Every finding on record at Gilpin Hall

Based on record review and interview it was determined that for one (R4) out of four residents reviewed for accidents the facility failed to provide assistive devices to prevent an accident. R4 was transported in a facility vehicle without all safety straps secured. The facility driver came to a sudden stop and R4 fell forward and acquired two broken legs causing physical harm. The facility was found to be in past noncompliance with correction completed as of 1/8/26. Findings include:Review of R4's clinical record revealed:12/3/25 - An annual MDS assessment documented that R4 was cognitively intact and required substantial maximum assistance with upper body dressing and weighed 265 pounds.12/7/25 - R4's care plan for self-care deficit included the intervention for staff to provide extensive assistance with upper body dressing.1/5/26 12:42 PM - The facility submitted an incident report to the State Agency that alleged R4 experienced a fall while traveling in the facility van.1/5/26 2:46 PM - R4 was admitted to the hospital with a diagnosis of bilateral foot pain. X-rays of both legs showed broken bones.1/5/25 - A statement written by E6 (CNA) documented, [E5 (driver) had to slam on the brakes. When I looked [R4] was on her knees with the seat belt still attached. 1/6/26 - A statement written by E4 (former NHA) documented [E5 (driver)] and I inspected the transport van to investigate the proper operation of the safety belts. We reviewed and inspected the wheelchair harness and seatbelts and wheelchair locking mechanisms an discussed their proper operation. We found the safety belts and devices not damaged and discussed searching for longer safety belts for bariatric (plus) sized residents.1/7/26 - The facility policy was revised to include, If using [facility] transportation, the driver must confirm that the wheelchair is properly locked in place and all seat belts are properly fastened before departure. If any defects or faults with equipment are found, the driver must report this information to the administrator or designee immediately and if not able to be fixed the appointment must be rescheduled.1/7/26 - An employee warning record documented that E5 (driver) was suspended by the facility for carelessness.1/9/26 - An employee warning record documented that E6 (CNA) was suspended by the facility for carelessness.7/13/26 2:30 PM - Review of the facility training and sign-in sheets revealed that on 1/7/26 - 1/8/26 the facility conducted education with staff who assist with resident transports on safe transfer of residents with the use of equipment [straps].7/13/26 2:40 PM - During an interview E1(NHA) stated, We inspected all our bariatric patients and determined one other patient at risk and cancelled their use of the facility van until arrival of our seat belt extender for safety of larger residents.7/13/26 3:08 PM - During an interview, E5 (driver) confirmed that the shoulder belt was not fastened for R4 during the transport in the facility van on 1/5/26. E5 stated the strap didn't fit across [R4]. We thought since the seatbelt and wheelchair were fastened it would still be safe.7/13/26 3:09 PM - E1 (NHA) provided copies of the audits that the facility completed 1/12/26 - 2/27/26 to verify residents were securely strapped in during transports on the facility vehicle. Review of the audits indicated 100% compliance.7/13/26 3:15 PM - During an interview, E6 (CNA) confirmed that she and [E5 (driver)] did not apply R4's shoulder belt during the transport on 1/5/26. E6 stated, It didn't fit and we were afraid it would hurt her chest being so tight. We thought with the seatbelt and the wheelchair secured that would hold her.7/13/25 3:30 PM - Review of facility investigation and corrective measures completed by E4 (former NHA) and E2 (DON) documented that immediately following the incident, the facility halted further use of the vehicle, inspected the vehicle for disrepair, and identified the need to order extenders for the shoulder straps to fit bariatric residents. Simultaneously, the facility reviewed all residents for safe use of the facility vehicle, educated all staff on safe security of residents during transport, and revised the transportation policy. The facility concluded interventions in response to R4's accident as of 1/8/26.7/14/26 3:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on observation, interview and record review, it was determined that for one (R1) out of five residents reviewed for resident rights, the facility failed to ensure that rights exercised by R1's resident representative were followed by staff. Findings include:Review of R1's clinical record revealed: 6/20/23 - R1 was admitted to the facility with a diagnosis of dementia. R1's resident representative was listed as R1's power of attorney for care. 6/16/25 - The annual MDS assessment documented R1's BIMS score as a 3 (severely cognitively impaired). R1 had a motion activated camera located in R1's room, which was permitted by the facility, supplied and viewed by R1's resident representative, and known to all nursing staff. The camera, located on top of the dresser, captured the following: 9/9/25 11:21 AM - Video observation of E7 (CNA) in R1's room standing in front of the dresser. E7 turned the camera to face the wall and R1's personal items. (Video 0:00:26 hour:minute:second) 9/24/25 11:47 AM - Video observation of E7 (CNA) exited the bathroom in R1's room and was putting on disposable gloves. E7 stood in front of the dresser and opened the doors. R1 was observed talking softly at the foot of her bed. E7 reached for the camera on top of the dresser and turned it away to face the wall and R1's personal items. (Video 0:00:59 hour:minute:second) 9/29/25 untimed - E7 (CNA) wrote the following statement: . On several days I did turn the camera around because I didn't ok (sic) to be recorded. 10/6/25 12:05 AM - During an interview, E7 (CNA) confirmed that she was educated that staff are not allowed to touch the resident's personal property, specifically the camera, in the room. 10/8/25 4:00 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON) and E12 (ED).

Based on video observation, interview and review of facility documentation, it was determined that for one (R1) out of five residents reviewed for abuse, the facility failed to protect a resident's right to be free from physical and mental abuse by staff. While there was no apparent decline in mental or physical functioning of R1 at the time of the survey, it can be determined that a reasonable person in the same position would have experienced psychosocial harm, specifically dehumanization, as a result of the physical and mental abuse by staff. Review and verification of the facility's immediate actions for the staff to resident incidents on 8/2/25 and 8/20/25 were determined to have been corrected prior to the survey. An additional finding of a resident to staff incident, dated 8/31/25, was also captured on video, but was unknown to the facility until 10/3/25. Findings include: 1. Review of R1's clinical record revealed: 6/20/23 - R1 was admitted to the facility with diagnoses that included, but were not limited to, dementia, depression and anxiety disorder. 6/30/23 - R1 was care planned for ADL self-care performance deficit related to dementia. Approaches included, but were not limited to:-independent for transferring in and out of bed (10/4/24 revised);-required partial/moderate (limited assist) from staff to dress and to encourage changing clothes;-able to transfer on toilet with supervision/touching assistance. Staff needs to make sure incontinence products are in place and clean, extensive (substantial/max) assist for incontinence care (6/30/25 revised).-encourage the resident to participate to the fullest extent possible with each interaction; and-praise all efforts at self care. 1/6/25 revised - R1 was care planned for frequent refusals/resistive to care. Approaches included, but were not limited to:-encourage as much participation/interaction by the resident as possible during care activities;-give clear explanation of all care activities prior to and as they occur during each contact;-if resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again;-praise the resident when behavior is appropriate; and-provide resident with opportunities for choice during care provision. 6/16/25 - The annual MDS assessment documented R1's BIMS score as a 3 (severely cognitively impaired); exhibited physical, verbal and other behaviors toward others and rejection of care occurred 1 to 3 days during the assessment; behaviors significantly interfered with the resident's care; and R1's behaviors and care rejection worsened since the last assessment. R1 had a motion activated camera located in R1's room, which was permitted by the facility, supplied and viewed by R1's resident representative, and known to all nursing staff. The camera, located on top of the dresser, captured the following staff to resident incidents: First Video: On 8/2/25 at 6:00 AM, E4 (CNA) was observed making R1's bed. R1 was standing in the doorway talking softly. E4 walks over to R1 and said, right here while pointing to the bathroom. E4 said, sit on the toilet, please thank you. E4 walked into the bathroom and said, right here. R1 says, then what. running down my leg. E4 said, no and walked out of bathroom and around R1 to the doorway. R1 said, what's wrong? E4 said, you don't have a pull up on. R1 said, I took it off. E4 said, why didn't you put on a new one? R1 responded (unable to hear clearly). E4 returned into the room from the doorway, closed the door and pointed to the bathroom. R1 then pointed to the bathroom. E4 forcefully grabbed R1 and pushed her into the bathroom while R1 was screaming. (Video 0:02:01 hour:minute:second) Second Video: On 8/20/25 at 5:35 AM, R1 was sitting on the side of the bed. E4 (CNA) was standing on the left side of R1. As R1 was observed to be taking her right arm out of her shirt, E4 immediately and forcefully grabbed R1's left arm and pulled her up off the bed, standing her up, and pushed R1 from behind as R1 said, Hey, Hey. Help and continuously yelled as R1 was pushed into the bathroom. E4 was not observed speaking to R1 during this physical interaction. (Video 0:00:25 hour:minute:second) 9/29/25 4:48 PM - In response to a meeting with R1's resident representative regarding R1's care where these videos were shown, the facility immediately reported the videos dated 8/2/25 and 8/20/25 to the State Agency within the two-hour requirement. Immediate action was taken when these video incidents were brought to the facility's attention and prior to the current survey that started on 10/2/25 at approximately 1:30 PM. 9/29/25 - The staff member involved was identified and a written statement was obtained by E2 (DON) from E4 (CNA) prior to being suspended pending investigation:-E4 wrote, I went to [R1's] room to give her care, took her to the bathroom and she was screaming but her clothes were really wet and I had to change her and was not happy to leave her in that state. The facility completed the following prior to the current survey, which was verified by the surveyor onsite:-9/29/25: Interview and written statement were obtained from E4 (CNA). E4 was immediately suspended pending a facility investigation.-9/30/25: E2 (DON) interviewed R1 who was unable to recall the incidents. E2 provided emotional support to R1.-9/30/25: All cognitive residents were interviewed for abuse concerns with staff.-9/30/25: E8 (RN/SD) in-serviced nursing staff on the Abuse Policy, Reporting Abuse, No Retaliation and Refusal of Care policy.-10/1/25: E2 (DON) reviewed R1's records for skin issues or bruising during the time period. No suspicious marks were identified.-10/1/25: E2 (DON) met with E4 (CNA) and showed the videos. E4 remained on suspension until E4's employment was terminated on 10/6/25.-10/1/25: QAPI team was updated by E2 (DON).Based on the actions above, the facility corrected the non-compliance on 10/1/25. 10/6/25 at 2:31 PM - During an interview with DHCQ staff, E4 (CNA) confirmed she worked 11 PM to 7 AM at the facility. In review of the 8/2/25 at 6:00 AM incident, E4 stated that she was trying to get R1 into the bathroom. E4 stated that she did not know that R1 had a dementia diagnosis. E4 stated that R1 doesn't like to use the bathroom and refuses care a lot. With toileting, R1 was really wet and R1 was shivering. I felt bad for her and was trying to take off her clothes. I didn't plan to hurt her. On 8/20/25 at 5:34 AM, E4 (CNA) stated that R1 was wet and the bed was wet. R1 wasn't standing. E4 stated, I was only helping her for the condition that she was in. I used that approach to try to help her, but I was not trained in that way. Yes, R1 was the most challenging resident I had. When asked what are you trained to do when a resident refuses (or was non-adherent) to care? E4 stated, . let the nurse know. I didn't tell the nurse, that was a mistake. I should have let the nurse know. When asked did you learn not to force a resident if the resident refuses, E4 stated, Yes, I will never do it again. I always ask for help. I am not sure what happened that day. She always yells like that and she doesn't like to be changed. Everybody knows and yes the nurses know that she doesn't like to be changed. When asked if she had dementia and abuse training, E4 stated, Yes. When reviewing resident rights, E4 replied in an upset tone of voice and said I'm sorry. 2. 10/3/25 10:06 AM - During an interview, E2 (DON) was asked by the DHCQ special investigator and surveyor to view an additional video to identify the nursing staff member involved. E2 immediately stated that she was not aware of this additional video, dated 8/31/25, and identified the staff member involved as E6 (RN). Third Video: On 8/31/25 at 9:48 AM, E6 (RN) was standing on R1's left side with R1 standing next to her bed. R1 said. (unable to hear clearly). E6 said, Please take your medicine [name of R1]. R1 said, All at one time? E6 said, Yep, like you do every day, every morning. R1 started to move. E6 said, You want to sit down. I will hold this. E6 reached for the cup of water in R1's left hand, but R1 doesn't let it go. E6 held the cup with R1 still holding it as R1 sat down on the side of the bed. E6 said, There you go. Put that in your mouth, your pills. R1 said (something unclear) and was holding the pills in her right hand in a fist. E6 bent slightly forward then stood up straight and said, Please take them. R1 said, No. I am not going to take them until.(unable to hear clearly). R1 had her right hand in a fist close to her chest. E6 reached for R1's right hand and was attempting to retrieve the medications. R1 asked, What are you doing now? E6 was bent down trying to get the medications out of R1's right hand. R1 said, You're breaking my fingers. You did too. R1 slapped/hit E6 on the right arm with R1's right hand. R1 was still holding the cup of water in the left hand. After getting hit, E6 turns to R1, bent over, and pointed her finger at R1's face and said, Do not hit me. E6 proceeded to pick up the medications off the floor. R1 said, You will break another finger. E6 exited R1's room and closed the door. R1 said, That's you alright. Get out of here. R1 drinks water out of the cup in her left hand. (Video 0:02:05 hour:minute:second) Immediately after seeing the 8/31/25 9:48 AM video, E2 (DON) removed E6 (RN) from the nursing floor to be interviewed by the DHCQ investigator and surveyor onsite. E6 met with E2 (DON) after and was requested to write a statement. Then E6 was suspended pending the completion of the facility's investigation. 10/3/25 10:51 AM - During an interview with DHCQ staff, E6 (RN) stated that she was very familiar with R1, a dementia resident. E6 stated that sometimes R1 becomes very anxious, confused, would scream out and become combative if R1 feels threatened. When asked about administering medications to R1, E6 stated that R1 likes to put the pills in her hand and count them (1,2,3,4,5,6). E6 stated that there was a time where she had to take the pills back, but she never forced her hand open. E6 stated she would wait 5-10 minutes to give R1 time to take the pills before taking them back. E6 stated that if reapproach doesn't work, you just have to keep trying. E6 stated that R1 can be verbally abusive and hit E6 once or twice during care. E6 stated she did not remember telling a supervisor about it. E6 stated that she would never hit R1 back or threaten R1. E6 stated that R1 had a reputation of being difficult. E6 stated that a resident cannot be forced to do anything. E6 confirmed that she received training for abuse and dementia care. 10/3/25 untimed - E6's (RN) written statement provided to the facility was: There was an occasion when [R1] had her medication in her hand, she would not take the medications, so I wanted to remove them from her hand. She had her fingers closed & [and] when I opened her fingers she started screaming. I did not force open her hand. I was simply trying to remove the pills from her hand because she did not want to take them. I did not put any force on her fingers. I just opened her fingers. She started screaming when I took the pills. I did not put any physical pressure on her hand. I just wanted to make sure that she did not have the pills in her possession for safety. 10/6/25 - The facility interviewed all residents again to determine if they were abused or mistreated by staff. No residents were identified. In addition, the facility reviewed R1's clinical record with the additional date from the video to determine if there was any bruising or suspicious marks, with none noted. 10/6/25 untimed - Facility management met with E6 (RN) to review the video in person. E6 submitted a second written statement to the facility: On 8/31/25, I attempted to administer [R1's] medication several times. If she had refused the medications, I would have documented as so. As I have previously stated, when I was in the patients' room [R1's room], I was trying to free-up the medication from her hand. I was not trying to do it forcefully. I only wanted to remove the medications from her possession to protect any mis-haps as the patient has (sic) does have a diagnosis of severe dementia. When [R1] struck me, I should not (sic) not have tried to reprimand her in any way. I should have calmly walked out after she hit me and got the nursing supervisor. Review of R1's clinical record revealed no evidence of a nurse's note documenting the 8/31/25 medication refusal. 10/7/25 - R1's care plan was updated to include key phrases to assist with encouraging the resident to allow care. and for staff to alert nurse if resident refuses care. 10/7/25 - QAPI committee was updated by E2 (DON). E6's (RN) employment was terminated and her license was reported to the State of Delaware's Board of Nursing. The facility failed to ensure R1 was free from physical and mental abuse. 10/8/25 4:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E12 (ED).

