dining rooms. The FS turned off the cooling system and the temperature rose from 64 degrees F to 66 degrees F. The FS said the temperatures throughout the facility should be monitor frequently.

Based on observations, record review and staff interviews, the facility failed to ensure professional standards of practice were followed for one (#2) resident out of three residents reviewed for respiratory care. Specifically, the facility failed to obtain written/signed physician order for [REDACTED]. Findings include: Resident status Resident #2, age 98, was admitted on [DATE] with [DIAGNOSES REDACTED]. The 6/21/18 minimum data set (MDS) assessment, the resident had clear speech, sometimes made self-understood and usually was able to understand others. Her cognitive skills for daily decision making were severely impaired. Delusions were present during the assessment period. No rejection of care was observed. She required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use and personal hygiene, limited assistance of one person for eating. The resident was under hospice care. The MDS assessment did not indicate the resident was receiving oxygen therapy. Observations On 7/9/18 at approximately 4:30 p.m. the resident was observed in her room, in bed, listening to the music. The oxygen was observed flowing from a concentrator to the resident's nose through the nasal cannula. On 7/10/18 at 4:15 p.m. the resident was observed in her room, in bed. The nasal cannula was observed in resident's nose and the O2 was flowing at two liters per minute (2l/min). On 7/10/18 at 5:10 p.m. the resident was observed in the dining room, sitting at the table, in her wheelchair. The portable O2 tank was observed attached to the back of the wheelchair. The O2 flow was set at 2 l/min. Interviews The certified nurse aide (CNA#1) was interviewed on 7/10/18 at 5:12 p.m. She said the resident was receiving the O2 for approximately two weeks. The registered nurse (RN#1) was interviewed on 7/11/18 at 9:55 a.m. She said, after looking in the resident's medical record that there was no physician order for [REDACTED].>The hospice registered nurse (RN#3) was interviewed on 7/11/18 at 10:00 a.m. She said the resident was on O2 for approximately two weeks. She said she did not request or complete the physician order for [REDACTED].

Based on observation, staff interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity, and cared for each resident in a manner that promoted maintenance of quality of life for one (#67) of one out of 32 sampled residents. Specifically, the facility failed to honor the resident's right to refuse services. The findings included: Facility Policy On 1/23/17 at 10:37 a.m. the nursing home administrator (NHA) provided a copy of the facility's 10/09 policy titled, Quality of life - dignity. The policy documented in pertinent parts, 1. Each resident shall be treated with dignity and respect at all times and 12. Staff shall treat cognitively impaired residents with dignity and sensitivity; for example: a. Addressing the underlying motives or root causes for behavior; and b. Not challenging or contradicting the resident's beliefs or statements. Resident #67 Resident #67, age 88, admitted to the facility on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 10/13/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment and was unable to complete the brief interview for mental status (BIMS) assessment. Mild depression symptoms were noted and the resident exhibited verbal and physical behavioral symptoms one to three days of the seven-day assessment period. The resident required supervision with one-person physical assistance for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, and eating; and extensive two-person physical assistance for dressing, toilet use, personal hygiene, and bathing. The resident was able to maintain stable balance without human assistance while walking. Observation Resident #67 was observed seated at a dining room table on 1/18/17 at 8:57 a.m. The resident was yelling at three certified nurse aides (CNAs) who were attempting to get him to get out of the dining room chair and into a wheelchair. The resident told the staff members no repeatedly, and told them to get the hell away from him. The three CNAs (#1, #2, #6) were then observed to lift the resident out of the dining room chair and put him in the wheelchair while the resident continued to yell no and obscenities at the staff. After the transfer was complete, the van driver took the resident to the elevator. Record review The care plan dated 2/4/16 documented (Resident #67) has impaired behavior related to dementia and possibly underlying personality as evidenced by resisting cares, particularly bathing, changing clothes, shaving, mouth care, eye drops. Goal: (Resident #67) will receive the necessary cares needed to ensure proper hygiene and health. Approaches: Explain all cares prior to start - briefly - and request his help; Allow (resident #67) to help with ADLs (activities of daily living) to