Based on record review and interview, it was determined that the facility failed to have a surety bond that covered the current balance in the residents' trust accounts ($28,733.79). Findings include:8/27/25 10:15 AM - The facility provided the surveyor with a copy of the facility's surety bond from [insurance company] in the amount of $20,000 with a term of 12/08/24 to 12/08/25. 8/27/25 10:18 AM - The facility provided the surveyor a list labelled Trust- Current Account Balance as of 8/27/25. The list named forty-five facility residents with personal funds accounts managed by the facility. The Client Account Summary stated that there was $28,733.79 currently in the account. 8/27/25 11:31 AM - During an interview with E3 (Executive Director) and E4 (Admissions), E3 confirmed, The surety bond is for $20,000.The facility failed to have a surety bond in sufficient amount to assure the security of all personal funds of residents that were deposited with the facility. 8/27/25 3:10 PM - The facility presented the surveyor with a bond rider document that stated that the Amount of bond changed from $20,000 to $30,000.8/29/25 2:30 PM - The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on record review and interview, it was determined that for one (R81) out of one resident reviewed for misappropriation, the facility failed to protect R81's property. This is being cited as past non-compliance with a compliance date of 6/19/25. Findings include: Facility's Resident Abuse Policy/Procedure.Steps in Procedure: . 4. Identification - a) For the purposes of this procedure, abuse, neglect or mistreatment may be suspected in, but not limited to, the following situations: . v. Misappropriation of resident property: Intentional theft of a resident's money or property, . intentional mishandling of resident money or property by personnel authorized to handle resident money or property. Reviewed 8/7/25.Review of R81's clinical record revealed:9/16/20 - R81 was admitted to the facility with diagnoses including, but not limited to, diabetes. 9/8/23 - R81 ordered Ozempic (a weekly diabetes injectable medication) 4 mg (milligram)/ 3 ml (milliliter) sq (subcutaneously) q (every) Friday for DM2 (diabetes). 4/19/25 - R81's quarterly MDS (Minimum Data Set) recorded R81's BIMS (Brief Interview for Mental Status) as 13, which was reflective of normal cognition.6/8/25 7 AM - E9 (LPN) signed the packing slip for delivery of R81's Ozempic 4 mg/3 ml pen (QTY) 3. E9 placed the Ozempic medication in the refrigerator in the locked medication room on the third floor. 6/13/25 8 AM - E11 (LPN) was unable to locate the medication in the refrigerator in the locked medication room.The facility failed to protect R81's property and ensure it was available for her usage. 6/13/25 approximately 6:45 PM - E10 (LPN) gave R81 her Ozempic shot, when the replacement dosage came from the pharmacy.8/28/25 11:50 AM - During an interview, E12 (LPN) stated, The Ozempic medication is stored in the refrig (refrigerator) in the locked med (medication) room. Only nurse have the keys to the med room. It is kept in a lock box in the refrig.Since the incident with the missing Ozempic, the facility started a Controlled Medication Accountability sheet, which is kept in the narc (narcotic) book and is counted with the narcs by the nurses at change of shift.8/28/25 1:45 PM - During an interview, R81 stated, I didn't give anyone permission to take any of my medications.8/29/25 11:03 AM - During a telephone interview, C1 (pharmacy billing specialist) confirmed that the facility ordered and paid for an additional dose of Ozempic on 6/13/25 with a cash price of $1122.04.8/29/25 12:30 PM - The finding was reviewed with E1 (NHA), who reiterated all the steps the facility performed after discovering the medication was missing. 8/29/25 3:45 PM - E1 (NHA) provided signed documentation of interventions the facility initiated after discovering that R81's Ozempic was missing. The actions included:- obtaining a new dose of Ozempic, which the facility paid for, on the evening of 6/13/25 so R81's care was not impacted.- notifying the police and filing a police report.- reviewing the video surveillance of the medication delivery on 6/8/25 and the staff processing of the medications to confirm proper handling of the medication.- identifying and interviewing all nursing staff with access to the 3rd floor locked medication room between 6/8/25 through 6/13/25. - notifying the Pharmacy of the medication disappearance. - assisting the Pharmacy in creating an accountability sheet to track Ozempic medication upon delivery to the facility. The accountability sheet requires nurses to check and sign off on the presence of the medication on each shift.- educating the nurses regarding the new process of the accountability sheet for Ozempic medication.- discussing the missing medication at the QAPI meeting on 6/17/25. During this meeting, it was noted that there were no video available from within the medication room.- initiated a plan for the QAPI committee to review the accountability sheets for Ozempic for a one year period. - installed new cameras in each medication room effective on 6/19/25.8/29/25 10 AM -The surveyor was able to confirm these actions were initiated and ongoing with a PNC compliance date of 6/19/25.8/29/25 2:30 PM - The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on interview, record review and review of the facility's policy and procedures, it was determined that for two (R49 and R90) out of six residents reviewed for abuse, the facility failed to report the allegations of abuse and injury of unknown origin within the two-hour requirement. Findings include:1. Review of R49's clinical record revealed: 7/18/25 3:27 PM - An x-ray report was received by the facility which stated that R49 had an acute hand fracture. 7/21/25 12:53 PM - Review of the State Agency's Incident Summary Report documented that the facility reported R49's injury of unknown origin, a hand fracture, approximately three days later. 8/28/25 2:40 PM - During an interview, surveyor reviewed finding with E2 (DON). E2 stated she wasn't aware of this and would look at it. 2. Review of R90's clinical record revealed: 6/4/25 10:00 AM - The facility's incident report documented an allegation of resident-to-resident abuse between R90 and R62. 6/4/25 1:59 PM - Review of the State Agency's Incident Summary Report documented that that the facility reported the incident approximately four hours after the altercation.

Based on record review and interview, it was determined that for one (R96) out of one resident sampled for closed record review, the facility failed to notify the Ombudsman of R96's discharge to the community. Findings include:Review of R9's records revealed:7/3/25 2:30 PM - A nurse progress note documented that R96's daughter arrived in the facility to pick up her mom [R96] as R96 was discharging home to live with her daughter. 8/28/25 1:15 PM - Review of the facility's April 2025 Transfer Log lacked evidence that the Ombudsman was notified of R96's discharge to the community on 7/3/25.8/28/25 4:09 AM - In an email correspondence, E1 (NHA) documented, Ombudsman was notified today (8/28/25) of [R96]'s discharge home. 8/29/25 8:39 AM - In a follow up interview, E1 confirmed that the Ombudsman was not notified of R96's discharge home when the July 2025 list was submitted to the Ombudsman on 8/15/25. 8/29/25 1:33 PM - Findings were reviewed with E1 (NHA) and E2 (DON). 8/29/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on record review and interview, it was determined that for two (R7 and R6) out of three residents reviewed for PASRR, the facility failed to coordinate with the PASRR program under Medicaid and refer the residents for assessments. Findings include:1. R7's clinical records revealed: 11/25/20 – A PASRR Level 1 Screen was completed by the facility and documented that a neurocognitive disorder/dementia as primary and progressed. R7's medications included Lexapro and Zyprexa for anxiety. 11/27/20 – R7 was care planned for the use of antipsychotic medication, Risperdal related to frontotemporal dementia, delusions and related history of psychosis. 10/24/22 2:40 PM – A psych progress notes documented, . Psych meds Risperdal 0.5 mg BID (twice a day) Lexapro 5 mg q (every) am (morning) . new diagnostic code F22 delusional disorder with psychosis. F03.93 unspecified dementia with psychosis . Review of R7's diagnoses list revealed the following new diagnoses:10/17/22 – Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence.10/17/22 – Major Depressive Disorder (MDD), recurrent, moderate10/18/22 – Delusional disorders10/24/22 – Unspecified dementia, unspecified severity, with psychotic.1/3/24 - Pseudobulbar affect. 4/25/25 – R7's care plan for the use of antipsychotic medication, Risperdal related to frontotemporal dementia, delusions and related history of psychosis. 7/2/25 - R7's quarterly MDS assessment documented anxiety disorder, depression, psychotic disorder and pseudobulbar affect among her active psychiatric/mood disorder diagnoses. 8/27/25 1:52 PM – In an email correspondence, S1 (State PASRR Authority) confirmed that the facility should submit a new assessment for a status change to include MDD as a new major diagnosis and to update R7's current mental status and diagnoses. 8/27/25 3:00 PM – Findings were discussed with E2 (DON). 2. R6's clinical records revealed: 1/29/24 – R6 was admitted to the facility with diagnoses including dementia, peripheral vascular disease, and diabetes mellitus. 4/22/24 – R6's Level I PASSR screening reflected diagnoses including dementia, anxiety, and major depressive disorder. The listed medications prescribed for R6 were trazodone to treat depression and lorazepam to treat anxiety. R6 had no known behaviors that affected interactions with others. 5/28/24 2:49 PM – Nursing staff documentation in R6's clinical record stated, Resident has been having increased issues AEB [as evidenced by].aggressiveness as well as physical altercations with staff. 5/28/24 4:21 PM - R6 was diagnosed with delusional disorder and unspecified psychosis. An antipsychotic medication, Seroquel, was ordered for R6. 7/28/25 6:17 PM – Psychiatric documentation in R6's clinical record stated, .Pt [patient] is difficult to manage.Pt [patient] has no impulse control.redirection not always effected [sic].meds [medication] required. 8/16/25 - A quarterly MDS assessment for R6 documented diagnoses including anxiety, depression, and psychotic disorder. 8/29/25 10:58 AM – During an interview, E2 (DON) stated, If 4/22/24 was the last PASSR screening in the chart for this resident, there was no PASSR screening after that date. 8/29/25 2:30 PM – The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on record review and interview, it was determined that for one (R1) out of three residents reviewed for hospitalization, the facility failed to have evidence that the physician's order for a daily weight was completed. Findings include:Review of R1's clinical record revealed:12/12/22 - R1 was admitted to the facility with a diagnosis of heart failure.10/24/24 - A physician's order stated, Weight 1 time a day at 8AM. Notify MD [Medical Doctor] for Weight Gain of 2-3LBS or more over a 2-day period or gain of 5LBS a week. Dx: [Diagnosis] Heart Failure.Review of R1's June 1-24, 2025, eMAR (electronic Medication Administration Record) revealed that the facility failed to obtain a daily weight or have a documented reason for not obtaining a weight on seven (7) out of 24 opportunities.8/29/25 9:25 AM - During an interview, E6 (RN) stated that it was the nurse's responsibility to weigh R1. Surveyor and E6 reviewed R1's weights and discussed that R1 refused at times. E6 acknowledged the finding.R1's clinical records lacked evidence that he refused to have his weights obtained.8/29/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on observation and interview, it was determined for two out of two medication rooms reviewed for storage of controlled substances, the facility failed to ensure that the locked boxes were permanently affixed to medication room refrigerators.8/27/25 10:12 AM - During a tour of the second-floor medication room, the storage box for the controlled substances was observed on top of the refrigerator. The third-floor controlled substances box was observed in refrigerator, but it was not permanently affixed. 8/28/25 9:30 AM - The second-floor medication room, the storage box for the controlled substances continued to be on top of the refrigerator. The third-floor controlled substances box continued to be in the refrigerator, but it not permanently affixed. 8/28/25 10:00 AM - During an interview E14 (RN) stated, The controlled substances that have to be refrigerated are kept in the refrigerators and counted every shift. 8/29/25 2:30 PM - The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on review of the facility's abuse policies and procedures and interview, it was determined that the facility failed to develop and implement an abuse policy that included all the requirements. The facility's policy lacked evidence of: established coordination with the QAPI program, required training regarding the signs of abuse and the different types of abuse, and failed to include language regarding the prohibition and prevention of retaliation for reporting. Findings include: 8/25/25 11:30 AM - The facility provided a copy of their Resident Abuse Policy/Procedure for the survey review. The facility's policy lacked evidence of: established coordination with the QAPI program, required training regarding the signs of abuse and different types of abuse, and failed to include language regarding the prohibition and prevention of retaliation for reporting. 9/29/25 10:34 AM - During an interview, E1 (NHA) stated that the facility does a lot of training regarding abuse throughout the year. She stated that she was not aware that the facility's abuse policy lacked several CMS (Centers for Medicare and Medicaid Services) requirements, including policy regarding training to recognize the signs of abuse and to identify different types of abuse, policy regarding the prevention of retaliation and the inclusion of QAPI in their abuse policy. 8/29/25 2:30 PM - The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on review of facility documentation and interview, it was determined that the facility failed to ensure that the monthly drug regimen review policy included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.12/5/20 - A facility document entitled, Medication Regimen Review, revised 8/31/21, 2/23/23, 7/15/24, and 8/6/25, documented, Medications are reviewed in multiple ways including, but not limited to the MRR conducted by the consultant pharmacist 8/27/25 11:27 AM - A review of the facility's Medication Regimen Review lacked evidence of the time frames for the different steps in the process and steps the pharmacist must take when an irregularity is identified. 8/27/25 12:30 PM - During an interview, E2 (DON) stated, The policy does not have the time frames for the different steps in the medication review policy. 8/29/25 2:30 PM - The findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E5 (ADON).