maximum potential; Respect (resident #67)'s right to refuse and re-approach as necessary; monitor each shift for resistance to care. Consult his wife for assistance in cares he routinely refuses. The ADL/Daily care list dated 2/4/16 documented, Can resist care due to dementia. Encourage, respect his wishes and re-approach and Behaviors: Resistive to care; Things to avoid: don't touch him - give him verbal cues and Transfer assist: Independent, SBA (stand-by assistance); device: walker, remind to use. Staff interviews CNA #1 was interviewed on 1/18/17 at 8:59 a.m. She said that resident #67 was scheduled to go to a doctor's appointment which was why they had to transfer him. She said he normally did not fight going to appointments because his wife would be there. Registered nurse (RN) #1 was interviewed on 1/23/17 at 8:04 a.m. She said she was on duty the morning of 1/18/17. She said she was in another resident's room during the time resident #67 was going to his doctor's appointment and was told about the situation after it happened. She said that resident #67 will frequently refuse care and services but can sometimes be redirected and will eventually accept the care and services. She said she felt resident #67 should have been allowed to refuse to go to the appointment if he did not want to go. She said the CNAs should not have lifted him out of the chair, but rather should have alerted the nurse the resident was refusing, so she could evaluate the situation and determine if the resident was truly refusing or if he was able to be redirected. She said the resident's wife usually assisted with encouraging the resident to attend appointments, and it was unusual that she was not there. RN #1 said the resident's appointment had been changed, and that is why the resident's wife was not present to assist staff. The director of nursing (DON) was interviewed on 1/23/17 at 9:40 a.m. She said if a resident was refusing a needed service, staff members should walk away and come back a later time or try another staff member. She said resident #67 should have been allowed to remain in his dining room chair. She said resident #67's wife lived in the independent apartments on campus and would frequently be present with the resident during appointments to avoid a refusal. She said staff were trained on residents' rights and dealing with difficult behaviors, and it was her expectation for staff to honor residents' rights, including the right to refuse.

Based on record review and staff interviews, the facility failed to ensure each resident had a comprehensive plan of care for one (#9) of five out of five sample residents. Specifically, the facility failed to complete a care plan to address the use of [MEDICAL CONDITION] medications for resident #9. The findings included: On 1/23/17 at 10:37 a.m. the nursing home administrator (NHA) provided a copy of the facility's 10/10 policy titled, Care plans - comprehensive. The policy documented in pertinent parts, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident and The resident's comprehensive care plan is developed with seven (7) days of the completion of the resident's comprehensive assessment (MDS) (minimum data set). Resident Status Resident #9, age 93, admitted to the facility on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 12/31/16 MDS assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident had moderate depression with a depression scale score of 10 out of 27. No behaviors were noted. The resident required extensive one-person physical assistance with activities of daily living. The resident did not use the PRN medications during the seven-day assessment period. The care area assessment (CAA) report documented the use of [MEDICAL CONDITION] medications was indicated to be included in the care plan. Record Review The physician's orders [REDACTED]. -[MEDICATION NAME] (an antidepressant) 25mg as needed (PRN) at bedtime for [MEDICAL CONDITION]; -[MEDICATION NAME] (an antidepressant) 10mg daily for depression; and -[MEDICATION NAME] (an antianxiety medication) 0.125mg twice daily PRN for anxiety. A review of the 12/16 and 1/17 Medication Administration Record [REDACTED]. A review of the resident's comprehensive care plans revealed there was no care plan addressing the use of [MEDICAL CONDITION] medications. Staff interviews The director of nursing (DON) was interviewed on 1/23/17 at 9:40 a.m. She said care plans should include all [MEDICAL CONDITION] medications. The MDS Coordinator (MDSC) was interviewed on 1/23/17 at 9:53 a.m. She said the resident triggered on the MDS assessment for the use of [MEDICAL CONDITION] medications and said there should have been a care plan for the medications. She agreed there was not a care plan in place, and said she would put one in place immediately. She said the purpose of the care plan was to inform staff of potential side effects of medications, monitor for using the lowest possible dose, and non-pharmacological interventions to help reduce episodes of depression and anxiety.

Based on observations, staff interviews, resident interview and record review, the facility failed to ensure the resident environment remains as free from accident hazards as is possible for one (resident # 101) of 12 out of 30 sample residents. Specifically, the facility failed to complete a side rail utilization assessment prior to implementation for resident #101; and the facility failed to monitor and ensure the side rail was secured to the bed frame for resident #101. The findings included: I. Resident Status Resident #101, age 88, was admitted on [DATE]. According to the 1/17 computerized physician's orders [REDACTED]. According to the 12/31/16 minimum data set (MDS) assessment, the resident's cognition was intact with a brief interview for mental status (BIMS) score of 15 out of 15. The mood assessment revealed mild symptoms with a score of four out of 27. He required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. He required limited assistance with eating, locomotion on/off the unit and walking in corridor/room. The care plan, initiated 12/17/16, identified potential for falls due to recent fall with fracture of right hip and right elbow. The interventions included reminding resident to call for assistance and reminding him of safety awareness. II. Observation An observation in resident's room on 1/17/17 at 11:23 a.m. revealed quarter size side rails on each side of the resident's twin bed. The side of the bed closest to the entrance of the room had a secured side rail with a call light wrapped around it. The side rail closest to the window was not securely attached and swung outwards freely. III. Observation/Family Interview/Resident Interview The resident and a family member were interviewed on 1/18/17 at 5:02 p.m. The resident had two quarter side rails on his bed. The rail closest to the entrance of the room had his call light wrapped around it. The rail closest to the window was not flush with the mattress. The rail when touched, swung freely away from the mattress/bed frame. The resident said he did not know it was loose. The family member said he was unaware of the loose side rail. IV. Observation/Staff Interview/Resident Interview The registered nurse (RN) #2 was interviewed on 1/18/17 at 5:11 p.m. She said a daily check by the staff was made to ensure the side rails were sturdy for resident safety. She said the side rails would snap into place and provide resident's assistance with transfers and mobility. She said the residents who had them, liked them for stability. She went to resident's #101's room during the interview. The resident was seated in his recliner. He was visiting with a family member. When the RN looked at the quarter side rail, she agreed it was swinging outwards and she attempted to snap it in place. There was a pin that needed to be pulled and released to secure it into place. The pin would not snap into place. She was unable to secure the side rail to the bed. The resident said he did not want to roll out of bed and break anymore bones. The RN left the room to get a certified nurse aide (CNA) to assist with securing the side rail to the bed frame. CNA #5 came back to the room with the RN. She attempted to secure the side rail to the bed. She was unable to snap it into place. The CNA said she would put a concern note into the electronic record system. This note would alert the maintenance staff to fix the side rail. IV. Record Review The health information manager (HIM) provided copies of the following documents on 1/19/17 at 2:30 p.m. The 1/17 physicians order revealed authorization for quarter side rails for mobility and transfer assistance. The resident daily care list dated 1/19/17 revealed a safety question for, Did you find any alarms or equipment malfunctioning or with any parts missing? The interdisciplinary team review bed safety-side rail/risk benefits consent form dated by the staff and resident on 12/17/16. This form revealed the resident would be assessed at the time of admission and anytime there was a significant change in condition. The facility takes responsibility to assess the safety and use of all assistive devices such as side rails. The risks for side rails included potential injury such as wounds, fractures, entrapment and even death. The benefits would include improving bed mobility or transfers. There was no side rail utilization assessment provided for resident #101 as outlined in the consent form. (See above form.) V. Staff Interviews The registered nurse (RN) #1 was interviewed on 1/18/17 at 9:56 a.m. She said the resident had side rails. He would lay up against one of them during the night when sleeping. The certified nurse aide (CNA) #4 was interviewed on 1/18/17 at 5:06 p.m. He said some of the residents had quarter side rails. She said the CNAs checked daily to make sure the side rails were secured to the bed and would make sure the side rails were secured when the residents were using them to assist with repositioning or transfers. She said resident #101 used his quarter side rail to help with transfers and the resident required limited assistance with transfers. She said staff would put a gait belt around his waist and he would hold the side rail. She said the CNAs would guide him to stand up. The CNA #5 was interviewed on 1/18/17 at 5:17 p.m. She said it was important for the resident's side rails to be secured for safety. She said the facility did not want the resident's falling out of bed. She said residents used the side rails for mobility and transfers and a loose side rail would be unsafe for the residents. The RN #2 was interviewed on 1/18/17 at 5:20 p.m. She said the side rails could be considered a restraint but the resident was using this side rail to help