Based on record review, interviews, and facility policy review, the facility failed to ensure: seven of 10 residents (Residents (R)69, R83, R89, R87, R20, and R67) reviewed for abuse were free from resident-to-resident abuse. These failures increased the risk of continued abuse towards the residents. Findings include: 1. Review of the Abuse Policy/Procedure, review date 06/27/23, under Identification indicated . abuse, neglect or mistreatment may be suspected in, but not limited to the following situations: ii. Physical Abuse: Intentionally and unnecessarily inflicting pain, injury, or degradation to a resident' This includes, but is not limited to hit, push, kick, slap, pinch, or sexually molest any resident'. iii. Verbal Abuse: ridiculing or demeaning a resident, cursing directed to a resident, threatening to inflict harm or verbal abuse to a resident . Under Protection . c. Residents will be protected from other residents in various ways depending on the level and type of abuse. Alternatives may include changing resident rooms, altering resident care plans or discharging a resident from the facility to protect the safety of other residents. d. Incidents involving resident to resident abuse will be reviewed by the clinical team. A care plan review will also be conducted to implement interventions to avoid further instances . a.Review of R69's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility with a diagnosis of Anxiety disorder, Dementia, and Major Depressive disorder, Review of R69's EMR quarterly MDS with an ARD of 08/26/24 indicated the resident had a BIMS score of three out of 15 which revealed the resident was cognitively impaired. Review of R69's EMR Care Plan located under the Care Plan tab, revision date 09/14/22, indicated the resident was at risk for elopement/wanderer, entering into other resident's rooms looking for family, car, related to impaired safety awareness and dementia. The Intervention/Tasks, revision date 12/22/21, indicated to distract resident from wandering, provide structured activities, visual safety checks every hour. Review of R69's EMR Nurse's Notes located under the Progress Notes tab, indicated that on 02/27/24 an altercation coming from R44's room was heard, R69 was observed placing his hand over his left eye. R69 was noted to have bloodshot and specks of blood within the orbital area. It was also documented in the same nurse's note that R69 stated he was hit in the eye by the other resident (R44) in the room. R69 was sent to the Emergency Department for further treatment and evaluation on 02/27/24 via ambulance services. Further review of the resident EMR indicated that R69 is on Xarelto, an anticoagulant medication, which can result in excessive bleeding and bruising. Review of the Emergency Department note, dated 02/27/24, indicated R69's sustained a Subconjunctival hemorrhage, and Corneal abrasion. R69 was discharged and returned to the nursing facility on 02/27/24 with a prescription for Erythromycin ophthalmic ointment. Review of the ER Discharge Instructions, dated 02/27/24, revealed the following prescription: Erythromycin ophthalmic (erythromycin 0.5% ophthalmic ointment) 0.5 inch in the eye four times a day. Review of the Medication Administration Record (MAR) of the months of February and March 2024, revealed that the resident was started on the Erythromycin ointment at 9:00 AM and with the last dose given on 03/04/24 at 12 noon. Review of the MAR for February 2024 revealed that on 02/27/24 the resident was medicated with Tylenol 325 mg ii tablets for pain. The pain was documented at a 5 out of 10 at 9:11 AM and 5:14 PM. During a telephone interview on 10/18/24 at 10:17AM, Registered Nurse (RN)1 stated R69 had wandered into resident R44's room and RN1 heard R44 say get out of my room, get out of my room. RN1 stated he went into the room and observed R69 covering his eye. RN1 stated he separated both residents and examined R69's eye and noted that R69's eye was bloodshot with blood specks. RN1 stated he notified the physician and transferred R69 to the Emergency Department for further treatment and evaluation. RN1 also stated that he talked to R44 and asked him to use the call light or call a staff member when someone enters his room. RN1 further stated R44 was in agreement with calling staff when someone entered his room. Review of R44's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility with diagnoses including Dementia and Alzheimer's disease. Review of R44's EMR annual MDS with an ARD of 08/16/24 indicated the resident had a BIMS score of five out of 15 which revealed the resident was cognitively impaired. Review of R44's EMR Care Plan located under the Care Plan tab, revision date 02/28/24, indicated the resident had the potential to become verbally and physically aggressive towards other residents that cause him to feel threatened or invade his personal space secondary to being impulsive, short tempered and territorial. The Intervention/Tasks revision dated 02/28/24 indicated the resident's behaviors was de-escalated by removing other persons from his space, . encourage seeking out of staff member when agitated before becoming physical . when the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress . Interview on 10/15/24 at 10:23AM, and 4:05 PM and on 10/18/24 at 8:15AM, R44 stated that R69 wanders into his room, and he tells him get out of my room but denied hitting R69. Interview on 10/18/24 at 5:20 PM, the Assistant Director of Nursing (ADON) stated R44 denied hitting resident R69. The ADON further stated that there have been no further altercations and or resident to resident abuse involving R44 and R69. b. Review of R83's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility diagnoses of Dementia, Personality Disorders, and Major Depressive disorder. Review of R83's EMR annual MDS with ARD of 11/20/23 indicated the resident had no BIMS score to determine the resident's was cognitive status. The assessment revealed the resident was dependent on staff for activities of daily living (ADL). Review of R83's EMR Care Plan located under the Care Plan tab, revision date 11/25/22, indicated the resident had an ADL self-care performance deficit related to Dementia, and had limited physical mobility related to being non-ambulatory. The Intervention/Tasks revision date 11/25/22 under locomotion indicated R83 was dependent on staff for locomotion using a Geri-chair. Further review of the Care Plan revealed R83 was at risk for emotional distress related to male resident rubbing her stomach and while she was seated in the lounge waiting for dinner. The Intervention/Tasks initiated date 07/18/24 indicated resident remains in common area for increased observation. Review of R83's EMR Nurse's Notes located under the Progress Notes tab, indicated a late entry note dated 07/21/24 indicated that on 07/20/24 a male resident was observed rubbing R83's groin area. R83 was sitting in a Geri-chair at the TV lounge. Interview with R83 was attempted during the survey without success. During an interview on 10/16/24 at 1:09 PM, Dietary Aide (DA) 1 stated that R83 was sitting in her Geri-chair near the nurses' station when R64 was observed rubbing R83's legs near the groin area, she stated I was breaking down the trays after lunch and I saw what he was doing and I told the nurse immediately. I separated them first, and then told the nurse, there were no nurses or staff around they were busy taking people to their rooms. He just rolled himself over to her, she doesn't talk so she did not tell him to get away or push him away. I rolled him to the opposite side of the room, locked his wheelchair and went to get and tell the nurse. Review of R64's EMR Admission Record located under the Profile tab, indicated the resident was readmitted into the facility with a diagnosis of Dementia. Review of 64's EMR quarterly MDS with an ARD of 08/21/24 indicated the resident had a BIMS of five out of 15 which revealed the resident was cognitively impaired. The assessment revealed the resident was dependent on staff for activities of daily living (ADL). Review of R64's EMR Care Plan located under the Care Plan tab, revision date 01/25/24, indicated the resident needed adequate supervision and observation as he had a behavior of becoming sexually inappropriate with female residents with dementia/cognitive impairment. The Intervention/Tasks revision date 07/22/24 indicated R64 was placed on 1:1 monitoring due to safety concerns when out of bed, 30-minute safety checks when in bed, re-direct resident if he displays any inappropriate behavior or verbalizations, visual safety checks put into place to monitor residents' location. Review of R64's EMR Nurse's Notes located under the Progress Notes tab, indicated a late entry note dated 07/24/24, revealed Currently, resident is being monitored by 1:1 supervision. Alternate placement on another floor is also being explored. However, it is the opinion of the clinical team that resident's behavior will continue as he identifies another target. Also discussed option to locate another facility that could better address needs. An interview with R64 was attempted during the survey process without success. Interview on 10/18/24 at 5:20 PM, the ADON stated that the dietary aide had stopped R64 if she had not stopped him, it could have gone a lot further. The ADON stated that no other incidences of touching other female residents have occurred to include resident R83. The ADON stated the dietary aide observed R64 touching the thighs of the resident near the groin area. R64 had wheel himself out of the Dining Room (DR) and approached the female resident who was sitting in her Geri chair outside the DR and near the nurses' station. R64 was immediately removed from the area and placed on 1:1 monitoring. The ADON further stated that the facility is trying to find more appropriate living arrangements for him. R64 remains on 1:1 monitoring until alternate placement is found for R64. 11599 c. Review of R89's Admission Record, located under the Profile tab in the EMR noted the resident was admitted with diagnoses that included dementia with agitation. Review of the quarterly MDS, located under the MDS tab in the EMR with an ARD of 07/18/24 revealed a BIMS score of six out of 15 which indicated R89 had severe cognitive impairment. Review of the Care Plan, dated 07/24, located under the Care Plan tab in the EMR revealed a problem of Potential to be verbally aggressive, short tempered, displaying outbursts related to dementia and poor impulse control. Included in the interventions were Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of R87's Admission Record, located under the Profile tab in the EMR noted the resident was initially admitted with diagnoses that included unspecified dementia, with mood disturbance, and cognitive communication deficit. Review of the admission MDS, located under the MDS tab in the EMR with an ARD of 09/12/24 revealed a BIMS score of seven out of 15 which indicated R87 had severe cognitive impairment. Review of the Care Plan, dated 07/24, located under the Care Plan tab in the EMR revealed no concerns related to behaviors, agitation, or aggression. Review of an incident report, dated 10/07/24, provided by the Assistant Director of Nurses (ADON), revealed Residents were sitting next to one another in common area. I was in hall talking with charge nurse and heard a commotion. I turned to look and saw [R87] standing up in front of [R89] holding her walker by the legs and trying to hit [R89]. Myself and the charge nurse immediately separated both residents. [R89] was ask what happened and she did not give me an answer. Just stated she did not do anything. She denied any pain and was assessed for injury. No inlury [injury] found. She was put on 15 min checks- [R87] was also assessed and visibly upset. He denied injury and stated he would be OK. Resident was noted with 2 small red scratches on his clavicle area. Both residents have a Hx [history] of dementia with anxiety. During an interview on 10/16/24 at 2:44 PM, the ADON, responsible for completing the investigation, stated [R89] was the aggressor. [R87] had his arm up talking with another resident, [R89] hit him on his arm. [R87] did not pay attention to her. [R89] then shook her hands at him. [R87] then stood up and pushed [R89]'s walker at her. The second time [R87] tried to hit [R89] with the walker, she held on and nothing occurred. 29728 d. Review of R20'sFace Sheet, located in the EMR under the Profile tab revealed R20 was admitted to the facility with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Depression, Anxiety and Acute Respiratory Failure. Review of the quarterly MDS located in the EMR under the MDS tab and dated 06/05/24, revealed the resident was assessed on the BIMS with a score of 14, indicating the resident was cognitively intact and exhibited no mood or behaviors during the same assessment period. Review of the resident's Care Plan located in the EMR under the Care Plan tab revealed the resident had the potential for sad mood, tearfulness, withdrawn state secondary to history of depression, anxiety and declining health. Review of a facility reported incident to the State Survey Agency (SSA) dated 04/01/24, indicated that the resident told the Director of Nursing (DON) that she wanted to talk to her privately about a particular aide. R20 said The evening aide screams at me. She verbalized that the aide makes her cry sometimes. Review of the facility's investigation revealed that in an interview with the DON and the Assistant Director of Nursing (ADON) it was revealed that Certified Nurse Aide (CNA) 7 was giving aide to R20 with an orientee. They turned the resident on her side and the resident started to scream in pain. CNA7 described and re-enacted backing away from the resident with her hands up in the air and saying, I'm not even touching you. CNA7 told the resident that her backside (used a derogatory term). She also told the resident that I guess that I will be in the DON's office on Tuesday. CNA7 described her relationship with the resident as friendly and they often joked around. The investigation determined that under the care of CNA7, the resident felt humiliated, tearful and manipulated. The resident was interviewed and indicated that she never felt comfortable with the aide, she disagreed with the description of their relationship. The CNA was initially suspended after the allegation was made and after the investigation, she was terminated from the facility. During an interview on 10/16/24 at 3:04 PM, R20 did not remember an incident with CNA7 and denied having any problems with staff. During an interview with the ADON on 10/16/24 at 3:36 PM, she stated that the resident about the incident. During the investigation, she asked the Quality Control Nurse to speak to the resident to see if she thinks the CNA should return to work. The resident stated she did not think the CNA should work at the facility. We decided to terminate her because of the resident's statement and what the CNA wrote up in her statement. The ADON also stated that she had not had any concerns about CNA7 before, she just would have a big mouth sometimes but she was a good worker. Review of the statement submitted by CNA7, dated 03/19/24 she stated, while changing R20, she was resistant to care, throwing her leg out of the bed at one point. I was not even touching her and she was screaming like I had my hands on her. I said to her, You sitting here yelling making it seem like I'm touching you and I'm leaning against the wall. The resident made the comment she would just leave or die. I stated you don't have to leave or die but please do not resist when someone is giving you care, you can do more harm to the aid than yourself. During an interview with the Quality Control Nurse on 10/17/24 at 9:52 AM, she stated she spoke to the resident about allowing CNA7 to return to work and the resident said no, she should not. She stated that she had not received any complaints regarding CNA7 in the past. In an interview with the DON, on 10/17/24 at 10:30 AM, she stated that she was involved with interviewing staff only when discipline was involved. The DON stated the way CNA7 described how she spoke to R20, just what she said to the resident, it was clear and concerning. After the interview with CNA7, I did not feel that she thought she had done anything wrong. We had to let her go. The ADON and I both thought she should not be here and was terminated. We did not feel like she was fixable. The DON stated she could not remember any complaints from other residents concerning CNA7's behavior. The DON stated that as soon as she found out about the incident, CNA7 was suspended and terminated. 12679 e. Review of R67's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R67's EMR titled annual MDS with an ARD of 08/29/23 indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no behaviors. During an interview on 10/17/24 at 2:09 PM, R67 stated he did not remember the resident-to-resident which involved R95. The resident stated he was not fearful and stated he was fine. Review of R95's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R95's EMR titled quarterly MDS with an ARD of 10/23/23 indicated the clinical staff could not determine the resident's BIMS and revealed the resident had short-term and long-term memory problems. The assessment indicated the resident had physical/verbal behavior directed towards others. Review of R95's EMR titled administration Progress Notes located under the Prog (Progress) Note dated 12/25/23 indicated the resident was observed to punch R67 in the eye and the resident was then redirected from the area. Review of a document provided by the facility titled Physical indicated R67 reported to the facility that R95 punched him in the left eye. R67 said that R95 attempted to open the dining room door. R67 stated he tried to stop R95 from doing so and that was when R95 punched him in the eye. The clinical staff assessed the resident and there were no injuries. The resident's physician and responsible party were notified of the incident.