him with transfers in and out of bed She said the side rails were also used for preventing falls for resident's who had confusion. She agreed it would be unsafe to have an unsecured side rail. She would contact the maintenance department to fix the side rail. She said she did not think the resident was using this side rail because it was on the far side of the room next to the window. She would request for the maintenance department to remove the side rail entirely. RN #2 was interviewed on 1/19/17 at 4:37 p.m. She wanted to clarify her response from 1/18/17. She said the side rails could be considered a restraint and only a few residents had them. She said when they had them it was for mobility. She said the physician had to write an order for [REDACTED]. She said the resident could have grabbed or reached for the side rail and it could have swung outwards and the resident could have fallen. She said she did contact maintenance the side rail closest to the window was removed RN #1 was interviewed on 1/23/17 at 11:51 a.m. She said all residents who had a side rail required a consent form which was to review risks versus benefits. She said there was nursing judgment when a side rail utilization assessment should be completed and residents that had dementia would need an assessment. She said a resident who may need a quarter rail for mobility or to assist with transfers may not need an assessment but the therapy department would also evaluate for placement of where the side rails should be placed. She said the side rails were always considered a restraint even if they were not used that way. She said when a resident was in bed, the side rails should always be checked. She said all staff when they were working with a resident, should ensure side rails were secured and in place. She said it was important to make sure any side rails were secured at all times to avoid falls or potentials injuries. The nursing home administrator (NHA) was interviewed on 1/23/17 at 12:09 p.m. She said her staff had made her aware of the loose side rail on resident' #101's bed. They did not have a side rail utilization assessment for resident #101 but he did have a consent form. She said the admissions nurses had been lenient in completing assessments for residents' who had requested side rails. They should have had a side rail assessment for resident #101. She was aware not all of the nurses were completing them. She said there should be a routine check by the CNAs to ensure the side rails were secured. The CNAs should check for this as they would place a call light and water within reach for residents. She said the loose side rail could have caused an accident. She said they had reviewed the rooms and learned they had 40 out of a possible 54 beds with side rails. She said she was working on potentially removing all side rails from the facility. VI. Facility Follow up The residents bed was observed on 1/19/17 at 8:46 a.m. The side rail had been removed from the bed frame on the window side of the room. The resident remained with one side rail closest to the entrance of the room.

Based on observation, interviews, and record review, the facility failed to ensure residents had the right to examine the results of the most recent state survey. Specifically, the facility failed to ensure the most recent state survey results were easily accessible to residents and that residents knew where to locate the survey results. The findings included: On 1/19/17 at 4:13 p.m. the nursing home administrator (NHA) provided a copy of the facility's policy updated 9/13/16 titled, Resident rights and responsibilities. The policy documented in pertinent part, You also have the right to see the state survey reports of this facility. Resident Interview A resident council representative, resident #44, was interviewed on 1/18/17 at 10:12 a.m. He said he was unaware the facility had the state survey results posted, and did not know where they were located. He said that he was given a book of information about the facility when he admitted , but said that it was a lot of information presented at once and was not sure what information was included in the book. Observation A search of the public resident areas in the facility was conducted on 1/18/17 at 4:22 p.m. The areas observed included the dining rooms, the seating areas near the dining rooms, the living room areas on each resident unit, the nurse's stations, and the front lobby reception area. There was no information posted about where to locate the survey results. At 4:34 p.m. a black unmarked binder was located in a bookshelf inside the administrative office hallway, behind the receptionist desk. The binder contained results of previous surveys, but not the most recent survey, with an exit date of 12/30/15. The most recent survey in the book had the exit date 2/4/15. On 1/19/17 at 8:54 a.m. the binder was observed a second time. The survey results were not updated. Staff interview The NHA was interviewed on 1/19/17 at 4:13 p.m. She said information about where to locate previous survey results was provided to residents upon admission. She said the book had been updated and was unsure where the copy of the most recent survey results had gone. She agreed the book should contain the most recent survey results. Record Review On 1/19/17 at 4:13 p.m. the NHA provided a copy of the resident admission agreement packet. The packet documented the residents' right to view survey results, but did not provide information to the residents on where to find the survey results. Facility follow-up The survey results binder was observed on 1/23/17 at 10:29 a.m. with the most recent survey results inside. The book remained on the bookshelf in the office area.