Based on observation, staff interviews, and review of the facility's policy, the facility failed to 1.) ensure staff changed gloves, performed hand hygiene, and followed proper cleaning techniques for one of one resident (Resident (R) 30) observed during incontinence care and one of one resident (R88) observed during wound care from a sample of 34 residents, and 2.) ensure staff followed recommended disinfectant drying times to disinfect a multi-use glucometer for two residents (R1 and R6) observed during medication pass. These failures increased the risk of cross contamination. Findings include: 1. Review of the facility's policy titled, Handwashing review date 02/28/24, revealed, Purpose To prevent or minimize the transfer of pathogens. 1. Hand washing is the most important procedure used to prevent the spread of pathogens. Review of the facility's policy titled, Peri Care of the Female Resident review date 01/03/24, revealed under Purpose To provide cleanliness and comfort while enhancing infection and irritation prevention . Cleaning is always done anterior to posterior (front to back) . Staff must change gloves after direct exposure to bodily fluids or fecal matter and clean/disinfect hands prior to completing resident care and touching other clean surfaces. Review of R30's Admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility with diagnoses of Arthropathy (arthritis), Dementia, and Alzheimer's disease. Review of R30's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was cognitively impaired. The resident required maximum assistance for toileting and was frequently incontinent of bowel and bladder. Review of R30's Care Plan located in the EMR under the Care Plan tab indicated the resident had bladder and bowel incontinence related to dementia, and impaired mobility with interventions to provide peri care after each incontinent episode. During an observation on 10/16/24 at 1:55 PM, Certified Nursing Assistant (CNA) 4 and (CNA) 5 provided incontinence care to R30. CNA 4 and CNA5 each donned a pair of gloves, removed the resident's pants and adult brief. After removing the adult brief, R30 was turned on her right side and was observed to be incontinent of bowel with brown fecal material noted on the resident's right and left buttocks. Using the same gloves, CNA 4 cleaned the top of the resident's perineal area in a downward motion. CNA 4 did not separate R30's labia. CNA4 then discarded the soiled used wipes directly onto the floor. CNA 4 and CNA5 then turned R30 on her left side and CNA 5 cleaned the resident left and right buttock cheek and anal area in a back to front motion towards the labia with disposable wipes removing large amounts of fecal material. Resident R30 was then turned on her back, CNA 4 then repeated to clean the top of the peri area in a downward motion removing fecal material. After cleaning the resident, R30 was turned on her right side and a clean adult brief was applied. With the same soiled gloves, the resident's pants were pulled up and her white blouse was adjusted. CNA4 and CNA5 then adjusted the resident's pillows and pulled up the blue comforter, adjusted to call light within reach of the resident. CNA 4 then moved the resident's bed in place (against the wall) moving the bed by the footboard with the same soiled gloves. After picking up the soiled disposable wipes from the floor, CNA 4 removed and discarded her soiled gloves, CNA 4 was observed to leave R30's room without washing her hands. During an interview with CNA 4 and CNA5, immediately after the observation, CNA 4 and CNA5 confirmed they should have cleaned the peri area from top to bottom, separating the labia and cleaning the buttock and rectal area from front to back to avoid contamination of the vaginal/peri-area. The CNAs stated that they should have removed their soiled gloves after cleaning the resident's soiled body areas, and before putting on a clean brief and adjusting the resident's clothing and, pillow, comforter and before repositioning the call-light. During an interview with the Director of Nursing (DON) on 10/17/24 at 10:00 AM, she confirmed the CNAs should have changed her gloves and washed their hands. 29728 2. Review of the facility's policy titled, Dressing Change, dated 04/18/24, revealed, . Purpose to prevent contamination of wound, while restoring skin integrity and monitor healing process . create clean field with paper towels or drape . Open dressing pack . Put on first pair of disposable gloves . Remove soiled dressing and discard in plastic bag . Dispose of gloves in plastic bag . Wash hands . Put on second pair of disposable gloves . Pour prescribed solution onto gauze to be used for cleaning . Cleanse wound with prescribed solution . Apply prescribed medication if ordered . Apply dressings and secure with tape . Remove gloves and discard with all unused supplies in plastic bag . Wash hands . Review of R88's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R88 was admitted on [DATE] with diagnosis of diabetes mellitus, muscle weakness, atrial fibrillation, malignant neoplasm of left kidney, peripheral vascular disease, and a stage III pressure sore. During an observation on 10/16/24 at 9:10 AM, LPN1, LPN2, and Certified Nursing Assistant (CNA) 3 were observed performing wound care for R88's stage III sacral pressure sore. LPN1 had placed her dressing change supplies on top of the overbed table. A protective barrier was not observed under the supplies. Prior to beginning the wound care, LPN2 suggested cleaning the resident before wound care to minimize the time she needed to be turned. A wash basin was placed on the same overbed table with the supplies and was used to wash the resident. After the bath was completed, the basin was removed from the overbed table which left a wet spot in the same area. Without cleaning the table, LPN1 proceeded to begin with the dressing change. She put on a pair of disposable gloves, removed the soiled dressing from the resident's sacral area and removed the gauze from the wound bed. LPN1 placed the soiled dressing in a plastic bag and removed her soiled gloves. Without performing hand hygiene, she put on a new pair of gloves and used a clean gauze and wound cleaner from the overbed table to clean the resident's wound. After cleaning the wound, LPN1 disposed of the gauze and gloves in the plastic bag and, without performing hand hygiene, she put on another pair of disposable gloves and placed a medicated ointment on top of a medicated gauze in the wound bed and covered the wound with a dressing. After completing the wound care, LPN1 removed her gloves and placed the remaining dressing supplies in the plastic bag and washed her hands. During an interview on 10/16/24 at 9:10 AM, LPN1 stated that she did not disinfect the top of the overbed table after CNA 3 removed the wash basin that left water on the table. LPN1 confirmed that she did not wash her hands between changing from soiled to clean gloves and stated she should have. During an interview with the Infection Preventionist (IP) on 10/16/24 at 3:14 PM, the IP stated that the nurse performing the wound care should have washed her hands between changing her soiled gloves to clean gloves and the overbed table should have been disinfected again after removing the wash basin. 3. Review of the facility's policy titled, Cleaning of Glucometers, dated 08/27/24, revealed, . The purpose of this procedure is to prevent the spread of infection . clean glucometers after every use . clean glucometer with approved product . allow appropriate amount of time for product to dry before using equipment on another resident . Review of the Clorox Healthcare Bleach Germicidal Wipes manufacturer's guidelines, located on the product's container, revealed the recommended drying times ranged from 30 seconds to kill bacteria to one minute to kill bloodborne pathogens. During an observation on 10/14/24 at 10:49 AM, Licensed Practical Nurse (LPN)4 prepared a blood glucose monitor to check the blood glucose level for RRe1. Using a disinfecting wipe, LPN4 wiped the monitor several times. Without allowing the disinfecting solution to dry, she used a tissue to wipe the monitor dry. LPN4 completed the blood glucose test for R1 and placed the monitor back on top of her medication cart. LPN4 used another disinfectant wipe on the same blood glucose monitor and approached R6 in the hallway. Before allowing enough time for the monitor to dry, LPN4 again used a tissue to dry the monitor before conducting the blood glucose test for R6. After obtaining the test, LPN4 placed the blood glucose monitor directly on top of the medication cart without a protective barrier underneath the monitor. During an interview on 10/15/24 at 2:34 PM, LPN4 was asked what process she followed for disinfecting the blood glucose monitor. She stated, I wiped the monitor, I was supposed to leave it for three minutes. I used the tissue because [the surveyor] was there. LPN4 stated, Usually, I would wait three minutes to air dry. She stated she had worked at the facility for four years and received training on blood glucose monitors when she was hired. During an interview on 10/15/24 at 1:42 PM, the Director of Nursing (DON) stated that the nurses are trained to allow three minutes for the disinfectant to dry on the blood glucose monitors when cleaning. She stated this was included in their policy.

Based on interviews, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) following a fall with injuries for one of three residents (Resident (R) 94) out of a total sample of 34 residents. The failure created a delay for R94 to have their RR to get to the hospital to see before R94's condition worsened. Findings include: Review of the facility's Fall Prevention/Post Fall Policy and procedure, last reviewed 08/25/24, revealed the following: A. On admission 1. The nurse completes Morse Fall Scale. 2. If it is determined that the resident is at risk for falls a care plan will be put in the record. B. Post-fall l. An Incident Report will be completed. 2. Nurse will document in the resident's progress note. 3. Morse Fall Scale will be completed. 4. Contact responsible party, physician, and Director of Nursing. This should be documented in progress notes as well as Action section of incident report. Closed record review of R94's Admission Record, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility with diagnoses that included dementia, abnormalities of gait and mobility, unspecified convulsions, and seizures. Review of R94's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 12/24/23, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R94 had severe cognitive impairment. R94 was identified to be dependent on staff for all cares and was not walking at the time of the assessment. Review of R94's Care Plan, updated 1023/23 located under the Care Plan tab in the EMR noted R94 had a history of wandering and a history of falls. The resident attended the Safety Program, identified as the Cottage, from 9:00 AM to 8:00 PM. Safety interventions were identified as every 30 minute safety checks, safety helmet when out of bed, hipsters on at all times, followed by neurologist for seizures, non-slip footwear, wheelchair with anti tippers, and Physical Therapy evaluation and treatment dated 12/07/23. Review of a 12/24/23 Incident Report, provided by the Director of Nursing (DON), noted Resident witnessed by dietary staff getting up from wheelchair and falling to the floor. Dietary staff notified nursing staff. Resident assessed for injuries, noted W [with] facial laceration and bleeding from the mouth, upper/lower extrimities [extremities] assessed no limitations noted, VS [vital signs] assessed WNL [within normal limits], area noted with adequate lighting, wheelchair noted in lock position. PCP [primary care physician] notifled [notified], resident sent to hospital for further evaluation. Review of the Nurses Note, located under the Progress Notes tab in the EMR, dated 12/24/23 at 11:53 PM, read Resident witnessed by dietary staff getting up from wheelchair and falling to the floor. Dietary staff notified nursing staff. Resident assessed for injuries, noted w/ [with] facial laceration and bleeding from the mouth, upper/lower extrimities [extremities] assessed no limitations noted, VS [vital signs] assessed WNL [within normal limits], area noted with adequate lighting, free of clutter, wheelchair noted in lock position. PCP notified, resident sent to hospital for further evaluation. Attempted to notify POA, unsuccessful. The incident was identified to have occurred at 6:30 PM. Both the incident report and the nurses note were written by Licensed Practical Nurse (LPN)1. During an interview on 10/16/24 at 9:41 AM, R94's RR stated On Christmas eve, 12/24/23, her sister's friend who works at the hospital, notified her sister that [R94] was at the hospital. The sister called [R94's RR] who called the facility to ask what was going on. Neither the [R94's RR] or the sister had been notified by the facility. [R94] should not have been left alone. She was in a wheelchair next to the desk outside the nurse's station. She stood up and fell over the foot pedals. The facility never called me. R94's RR stated When I questioned nurse, the nurse [LPN1] said she called the resident's husband, she could not have, that number is disconnected, he passed on 11/01/23. Then the nurse said she had tried the next number, [RR's] cell, but couldn't get through. That's not true either. I did not receive any calls. By the time I got to the second hospital where she was transferred, [R94] was intubated, and I didn't get to speak to her. R94 was placed on Hospice (end of life) care and subsequently passed away. During an interview on 10/16/24 at 10:17 AM, LPN1 said I was on second floor, called when incident happened. I assessed the resident; she was bleeding from her head and lip. I called the ambulance, called the Power of Attorney [RR] home number, couldn't get through, tried both numbers but they didn't work. I remember that I talked to the daughter who had got wind of the incident, so I told her what happened and that I tried both numbers, they were busy or not working. [R94] was in the safety program, the Cottage, and had just come down from there. She was seated next to the desk, tried to get up and fell . Dietary saw it happen. During an interview on 10/18/24 at 11:55 AM, LPN5 stated I remember [R94], she walked all the time, we would have to encourage her to sit down or sit in the recliner to get her to rest, especially when she appeared tired. She did not always use a wheelchair, just sometimes. When you are sending someone to the hospital, you first take care of the resident, if bleeding put pressure, call doctor, get order to transmit, call ambulance, notify family. May not always check the box on the form, but always put it in the progress notes. The hospital transfer form for the 12/24/23 incident was not located in the EMR. The form had an area to check that the RR had been notified. The DON and Administrator were asked, on 10/18/24 at 12:19 PM, to locate the document. No documentation was provided as of exit on 10/18/24 at 4:00 PM. During an interview on 10/18/24 at 1:00 PM, the Administrator said she knew about the concern with notification because the RR had come in after the resident passed away. I thought [RR] had been notified.

Based on interview, record review, and facility policy review, the facility failed to provide Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two of three residents (Resident (R) 10 and R77) reviewed for liability notices out of a total sample of 34 residents. This failure prevented the resident or responsible party the ability to make an informed decision related to the cost of continued therapy services. Findings include: Review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 accessed at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/abn-form-instructions.pdf on 06/04/24 revealed, The beneficiary or his or her representative must choose only one of the three options listed in Blank (G). Unless otherwise instructed to do so according to the specific guidance provided in these instructions, the notifier must not decide for the beneficiary which of the 3 checkboxes to select . If the beneficiary cannot or will not make a choice, the notice should be annotated, for example: beneficiary refused to choose an option. 1. Review of R10's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled provided by the facility titled Notice of Medicare Non-Coverage indicated R10's skilled services ended on 10/12/24. Review of R10's EMR indicated the resident remained in the facility after the end of her skilled services. 2. Review of R77's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled provided by the facility titled Notice of Medicare Non-Coverage indicated R77's skilled services ended on 08/28/24. Review of R15's EMR indicated the resident remained in the facility after the end of her skilled services. During an interview conducted on 10/16/24 at 9:50 AM, the Admission Coordinator confirmed she never provided the ABN letter along with the NOMNC notice. During an interview conducted on 10/18/24 at 11:07 AM, the Administrator stated they have never provided the ABN notice since there were residents who remained in their facility and Medicaid was their payment source and this would add to the confusion for the resident and/or family members, if the facility broke down the costs to provide continued skilled services.

Based on facility policy review, record review, and interviews, the facility failed to ensure their grievance procedures were followed for one resident (Resident (R) 79) of one resident reviewed for grievances out of a total sample of 34 residents. This failure increased the potential for resident grievances to go unresolved. Findings include: Review of a policy provided by the facility titled Grievance Procedure dated 03/11/22 indicated .The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.Notice on how to make a grievance is included in the Resident Handbook, and is also reviewed upon admission, is posted on each nursing floor.A copy of this procedure must be given to the resident upon request. Equipment and Supplies.Point Click Care Risk Management Incident report form (online).Grievance Form. Review of R79's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled Grievance Log dated 01/16/24 indicated a family member of R79 filed a grievance alleging the resident did not receive a dinner tray the night before. Under a heading titled Resolution it revealed there was a delay in staff delivery. During an interview conducted on 10/16/24 at 12:01 PM, the Administrator stated she was the staff member who handled all of the facility grievances and stated she had no additional information to provide on the meal tray issue and R79. A subsequent interview was conducted on 10/16/24 at 12:23 PM, and the Administrator confirmed she did not provide residents and/or family members with a written response of grievance(s) which included the resolution.

Based on review of facility policy, record review, and interview, the facility failed to ensure three of three residents (Residents (R) 20, R67, and R95) allegations of physical/verbal abuse were fully investigated out of sample of six residents reviewed for abuse out of a total sample of 34 residents. This lack of investigation had the potential to lead to continued episodes physical and verbal abuse. Findings include: Review of a policy provided by the facility titled Resident Abuse Policy/Procedure dated 06/27/23, indicated .Investigation.Facility will thoroughly investigate any incidents reported regarding the identification if incident as listed above.The facility will investigate all incident reports based on information obtained from witness statements, caregiver statements, and interviews as available. 1. Review of R20'sFace Sheet, located in the EMR under the Profile tab revealed R 20 was admitted to the facility with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Depression, Anxiety, and Acute Respiratory Failure. Review of the quarterly MDS located in the EMR under the MDS tab, dated 06/05/24 revealed the resident indicating the resident was cognitively intact and exhibited no mood or behaviors during the same assessment period. Review of the resident's Care Plan located in the EMR under the Care Plan tab revealed R20 had the potential for sad mood, tearfulness, withdrawn state secondary to history of depression, anxiety, and declining health. Review of the facility's investigation of a facility reported incident to the State Survey Agency (SSA) dated 04/01/24, revealed that in an interview with the DON and the Assistant Director of Nursing (ADON), Certified Nurse Aide (CNA) 7 stated she was giving aide to R20 with an orientee. They turned the resident on her side and the resident started to scream in pain. CNA7 described and re-enacted backing away from the resident with her hands up in the air and said, I'm not even touching you. CNA7 told the resident that her backside (used a derogatory term) was showing. She also told the resident that I guess that I will be in the DON's office on Tuesday. CNA7 described her relationship with the resident as friendly, and they often joked around. The investigation determined that under the care of CNA7, the resident felt humiliated, tearful, and manipulated. The resident was interviewed and indicated that she never felt comfortable with the aide, and she disagreed with the description of their relationship. CNA7 was initially suspended after the allegation was made and after the investigation, she was terminated from the facility. During an interview with the ADON on 10/16/24 at 3:36 PM, she stated that the DON spoke to the resident about the incident since the DON was responsible for investigating and reporting the incidents. During the investigation, the Quality Control Nurse was asked to speak to the resident to see if she thought CNA7 should return to work after suspension. R20 stated she did not think CNA7 should work at the facility. So, based on the statement from R20 and CNA7, the decision was made to terminate CNA7. When asked for documentation of other interviews conducted during the investigation, the ADON stated that she did not interview other residents during the investigation that may have had any interactions or care provided by CNA7. The ADON stated she had asked other staff about CNA7, and they did not have any problems with her. When asked if she documented the interviews with other staff members regarding CNA 7, she stated no, she did not have any written documentation. 12679 2. Review of R67's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. 3. Review of R95's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled Physical dated 12/25/23 indicated R67 reported to staff he was punched in the eye by R95. R67 stated he attempted to intervene when R95 tried to open the dining room door. Continued review of the file failed to contain evidence of other potential staff and residents who may have witnessed the incident. During an interview on 10/17/24 at 12:29 PM, the Assistant Director of Nursing (ADON), with the Director of Nursing present, confirmed the investigative file did not contain evidence of interviews gathered from potential witnesses which would include staff and residents. During an interview on 10/18/24 at 11:10 AM, the Administrator stated the staff collect interviews from potential witnesses depending on the situation.

Based on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 30) reviewed for accident hazards did not suffer a delay in treatment when the facility did not notify the physician of the delay in obtaining an x-ray as ordered. R30 experienced swelling to the right knee area and was administered non-narcotic pain medication for three days. The x-ray was obtained three days after being originally ordered and showed the resident had suffered an acute fracture to the distal femur. Findings include: Review of R30's electronic medical record (EMR) Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Arthropathy (arthritis), Dementia, and Alzheimer's disease. Review of R30's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was cognitively impaired. The assessment indicated R30 was dependent on staff for transfer (movement from one surface to another) mobility and activities of daily living (ADL). Review of R30's EMR Nurse's Notes located under the Progress Notes tab, indicated that on 07/19/24 at 3:17 PM, R30 was noted to have swelling to her right knee. The physician was notified and ordered a 2-view x-ray of the right knee. On 07/19/24 at 10:02 PM Nurse's Notes indicated R30's right knee remained with swelling and awaiting x-ray to be completed. Further review of the Nurse's Notes for 07/19/24 indicated R30 was medicated for pain with Tylenol. On 07/20/24 at 2:23 PM Nurse's Notes indicated an ice pack was applied to the right knee. Tylenol 325mg two tablets administered for pain. waiting for x-ray to the R[right] knee. On 07/20/24 at 9:55 PM Nurse's Notes indicated affected leg supported with pillow, awaiting x-ray of right leg. On 07/21/24 at 3:19 PM Nurse's Notes indicated Tylenol administered for right knee pain. Attempted to reach Mobilex [x-ray] to know when staff was coming for x-ray no response. On 07/21/24 at 9:19 PM Nurse's Notes indicated resident continues with swelling to R knee, pain medication administered. Awaiting x-ray of the right knee. Review of R30's EMR Nurse's Notes and Orders revealed no documentation the physician was notified that the ordered x-ray had not been obtained. There was no documentation the facility attempted to contact another mobile x-ray company. There was no documentation the facility attempted to obtain physician guidance related to the resident's need for pain medication. Review of the Nurse's Notes revealed that the attending physician was called three days later on 07/22/24 at 9:51 AM and notified of the delay in completing the x-ray. On 07/22/24 at 9:51 AM nurse's notes indicated resident continued with right knee pain with movement, Tylenol administered as needed. [name of x-ray facility] contacted requesting estimated time of arrival for x-ray. The physician was notified [that the x-ray had yet to be completed], resident to remain on bedrest until x-ray is completed. Further review of the Nurse's Notes indicated that the x-ray to the right knee was completed on 07/22/24 at 10:41 PM, three days after the x-ray was ordered. On 07/23/24 at 7:28 AM nurse's notes indicated x-ray results received with following conclusion acute fracture of right distal femur [thigh bone are close to the knee] with modest displacement and angulation [fractured bone segments at an angle], old fracture of right mid patella [kneecap] with modest displacement without callus formation. Intact right knee Arthroplasty. MD [physician] made aware. On 07/23/24 at 10:14 AM nurse's notes indicated Oxycodone 1 tablet po Q 6H PRN for Pain . Oxycodone is a narcotic pain medication. In addition, the nurse's notes dated 07/23/24 indicated R30 was diagnosed with a fractured femur and sent to the Emergency Department for evaluation of the right knee and swelling, and her pain management was adjusted to better regulate her pain. While R30 had initially been receiving Tylenol for pain relief, a stronger medication, Morphine was prescribed upon her return to the facility to more effectively address the pain associated with the fractured femur. On 07/23/24 at 12:14 PM nurse's notes indicated R30 was sent to the Emergency Department for an Ortho consult and further evaluation and treatment. Interview on 10/19/24 at 12:30 PM, the Director of Nursing (DON) confirmed that obtaining the x-ray was delayed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 30) reviewed for accident hazards out of a total sample of 34 was transferred using the appropriate mechanical lift and number of staff as per the resident's plan of care. Findings include: Review of the EZ Lift Policy and Procedures revised date 08/01/24 indicated under Purpose . To prevent injury to the resident and staff when lifting and transferring . Key Procedural Points item 1. There will be (2) staff at all times when using the EZ way Lift or EZ Way stand up lift. Review of R30's electronic medical record (EMR) Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Arthropathy (arthritis), Dementia, and Alzheimer's disease. Review of R30's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was cognitively impaired. The assessment indicated R30 was dependent on staff for transfers (movement from one surface to another) and activities of daily living (ADL-bathing, toileting, dressing). Review of R30's EMR Care Plan located under the Care Plan tab, revision date 02/06/20, indicated the resident had an ADL self-care performance deficit related to dementia and decreased mobility. The Intervention/Tasks revision, dated 01/09/24, under transfers indicated R30 was a Hoyer lift with two staff. Review of the facility's follow up report to the State Survey Agency (SSA), dated 07/26/24, indicated our investigation checked hours of video to check on who took care of resident on that particular day . we believe that CNA caring for the resident might have used incorrect mechanical lift . Review of documentation provided by the Director of Nursing (DON), dated 07/24/24, revealed video reviewed which indicated Certified Nursing Assistant (CNA) 9 took the stand-up lift into R30's room that morning and was later seen removing the stand-up lift from the room and placing it in the hallway. After lunch, the video showed CNA 9 taking the resident into the spa room alone and leaving the spa room two minutes later. CNA9 was then seen getting another CNA and the Hoyer lift and taking it into the resident's room. Review of a written statement by CNA9 dated 07/18/24 and 07/19/24 provided by the DON revealed: Question: Did you help transfer resident to wheelchair? - Response by CNA: Yes, transfer to wheelchair. Question: How did you transfer Resident? Who assisted you with transfer? Response by CNA: Mechanical Lift 2 person. Review of Employee Warning Record dated 7/19/24 indicated that the CNA was witnessed using the wrong lift on a resident and not having a second person assist. She failed to follow the resident's care plan and failed to follow the company policy of having a 2nd person with her while using the lift. She was previously made aware of this policy and signed a lift agreement that she knew if she would be terminated if she violated this policy . During an interview on 10/19/24 at 12:30 PM, the DON confirmed that she reviewed the videos for several days prior to the incident and observed CNA9 take the stand-up lift into R30's room and later removing the stand-up lift and placing it in the hallway. And then after lunch CNA 9 was seen in the video taking the resident into the spa room alone. The DON stated that two people are to be used when the stand-up and Hoyer lift are used. The DON further stated that patient care information provided to CNAs in Point Click Care (PCC) under the Tasks tab included patient care information under the Task Care Record, Kardex and Task List. The DON confirmed CNA9 was aware of how the R30 was to be transferred by two staff using the Hoyer lift Review of the PCC patient care information under the Task Care Record, Kardex and Task List revealed that the facility staff, including CNA9, had easy access to the resident's care activities information to include ADL's, safety, bed mobility, bathing, and transfers. Review of the PCC Kardex documentation for R30 for the month of July 2024 indicated that R30 was assessed as a 4/3for the task of ADL-Transferring Hoyer Lift (2) staff members. The legend indicated 4 was Total assistance and 3 was Two plus person physical assist. CNA9 was aware that R30 was Total Dependence for transfer and required transfer support of 2 plus people when transferring with the use of the Hoyer Lift and not with the standup lift. Review of the Lift agreement signed and dated by CNA 7 on 07/12/23 revealed I verify that I have received training for the proper use of the EZ lift. I understand that there must always be two employees present while using the lifts . 29728 2. Review of the Face Sheet located in the Electronic Medical Record (EMR) under the Profile tab revealed R38 was admitted to the facility with diagnoses including Multiple Sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/25/24 revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R38 was cognitively intact. Further review of this MDS revealed R38 had no impairment of the upper extremities and was independent with eating. Review of the Care plan located in the EMR under the Care Plan tab revealed R38 was identified as being independent of dressing his upper extremity and with hygiene. Observation of the resident's room on 10/14/24 at 10:04 AM revealed R38 was in his room in his electric wheelchair, well dressed, alert and oriented. On the nightstand next to the bed, R38 had multiple bottles of water and a Keurig single use coffee maker. During an interview on 10/14/24 at 1:35 PM, R38 stated that he has had the Keurig for several years and he has never had a problem with it. He does not drink the water at the facility, which is used to make coffee, so that is why he has his own coffee maker. During an interview with the Assistant Director of Nursing (ADON) on 10/14/24 at approximately 2:30 PM, she stated she did not think the resident used the Keurig, but staff made it for him. She did not know if the resident had been assessed for the use of the Keurig. She stated that she would observe R38 using the Keurig coffee maker for safety. Further review of the EMR revealed no documentation of an assessment for the safe use of the Keurig coffee maker.

Based on interview and record review it was determined that for three (R1, R2, and R4) out of four residents reviewed for accidents, the facility failed to ensure supervision to prevent accidents. For R1 the plan of care was not followed resulting in an accident that led to R1's severe adverse outcome, death. This was identified as an IJ on [DATE] at 12:20 PM and abated on [DATE] at 8:00 AM. For R2 the facility failed to provide the appropriate supervision to prevent a fall with injury requiring a transfer to the ER and two staples to the head, R2 sustained harm. R4 was left unattended and fell from a shower chair resulting in a broken arm, R4 was harmed. Findings include: 1. Review of R1's clinical record revealed: [DATE] - R1 was admitted to the facility. [DATE] - A progress note on admission documented that R1's admitting diagnoses included the following: dementia, fall risk with history of falls, self ambulatory dysfunction, Alzheimers dementia, and a left hand contracture. [DATE] - A care plan documented that R1 was physically aggressive related to dementia, interventions included: When the resident becomes agitated; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. [DATE] - [DATE] - A Physical Therapy evaluation documented, R1's baseline as total care, requires support to maintain position, unable to move without loss of balance and does not bend at the waist. [DATE] - An annual MDS documented that R1 required extensive assist (staff provide weight bearing support) with two person physical assist with transfers and bed mobility. [DATE] - R1's fall risk score was 75 indicating R1 was a high risk for falls. [DATE] - A care plan documented that R1 was resistive to care, interventions included the approach of if resident resists with ADL's, reassure resident, leave and return ,d+[DATE] minutes later and try again. [DATE] 6:10 AM - A progress note documented E3 (CNA) reported to E13 (LPN) that E3 put on R1's hipsters (impact-absorbing pads worn under clothes to minimize potential damage that can occur from a fall), pants and shoes on while R1 was laying in the bed. Then E3 assisted R1 from a laying to a sitting position; placing R1's feet on the floor, sitting him upright on the edge of the bed with only a small portion of R1's buttocks touching the mattress, his butt cheeks were on the edge of the bed. E3 was standing in front of R1. E3 reached to his left for a washcloth, and by doing so E3 was positioned to the right of R1. R1 fell to the floor on his left side hitting his head and was bleeding. E13 assessed R1 and described the wound as active bleeding from a laceration that measured 2.3 cm x 0.2 cm above the left eyebrow. The facility called EMS (emergency medical services) and R1 was transferred to the hospital. [DATE] 9:04 AM - A hospital document titled Trauma History and Physical/Consult documented a left eye laceration after a fall, CT scan of the head (imaging that takes detailed pictures of the inside of the body) revealed a intracranial hemorrhage measuring 9 x 10 mm. (bleeding between brain and the thin tissue that covers the brain). [DATE] - A Certificate Of Death documented R1 died at 9:15 AM with a worsening brain bleed following a fall from side of the bed at a skilled nursing facility. [DATE] 10:45 AM - During an interview, E3 (CNA) confirmed that R1 was a two person assist for moving in the bed and transfers but did get R1 up alone. E3 stated that R1 did not want to get up and was resistant to care kept trying to lay back down. E3 stated that he put on R1's hipsters, pants and shoes on while R1 was laying the bed. Then E3 assisted R1 alone from a laying to a sitting position; placing R1's feet on the floor, sitting him upright his butt cheeks were on the edge of the bed. E3 was standing in front of R1. E3 reached to his left for a washcloth, and by doing so E3 was positioned to the right of R1. R1 was without the weight bearing support that was required. R1 fell to the floor on his left side hitting his head and was bleeding. E13 assessed R1 and described the wound as active bleeding from a laceration that measured 2.3 cm x 0.2 cm above the left eyebrow. The facility called EMS (emergency medical services) and R1 was transferred to the hospital. [DATE] At approximately 2:00 PM - E11 (NHA) and E2 (DON) were notified by the survey team that during the investigation, it was determined that for one (R1) out of four residents reviewed for falls the nursing staff failed to follow the plan of care resulting in accident that lead to R1's death. [DATE] - An IJ was called at 12:20 PM. The State agency accepted the abatement plan on [DATE] at 3:30 PM which included: All CNA's will demonstrate a clear understanding of how to access each resident's care plan, a clear comprehension of the resident's transfer status, sitting balance and how to identify any safety devices required in providing care. [DATE] - Through interview and record review the survey team confirmed: - Nursing staff currently working in the facility had received the education and training was conducted and their competencies had been signed by E16 (staff development coordinator). - Oncoming staff were provided the education and training prior to being allowed on their assigned units. - During an interview E14 (CNA), E15 (CNA) confirmed they had been signed off on the competencies. E13 (CNA) oncoming for evening shift also confirmed she had to complete the training prior to starting her shift. [DATE] At approximately 11:00 AM - During an interview E17 (CNA), E11 (CNA) and E18 (CNA) confirmed that they had received the education and training and their competencies had been signed by E16. [DATE] - Review of facility staff competencies and staff interviews revealed that the education and training outlined in the abatement plan was completed on [DATE] at 8:00 AM, the IJ was removed. 2. Review of R2's clinical record revealed: [DATE] - R2 was admitted to the facility. [DATE] - An admission progress note documented that R2's admitting diagnosis included: Alzheimers, one broken rib on the right side and broken bone segments of the lower spine that support the body and permit movement. [DATE] - A Physical Therapy evaluation documented, R2 as being unsteady, only able to stand unsupported for ,d+[DATE] minutes and supported for ,d+[DATE] minutes. [DATE] - Review of R2's quarterly MDS documented, R2 required extensive assist (staff provide weight bearing support) for dressing. [DATE] - A care plan documented that R2 had an ADL self-care deficit related to limited physical mobility and dementia. R2 i s unsteady and had limited range of motion in her legs. [DATE] - A facility incident report documented, R2 was being changed while holding onto a night stand, E12 reached for a clean brief and R2 fell backwards hitting her head, sustained a head injury requiring two staples to the back of the head. [DATE] - A progress note documented R2 returned from the hospital at 9:22 AM via wheelchair. R2 was awake, alert and denied any pain or discomfort. Discharge instructions were to remove the staples in ten days. [DATE] 11:07 AM- During an interview with E9 (CNA) it was confirmed that R2 was a one person assist. When asked How do you know how to care for residents, as their condition may change and do you check the Kardex (tool that is used for staff to know how each resident' ADL status) E9 replied I get report from the nurse, I don't usually check that every shift. [DATE] 11:20 AM- During an interview E10 (CNA) stated that R2 was a two person assist and R2 was able to pivot during transfers. E10 stated that she does not check the Kardex every shift. [DATE] 11:45 AM - During an interview E8 (RN) confirmed that the CNAs know they should be checking the Kardex at the beginning of each shift as the plan of care can change daily. E8 also stated that CNAs are educated during their orientation on checking every shift. [DATE] 12:00 PM - During an interview, E11(CNA) confirmed that she changes or dresses R2 while in bed as R2 cannot stand for very long. R2 is a one or two person physical assist and I always ask another aide to help when I have R2. E11 stated that at the beginning of the shift I always check the Kardex because I know I will have the correct information I need and, that's what I've always done. [DATE] 11:55 AM - During an interview E12 (CNA) confirmed she had been providing care and R2 was holding onto the night stand as it was a solid piece of furniture. E12 stated that R2 was able to follow directions at the time and had been able to stand alone in the past. E12 stated she had reached for a clean brief and witnessed R2 falling backwards and hit her head on the closet. E12 stated she couldn't stop the fall. [DATE] 1:40 PM (approximate) - During an interview E1 (NHA) and E2 (DON) confirmed that R2 was placed in an unsafe position resulting in a fall with injuries. Findings were reviewed with E1 (NHA) and E2 (DON) on [DATE] at 3:30 PM. 39058 3. Review of R4's clinical record revealed: [DATE] - [DATE] - An occupational therapy discharge summary documented that R4's normal position was in a wheel chair with a half lap tray and leg rest and R4 had a fair sitting balance. [DATE] - A facility fall risk assessment documented R4 was a high risk of falling. [DATE] - A quarterly MDS documented that R4 had a diagnosis of a stroke, paralysis and muscle weakness. It was further documented that R4 required extensive assist (staff provide weight bearing support) one person physical assist, also for surface to surface transfers R4 was not steady and only able to stabilize with staff assistance. [DATE] - A care plan documented R4 was at risk for falls and had limited physical mobility related to a stroke that paralyzed the left side. R4 had an activity of daily living self-care performance deficit (R4 required assistance with care) due to confusion related to dementia and stroke with left side weakness. [DATE] 9:15 AM - A progress note documented that E4 (CNA) reported to the charge nurse that R4 was found on the floor next to the shower chair. E4 stated resident slid out of the shower chair. Initial assessment documented that R4 was okay,15 minutes later [R4] complained of left shoulder and or arm pain. Pain medication was given to R4, the physician was notified and a X-ray was ordered. [DATE] 4:44 PM - A Radiology Report documented that R4 had a broken left arm. [DATE] 6:56 AM - A progress note documented that R4 complained of left shoulder soreness pain medication was administered. Ice was applied to the swelling area and arm was elevated. [DATE] 12:46 PM - A progress note documented a Therapy Fall Screen was completed on the resident due to R4 sliding out of shower chair. The X-ray revealed a possible broken left arm and a sling was ordered. [DATE] - 5:59 PM - A progress note documented that a family member was visiting and noticed a bump on the back of R4's head and the POA called facility requesting that R4 be sent to the hospital. [DATE] 9:37 PM - A progress note documented that R4 was sent to the hospital per the family's request. [DATE] 1:37 AM - A progress note documented that R4 returned from the hospital emergency room Discharge diagnosis from the hospital emergency room was left humeral fracture (broken arm). [DATE] 1:55 PM - During an interview with E5 (Housekeeper) revealed that she walked into R4's room the curtain was closed and E4 (CNA) was in the room alone. E5 told E4 that you are supposed to get help. E4 asked E5 to get the sit to stand and put it in the bathroom. [DATE] 2:04 PM - During an interview with E4 (CNA) it was revealed that E4 left R4 in the shower chair without support or supervision, E4 turned to retrieve a bottle of deodorant and when E4 returned, E4 found R4 in the floor next to the shower chair. [DATE] 2:35 PM - During an interview with E2 (Therapy Director) revealed that R4's assessment on [DATE] to [DATE], R4 is totally dependent and unable to sit unsupported. R4 would not be appropriate for leaving unattended in a shower chair. [DATE] 11:35 AM - During an interview with E10 (CNA) it was revealed that the resident was always a two person assist with showering and that she could not sit without assistance. [DATE] approximately 11:45 AM - During an interview with E8 (RN) it was confirmed that R4 was not steady and she would need guidance to sit in a shower chair. R4 was left unsupervised and unsupported in a shower chair where she fell from the shower chair that resulted in a broken arm. Findings were reviewed with E1 (NHA) and E2 (DON) on [DATE] at 3:30 PM.

Based on clinical record review, interview, and review of facility documentation, it was determined that for one (R47) out of three residents sampled for accidents, the facility failed to ensure that R47 received adequate supervision and assistance to prevent an accident that resulted in harm to R47. R47 was harmed when the facility failed to ensure the care planned interventions were followed for transfers, resulting in R47 falling from his/her bed sustaining a nasal fracture, facial laceration, and lip abrasion. Findings include: Review of R47's clinical record and facility documents revealed: 1/9/14- R47 was admitted to the facility. 1/21/14- A care plan was initiated stating that R47 had an ADL self-care performance deficit due to cognitive impairment related to Alzheimer's dementia. On 9/29/18, an intervention was revised stating that for transfers R47 required extensive assistance of two staff using a stand up lift. 12/9/18- An annual MDS assessment documented that R47 required extensive assistance of two staff members for bed mobility and transfers. 12/31/18 at 8:00 AM - Review of an incident report revealed that the nurse was called into R47's room by the CNA (E4) who stated R47 was on the floor. R47 was found lying in a prone position with the right side of his/her face on the floor. There was noted to be a pool of blood by R47's face that appeared to be coming from R47's nose. R47 was awake and alert to person. Staff were unable to fully assess R47 due to keeping R47 immobilized after the fall. R47 had some moaning and facial grimacing noted. Emergency Medical Services arrived and left the facility with R47 at 8:25 AM to the emergency department (ED). 12/31/18 1:57 PM- A progress note documented that R47 returned from the ED and was diagnosed with [REDACTED]. R47's nose laceration was repaired with dermabond, and R47 had a [MEDICATION NAME] vaccine administered in the ED. 1/2/19- Review of the facilities incident summary revealed that the fall that occurred on 12/31/18 was witnessed by a staff member in R47's room. According to the assigned CNA (E4), R47 received AM care and E4 was ready to transfer R47 to his/her wheelchair. E4 stated that she sat R47 on the side of the bed and turned around to get R47's wheelchair. E4 heard R47 hit the floor and saw him/her lying face down (Incident report dated 12/31/18 stated R47 fell on the right side of his/her face). 1/7/19- Review of the facility's incident investigation revealed the root cause of R47's fall on 12/31/18 was that E4 (CNA) did not follow R47's care plan. E4 stated that she sat R47 on the bed by herself prior to this incident and sometimes she used the stand up lift and sometimes she did not use a lift at all. E4 stated when not using the lift, she lifts R47 and transfers him/her from the bed to the wheelchair. E4 stated that she never communicated to anyone that she transferred R47 without a lift and that she was the only staff member in the room when R47 fell on [DATE]. E4 was suspended for not following R47's care planned interventions to have two staff assist with bed mobility and transfers, resulting in R47 falling on to the floor and injuring his/her face. 5/16/19 9:20 AM- Findings were reviewed and confirmed with E2 (DON). The facility failed to ensure that R47 received adequate supervision and assistance to prevent an accident on 12/31/18. The facility failed to ensure that R47's care plan interventions were followed, stating that R47 required extensive assistance of two staff using a stand up lift. This resulted in harm to R47 when he/she fell from his/her bed sustaining a nasal fracture, facial laceration, and lip abrasion.

Cross refer F279 Based on clinical record review, review of facility documents and staff interviews it was determined that the facility failed to provide adequate supervision and physical assistance to prevent a fall with injury sustained by one resident (R1) out of 4 (four) sampled. Findings include: Clinical record review revealed R1 had [DIAGNOSES REDACTED]. According to the MDS dated [DATE] and completed for a significant change, the annual MDS dated [DATE] and the quarterly MDS dated [DATE] R1 experienced short-term and long- term memory problems and impaired cognitive (thinking) skills for daily decision-making. Further review of the above referenced MDS assessments also revealed that R1 exhibited limited range of motion of both upper and lower extremities. The significant change MDS dated [DATE] and the annual MDS dated [DATE] also revealed that R1 was totally dependent on the physical assistance of two staff members for bed mobility. Further review of the clinical record also revealed a nurse's note dated 11/25/2014 and timed 6:23 PM that stated .E5 (CNA) .notified E6 (LPN) .R1 on floor .R1 noted with a hematoma and a cut bleeding moderately on the left parietal (area of the head that forms the sides and top of the skull) .left facility at 5:02 PM (to acute care facility). Another nurse's note dated 11/26/2014 and timed 12:37 AM stated R1 returned on 11/25/2014 at 11:45 PM to the long-term care facility from an acute care facility with a discharge [DIAGNOSES REDACTED]. Review of the completed facility incident report dated 11/25/2014 with attached investigation revealed that : - E5 witnessed R1's fall - E5 was providing care to R1 without the assist of a second person - R1 fell to the floor while being turned in bed - R1 hit her head on the floor when she fell During an interview with E5, conducted on 2/23/2015 at 2:15 PM, these findings were reviewed and confirmed. The facility failed to ensure that R1 was provided the required physical assistance when she sustained a fall with injury on 11/2/2014 during the repositioning in bed with the assistance of one staff member. These findings were reviewed with E1 (ED), E2 (NHA), E3 (DON) and E4 (ADON) on 2/24/2015 at 4:15 PM and again with E2 by telephone on 3/3/2015 at 2:55 PM.

Based on observation, interview and record review, it was determined that the facility failed to have a system that accurately assessed the resident's nutritional status, identified weight loss and modified interventions in a timely manner for 3 (R12, R79 and R98) out of 27 Stage 2 sampled residents. The facility failed to identify, implement interventions, monitor and modify the interventions in a timely manner when R79 had a severe weight loss of 18 -19 pounds or 11-12% in one month. The facility failed to identify, implement interventions, monitor and modify the interventions in a timely manner when R12 had a significant weight loss of 7.6 pounds or 5.6% over one (1) month and failed to act upon the alert triggered by their electronic system until after it was brought to their attention. The facility failed to re-weigh R98 immediately, as per facility procedure, when a 16.2 pound or 11.4% weight loss over one (1) month occurred and failed to act upon the alert triggered by their electronic system. Findings include: The facility's policy entitled, "Weight Measurement", last revised on 3/15/13 stated, "Residents are weighed ... monthly unless otherwise ordered by nursing or the attending physician (doctor), to monitor the resident's condition. Weights will be rechecked immediately or as soon as possible if an alert is triggered in POC (plan of care) for significant weight change ... USE SAME EQUIPMENT EACH MONTH ON INDIVIDUAL RESIDENT ... Record weight in resident medical record. Report to physician and dietician if there are any significant weight changes. Notify family or resident of significant weight changes." A nutritional standard documented in the article, "Nutritional Management in Long-Term Care: Development of a Clinical Guideline", Journal of Gerontology: MEDICAL SCIENCES 2000, Vol. 55A, No. 12, M725-M734 (pages), revealed that interventions for an "involuntary 5% weight loss in 30 days or 10% in 180 days or less ...". include, "Put on weekly weight monitoring program/Proceed with documentation utilizing Nursing Nutritional Checklist ... Inform physician/dietitian, Food/environmental considerations, Needs feeding assistance, Calorie-dense foods, Between meal liquid calorically dense supplements ...". 1. R79 had Alzheimer's dementia (loss of mental functions such as memory and reasoning that is severe enough to interfere with a person's daily functioning) with delusions (a belief held with strong conviction despite evidence to the contrary). R79 had been on a liquid dietary supplement, Ensure, three times a day since 9/15/11. On 6/6/13, R79 weighed 157.2 pounds on the "wheel chair scale 3rd floor Van Buren" wing. On 6/13/13, an outside company inspected the second and third floor scales to ensure their accuracy. The 3rd floor wheelchair scale used to weigh R79 had no errors and needed no correction. According to the 6/25/13 nutritional progress note, R79's estimated needs were 1399 calories per day and 57 to 71 grams of protein per day. The annual Minimum Data Set (MDS) assessment, dated 7/3/13, stated that R79 had unclear speech, was usually understood, usually understood others, had memory problems and was moderately impaired for daily decision making. R79 required supervision and/or encouragement of one person for eating. R79's height was 5 feet and weight was 157 pounds. The care plan entitled, "Nutritional problem (weight loss) r/t (related to) poor appetite, diuretic use (medicine that reduces excess fluid in the body) and advancing dementia", revised on 10/29/13 and again on 12/2/13, had interventions to provide and serve (R79's) diet as ordered, monitor food and fluid intake and record every meal, and the dietician was to evaluate and make diet change recommendations as needed. Review and analysis of R79's June 2013 meal intake record revealed that R79 consumed the following percentages during the month: 62% of the month R79 consumed 50% or less of the meals. Additionally, 10% of the June 2013 meal intake record was left blank, which indicated that staff failed to record the meal consumption for those meals. The 6/13 Medication Administration Record [REDACTED]. Review of R79's July 2013 meal intake record revealed that R79 consumed the following percentages during the month: Blanks, meal consumed was not entered = 26 (28%). Therefore, 49.4% of the month R79 consumed 50% or less of the meals. Additionally, 28% of the July 2013 meal intake record was left blank, which indicated that staff failed to record the meal consumption for those meals. The 7/13 Medication Administration Record [REDACTED]. On 7/9/13, R79 weighed 137.8 pounds on the "wheel chair scale 3rd floor Van Buren" wing which represented a weight loss of 19.4 pounds or 12.34% over one month. On 7/11/13, the facility obtained another weight/reweight and R79 weighed 139.2 pounds, on the same scale, which represented a weight loss of 18 pounds or 11.45%. This was a severe weight loss. The facility's computerized program for resident's weights automatically alerted staff when the weights were pulled up on the screen (of weight losses or gains of 5% or more in one month and 10% over 180 days). On 7/9/13 and on 7/11/13, R79's weight loss of 12.3% or 19.4 pounds and 11.5% or 18 pounds, respectively, were listed next to the weights as a warning on the electronic screen and printout. Despite this "warning" system, review of nurses' notes from 7/10/13 through 7/26/13 lacked evidence that the dietician and physician were notified of R79's severe weight loss. On 7/16/13, R79's weight was entered as 115.8 pounds when weighed on the "wheel chair scale 3rd floor Van Buren" wing. This was an additional loss of 23.4 pounds from 7/11/13 to 7/16/13 or 16.8% weight loss in five days. However, on 7/17/13, R79's reweight was listed as 152.6 pounds when R79 was weighed on the same scale, a gain of 36.8 pounds in one day. There was no evidence that a further reweight was obtained to determine an accurate weight for R79 for 7/16/13 and 7/17/13. The 7/24/13 physician progress notes [REDACTED]. This annual physical examination, dated 7/24/13, was blank in the areas of height and weight and had an active [DIAGNOSES REDACTED]. Review revealed that no nutrition notes were written during the month of July 2013. On 8/6/13, an outside company again inspected the second and third floor scales to ensure their accuracy. The 3rd floor wheelchair scale had no errors and needed no correction. On 8/7/13, R79 weighed 136 pounds on the "wheel chair scale 2nd floor Gilpin" wing. On 8/23/13, R79 weighed 140.4 pounds again on the "wheel chair scale 2nd floor Gilpin" wing. On 8/7/13 and 8/23/13, the facility failed to use the same scale that had previously been used to obtain R79's weight as per the policy. Review revealed there were no physician progress notes [REDACTED]. Nurse's notes from 8/2 through 8/16/13 lacked evidence of any notification or new interventions regarding R79's weight. E14's (Registered Dietician/RD) note, dated 8/28/13 stated, "Nutrition alert received. Wt. (weight) Aug. - 140.4 (pounds), July 154.6 (pounds), Feb. 153.2. Wt. (down) 14.2# (pounds), (down) 9% in 1 mo. (month), wt.(down) 12.8#/8% x (times) 6 mo. Appetite varies 25 - 50%/100%. Resident occasionally refuses meals, and assistance with meals. Staff cuts up foods and encourages intake. Resident accepts Ensure TID (three times/day) -100%. Will begin a calorie count 8/28/13 -8/30/13. Request 2 Cal HN (dietary supplement) at 120 cc (cubic centimeters) (at) 10 AM and 4 PM. Resident is 140% of IBW (ideal body weight)." This note was written six weeks after the severe weight loss on 7/9/13 and 7/11/13 and it failed to address that weight loss. As noted above, the weight used for July was 154.6 pounds which was incorrect according to the computerized weight summary for R79 which stated that her weight was 152.6 pounds. The three day calorie count from 8/28/13 through 8/30/13 revealed that the third day (8/30/13) of the calorie count was left blank and not completed. Additionally, review of the August 2013 meal intake record revealed that for 50.5% (47 meals) of the month there was no data for R79's meal consumption. E14's dietary note, dated 9/4/13, stated that the average intake over two days (from the calorie count) including supplements met R79's calorie and protein needs. The note also stated that daily intake fluctuated from 25% to 50%, occasionally just taking bites and refusing food and "... Resident is often asleep during lunch and awake all night, DX (diagnosis) [MEDICAL CONDITION]. The 2 days of the calorie count recorded ... were favorite foods of the resident ...". On 10/10/13, R79 weighed 132 pounds on the "wheel chair scale 3rd floor Van Buren" wing. E14's note, dated 10/23/13, stated that a nutrition alert was received for weight loss and she requested that a sandwich be offered in the evening. On 11/5/13 R79 weighed 129.6 pounds on the "wheel chair scale 3rd floor Van Buren" wing. Weekly weights were ordered by the physician on 11/5/13; almost four months after the severe weight loss on 7/9/13 - 7/11/13. On 11/12/13, R79 weighed 128 pounds on the "wheel chair scale 3rd floor Van Buren" wing. On 11/27/13, an additional supplement, [MEDICATION NAME], was ordered by R79's doctor to be given at 7 PM and a soft sandwich to be given daily at 8 PM. On 12/3/13, R79 weighed 128.8 pounds on the "Parker scale tub 3rd floor Gilpin". Again, the facility failed to consistently weigh R79 on the same scale as per facility procedure. On 12/11/13, R79 weighed 131.2 pounds on the "wheel chair scale 3rd floor Van Buren" . On 12/13/13 at 8:57 AM R79 was observed during breakfast. R79 was served scrambled eggs, creamed chipped beef on toast and orange juice. The resident did not eat or drink any of her breakfast. She was then observed eating a banana while self propelling her wheelchair with her feet. She ate about 1/3 of the banana. On 12/13/13 at 9:08 AM, in an interview, E16 (Certified Nurse's Aide/CNA) stated that R79 just picked up her banana and ate nothing else. E16 also confirmed that no one had assisted R79 to eat. On 12/13/13 at 9:19 AM, in an interview E17 (CNA) stated that R79 threw the banana on the floor, so she threw it out. E17 stated that R79 ate half of the banana. On 12/13/13 at 1:22 PM, observation revealed that R79 had eaten approximately 90% of her lunch. Additional observations of R79's meals revealed the following: 12/16/13 at 9:10 AM, ate more than 75% of breakfast; 12/16/13 at 1:10 PM, did not eat any of the entree, consumed half of a piece of cake and three ounces of fluid for lunch. On 12/17/13 at 12:09 PM, during an interview, E14 stated that all residents are weighed monthly. A reweight was done if there was a five pound weight gain or loss in a month. The reweight should be done within 24 hours. If there is a weight loss of 5% in 1 month, 7.5% in 3 months and 10% in 6 months there is an alert, then the resident's doctor and the dietician are notified along with the family. E14 stated that with a resident with known weight loss, E3 (Assistant Director of Nursing/ADON) would notify her. E14 stated that she was not aware of any problems with the scales. On 12/18/13 at 2:10 PM, during an interview, E14 stated that the resident had lost about 20 pounds in the last 6 months. E14 stated that R79 had been losing weight and interventions for residents with weight loss included adding supplements. When asked about the severe weight loss on July 9 and July 11, 2013, E14 stated that she was not notified of the weight loss. E14 also stated that the weight on 7/17/13 was "obviously not the right weight " and there should have been a reweight. Despite stating that the 7/17/13 weight of 152.4 pounds was "obviously" the wrong weight, E14 used that weight in her assessment. E14 incorrectly noted the July 17th weight as 154.6 pounds and compared it to the 8/23/13 weight of 140.4 pounds which she then stated was a 9% weight loss in one month for August. E14 stated that when someone was weighed and showed a different weight, there should be a reweight within 24 hours and it should be entered into the computer. E14 further stated that the facility "should not be putting in crazy weights" and that when there was a discrepancy in the weight that it went to E3 (Assistant Director of Nursing/ADON) who had always analyzed the weights. After reviewing her notes, E14 acknowledged that there were no interventions for 6 weeks from mid July until the end of August for R79's weight loss including interventions for additional assistance and/or cueing for R79 to feed herself. E14 also confirmed that the facility failed to complete the third day (8/30/13) of R79's three day calorie count. Additionally, E14 stated that the resident ate "favorite foods" during the two documented days of the calorie count. On 12/18/13 at 3:15 PM, during an interview, E3 stated that when there was a 5 pound gain or loss that a reweight needed to be done, "right away". If there was a weight discrepancy, reweights were done two to three times. However, they do not enter the reweights, they entered the weight closest to the previous weight. E3 stated that when she got the weights she looked for the weight gain or loss of 5 pounds, but that E14 used percentages. E3 stated, "I don't know (how to do) the calculation for the weight loss percentage". E3 stated that there was no policy for when weights were to be completed for the month, but that she tried to have them done by mid month. E3 further stated that for consistency, the facility only had two CNAs weighing residents which started this past summer and with varying weights, a reweight may be done. However, reweights were not documented as such. E3 stated that she checked with nursing staff to ask about whether a resident was eating, she observed residents to see if they were eating, but stated that she did not document these observations. Also, E3 stated that the doctor wanted notification of weight loss to go into his bin/mailbox at the facility. (R79's doctor comes to the facility weekly.) On 12/18/13 at 3:50 PM, during an interview, E3 reviewed R79's weight summary list from June 2013. E3 acknowledged the weights for July 2013 of 137.8 pounds on 7/9/13 and 139.2 pounds on 7/11/13. She stated for July 16th, "I don't know what happened here" when the weight listed was 115.8 pounds. E3 further stated that because of the fluctuations, "I looked at the resident and it didn't look like she lost weight ... I ignored the 7/9, 7/11, and 7/16/13 weights because the 7/17/13 (152.6 pounds) weight was closer to the previous weight" referring to the June weight of 157.2 pounds. The facility failed to have a system that accurately assessed R79's nutritional status which resulted in a severe weight loss between 11.45% and 12.34% in one month, from June to July 2013. The facility failed to identify R79's severe weight loss in one month (July); failed to notify R79's physician and the dietician of the severe weight loss in July; failed to act upon the weight loss with interventions in a timely manner with a delay of six weeks before R79 was placed on the supplement, Two Cal HN; failed to place the resident on weekly weights until 11/5/13 almost four months after the severe weight loss in July; failed to weigh the resident on the same scale; failed to accurately determine the percentage of weight loss when a weight was incorrectly noted in E14's note, dated 8/28/13; failed to reweigh; failed to consistently document the reweights; failed to have meal intake records that were complete; and failed to complete a three day calorie count. Cross refer F157 Example 2, F281 Example 5 2. R12's dietary notes and assessment since 10/24/12 revealed that R12's target weight was 110 lbs per IBW (ideal body weight) despite R12's usual body weight of being in the mid 130's - 141.2 lbs since October 2012. IBW is not the standard of practice for LTC (long term care) residents. The standard of practice is UBW (usual body weight). R12's care plan, dated 7/16/13 and entitled, "Potential for weight loss... R/T (related to): increased confusion, and need for staff assist with meals" listed the goal, "... will maintain weight within IBW (ideal body weight) range of (space left blank) during this review." Interventions of the care plan included to notify MD (physician) and RD (Registered Dietician) of weight loss +/- (plus or minus) 5 lbs in 30 days or less. R12's quarterly Minimum Data Set (MDS) assessment, dated 10/8/13, stated she had memory problems and was severely impaired for daily decision making. R12 required extensive assistance of one person for eating. R12's height was 62 inches and weight was 133 lbs (pounds). Review of R12's electronic record stated that her monthly weight on 11/11/13 was 135.2 lbs, an increase of 5.2 lbs from 10/14/13. R12's monthly weight on 12/11/13 was 127.6 lbs. A "warning" that a 7.6 lbs or 5.6% weight loss had occurred over one (1) month was noted by the electronic program on 12/11/13. During an interview on 12/16/13 at 12:25 PM, E10 (Licensed Practical Nurse/LPN) stated that when a resident has a 5 lb or 5% +/- change in weight, the staff was supposed to do a reweight. If the reweight confirmed a 5 lb or 5 % change in weight, the facility was supposed to notify the physician, family and RD. The resident should be put on weekly weights times 4 until stable and the RD's recommendations would be followed. E10 reviewed R12's clinical record including progress notes and reviewed the communication/fax book. There was no evidence that the physician and RD were notified of R12's weight loss. There was no evidence that any further action was taken to evaluate and/or address the weight loss. The facility failed to act upon R12's documented weight loss on 12/11/13 in a timely manner, which had the potential to result in further weight loss, until after it was brought to the facility's attention on 12/16/13. During an interview on 12/16/13 at 3:05 PM, E3 (Assistant Director of Nursing/ADON) stated the facility had 5 days to obtain a reweight and that a reweight would be done that day. This was not in accordance with the facility's weight measurement policy. On 12/16/13, five (5) days later, a weight was obtained indicating R12's weight was 128.4 lbs. On 12/17/13 at 11:15 AM, E3 (ADON) and E29 (Certified Nurse's Aide) were both interviewed. E29 initially stated that the reweight was done yesterday (12/16/13). The surveyor and E29 asked E3 about a reweight done on or about 12/12/13 and E3 stated that she did not keep paper copies. E3 stated that the facility suspected that the scales were inaccurate and the facility "needed to replace them, but there really wasn't money in the budget to allow for this yet." E29 stated she could provide a copy of her documentation of R12's recent weights. E29 provided a copy of two sheets of paper that listed the nursing unit, room number, resident's name (typewritten) and next to that was a handwritten weight. One sheet was dated 12/10/13 and the other was undated. E29 stated that the weights were both from 12/10/13. R12's weight on the undated sheet was listed as 127.6 lbs. E29 also provided a copy of another undated handwritten sheet that listed nine (9) residents on the "2nd Floor" (on one side of the page) and nine (9) residents listed on the "3rd" (floor) on the back side of the sheet. E29 stated this was the sheet she was given to do reweights. R12's reweight was listed as 127.2 lbs on the handwritten, undated reweight sheet. When asked where this reweight was documented, E29 stated the reweights were supposed to be given to E3 and she decides if they are accurate and what gets input into the computer. E3 stated she does not keep copies of the CNA sheets with reweights. She stated that if she saw a discrepancy, she would interview the nurses. E3 denied having documentation of these discussions. E3 also denied notifying R12's physician, RD, or family of R12's weight loss. She stated that she was "planning on alerting the RD and physician today (12/17/13)". Review of the facility documentation from their contracted service to monitor and maintain the scales revealed there was no evidence of problems with the accuracy of the scales. During an interview on 12/17/13 at approximately 3 PM, E14 (Registered Dietician/RD) provided a copy of her notification by the facility of R12's weight loss, dated 12/17/13. E14 stated that she just received it "today" (12/17/13) in her box. R12's record review revealed a nurse's note, dated 12/17/13 and timed 6:28 PM that stated, "N/O (new order) for [MEDICATION NAME] (name of) supplement BID (twice daily) at 10 am and 2 pm due to weight loss. POA (Power of Attorney) (name) notified." During an interview on 12/18/13 at approximately 3:30 PM, E3 stated that when R12's weight increased 5.2 lbs in 11/2013, she interviewed staff and was informed that R12 increased her oral intake and therefore a reweight was not done "because we wanted a weight increase and the resident was on supplements." E3 denied notifying the RD, MD or family of R12's weight increase. E3 stated that multiple weights were taken, but only one weight can be input into the computer system. When questioned about the differing weights obtained on 12/10/13 of 127.6 lbs and an undated reweight of 127.2, how did the electronic record have a weight of 127.6 lbs on 12/11/13. E3 stated that she always uses the weight that is closest to the last month's weight as the "more accurate" weight. The facility failed to notify E14 (RD) or E23 (physician/MD) in a timely matter of R12's weight gain on 11/11/13 as per R12's care plan and R12's significant weight loss from 11/11/13 to 12/11/13 of 7.6 lbs (5.6%), despite an electronic warning. Additionally, the facility failed to modify interventions until after it was brought to their attention on 12/16/13. 3. Cross refer F281, example #2 R98 was admitted to the facility in June 2013. On 6/14/13 a care plan was developed for the problem potential for weight loss related to being newly admitted to LTC (long term care) facility. The goal of this care plan stated the resident will maintain current weight. However, the DBW (desired body weight) was left blank. Interventions of the care plan included to notify the physician and RD (Registered Dietitian) of weight loss plus or minus 5 lbs. (pounds) in 30 days or less. Record review revealed R98's admission weight was 138.5 lbs. (pounds) on 6/12/13. On 12/3/13, R98's electronic record stated her weight was 126.2 lbs. A "warning" that a 16.2 lbs. or 11.4% weight loss had occurred over one (1) month was noted by the electronic program. There was no evidence that a re-weight was completed as per facility procedure, nor was there any evidence that the physician and RD were notified. There was no evidence that any further action was taken to evaluate and/or address the weight loss. The facility failed to act upon R98's documented weight loss on 12/3/13 in a timely manner, which had the potential to result in further weight loss. On 12/12/13, nine (9) days later, a weight was obtained indicating R98's weight was 146.0 lbs. During an interview with E14 (Registered Dietitian) on 12/18/13 at 2:40 PM, she stated that she was not notified of the 12/3/13 weight, that no action was taken and that there was a "system problem."

Based on observation, interview, record review and review of other facility documentation as indicated, it was determined that the facility failed to ensure that 2 sampled residents (R28 and R56) who entered the facility without limited ROM (range of motion) did not experience a reduction in ROM. The facility failed to adequately assess, care plan and/or follow care plan interventions, and failed to provide preventative care for R28, who experienced a decline in R (right) shoulder ROM and for R56, who experienced a full contracture of her L (left) hand. Findings include: 1. R56 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 2/10/06, coded R56's hand ROM as "0-0" (no ROM limitation and no loss of voluntary movement). R56 was independent in cognitive skills for decision-making with short-term memory loss. Review of the 12/12/08 annual and 3/10/09, 6/9/09, and 9/7/09 quarterly MDS assessments, coded R56 as "1-0" for the hand (ROM limitation on one side without loss of voluntary movement). The annual 12/2/09 MDS assessment coded R56's hand as "1-2" (ROM limitation on one side with full loss of voluntary movement). On 12/2/09, R56's cognition was coded as moderately impaired. Review of physician orders [REDACTED]. On 12/12/09, OT was ordered 2 times per week for 90 days to address the left hand contracture. On 1/5/10, R56's physician ordered to place OT rehab (rehabilitation) on hold due to R56'[MEDICAL CONDITION] (infection in her PEG tube area-abdomen) and to follow up after a clearance order was given. An OT evaluation, dated 11/12/09, stated, "Left hand contracture into very tight fisted position, c/o (complaints of) pain on attempts to open hand...". Short term goals included, "1. open hand fully c (with) min difficulty 2. staff to clean hand c min difficulty." OT was provided from 11/12/09 through 12/22/09. A 12/8/09 OT progress note stated, "... Attempt to apply carrot orthosis c/o very painful...". An OT progress note, dated 12/22/09, stated, "L hand fisted flexion contracture, painful to move, increase PROM (passive range of motion) of digits able to increase cleaning... Reasons for Lack of Progress or Speed of Progress: painful, tenses c (with) PROM... Rehab potential to meet goals (prognosis) good...". An OT note, dated 1/5/10, stated, "Place on Hold 2 (secondary to)[MEDICAL CONDITION] and Contact isolation." Review of R56's record revealed that the facility developed a care plan for "potential for development of contractures" on 12/7/09. In addition to a neck contracture, the facility stated, "... also has decrease (sic) function in hand (left)... will maintain current had (sic) function this review...". Interventions related to the L hand included, "... provide range of motion to left hand when care is being provided. Report any changes or worsening in condition to physician. Medicate for discomfort as needed. OT in progress for L hand contracture." On 12/7/09, another care plan for the "potential for development of contractures" stated that R56 was at risk for worsening of contractures r/t (related to) limited ROM on both sides of body. Interventions included, "... visually compare and record appearance of contractures to the description in the most recent FCS (functional care summary) or to the most recently recorded actual measurements... Offer Tylenol as ordered (sic) pain." Review of the previous care plan for potential for development of contractures, dated 12/17/08, listed only a neck contracture. ADL (activities of daily living) flow sheets (used by CNA's-certified nurses aides), dated 1/13/10 to 2/2/10, were reviewed; they lacked the intervention to provide ROM to the L hand when care was being provided as per the care plan. FCS sheets were reviewed from 9/09 through 1/10 and there was no documentation related to contractures. Additionally, the clinical record lacked actual contracture measurements, including OT. R56 was observed throughout the survey with her left hand tightly contracted and no splint devices in place. During an interview with E27 (CNA assigned to resident) on 1/29/10, E27 stated she was unable to do ROM to R56's L hand because "she screams from pain." When this surveyor requested to see R56's L hand fingernails, E27 declined and told the surveyor to get a nurse. Consequently, on 1/29/10, E28 (nurse) showed this surveyor R56's nails. R56 hollered out loud when her L hand was manipulated. E28 was unable to fully open R56's L hand and fingers and the palm was not visible. On 2/1/10, R56's daughter performed ROM on her mother's L hand (had been taught by OT) and screams were audible in the hallway. During an interview on 2/2/10, E29 (OT) confirmed that he had not seen R56 for her L hand contracture until 11/09. When asked if R56 had a L hand splint or device in place prior to his evaluation in 11/09, he stated not unless she came to the facility with one (R56 did not have a hand contracture on admission). E29 additionally stated that annual contraction measurements have not been done in the facility since approximately 2008 when he was told not to do them anymore. E29 confirmed that it would have been better if R56 was referred to him sooner. On 2/1/10, during an interview with R56's daughter, she stated that her mother's L hand has been contracted like it currently is for 1 1/2 years or so. She further stated that she did not recall any devices used in the facility until the carrot was tried in 11/09. When asked if her mother had previously received ROM, she stated that she was unsure, "it was probably too painful." On 2/2/10, E31 (nurse) stated when she began employment in the facility about 2 years earlier, R56's L hand was slightly painful, but she was able to fully open her fingers. E31 stated that the resident's L hand had been fully contracted and very painful for about a year. Review of the 1/10 POS (physician order [REDACTED]. On 2/3/10, findings were discussed with E2 (Director of Nursing). E2 confirmed that contracture measurements or description of contractures as per R56's care plan were not current facility practices. She stated that contracture measurements have to be specifically ordered for residents and none were ordered for R56. E2 confirmed that L hand ROM during care as per the care plan was not being done, and she stated that R56 had no previous interventions in place prior to 11/09 when an OT evaluation was ordered. In review, R56 was admitted to the facility without any ROM limitations to the left hand and on 12/2/09, she was determined to have full loss of motion of her L hand. The facility failed to accurately and adequately assess R56 for contractures to determine changes, they failed to provide preventative and timely interventions in an attempt to maintain or prevent a worsening of her L hand contracture, and the facility failed to follow care plan interventions, including ROM with care by CNA's and they failed to medicate R56 adequately prior to ROM to decrease pain so ROM could be done more effectively. 2. Review of R28's quarterly Minimum Data Set (MDS) assessment, dated 1/19/10, indicated a functional limitation in ROM (range of motion) of one arm and locomotion on/off the unit required a limited assist of one person. Review of the annual MDS, dated [DATE], and quarterly MDS, dated [DATE], indicated that R28 had no limitations in arm ROM. The resident self propelled in a wheelchair on the unit and required one person physical assistance off the unit. R28 experienced a decline in self performance for locomotion on/off the unit from independent to one person assistance. E45 (Registered Nurse Assessment Coordinator in training) was interviewed on 1/29/10. E45 stated that the assessment information regarding arm limitation was received from the resident and a nurse, she was unable to recall which arm was limited, and she stated that R28's current nurse (E28) knew the resident had limitations, but did not know which arm or if both arms. E45 stated that she should have documented her assessment and she would ask the resident which arm and then inform the physician of the change in arm ROM. R28 failed to receive any therapies, ROM or restorative therapies. After speaking with the resident, E45 stated it was the right arm which had a decline in ROM limitation.