Every finding on record at Glenwood Springs Healthcare

Based on record review and interviews, the facility failed to provide reasonable accommodations for six (#9, #7, #8, #15, #2 and #13) of 10 residents out of 15 sample residents.Specifically, the facility failed to ensure call lights were within reach for Resident #9, Resident #7, Resident #8, Resident #15, Resident #2 and Resident #13.Findings include: I. Facility policy and procedure The Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. The policy read in pertinent part, Ensure that the call light system is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, chronic kidney disease and dysphagia. The minimum data set (MDS) assessment was not completed at the time of the survey. The 4/21/26 at 2:04 p.m. progress note revealed Resident #9 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out 15. B. Resident observations and interview On 4/20/26 at 4:22 p.m. Resident #9 was in her room, requesting assistance. Resident #9 lifted up her right hand. Her lifted hand had feces covering her palm and fingers. She requested wipes to clean up with and said she already used her napkin. A soiled napkin was on top of her lunch plate on the bedside table next to her. Her call light was not turned on and it was not accessible. The resident identified that she was lying partially on top of it and could not reach it. The staff were not observed in the hallway or near the resident's room. At 4:23 p.m. a resident in a room near Resident #9's room turned their call light on to notify staff that Resident #9 needed assistance. At 4:26 p.m. an unidentified certified nurse aide (CNA) entered Resident #9's room and closed the door. C. Record review The activities of daily living (ADL) care plan, revised 4/21/26, documented Resident #9 had an ADL self-care performance deficit related to chronic kidney disease. The fall care plan, revised 4/21/26, identified Resident #9 needed a safe environment and prompt response to all requests for assistance. Interventions, initiated 4/21/26, included ensuring the resident had a workable, reachable call light and encouraging her to use the call light for assistance as needed. III. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the April 2026 CPO, diagnoses included unspecified sequelae of unspecified cerebrovascular disease, dysarthria (speech disorder) following other cerebrovascular disease, cognitive communication deficit, need for assistance with personal care, muscle weakness, unspecified lack of coordination, other abnormalities of gait and mobility and repeated falls. The 3/25/26 MDS assessment documented Resident #7 had moderate cognitive impaired with a BIMS score of nine out 15. The MDS assessment revealed the resident did not have inattention or disoriented thinking and understood what was said to her. Resident #7 was dependent on staff assistance for bed mobility, toileting, dressing, personal hygiene and surface-to-surface transferring. Resident #7 used a wheelchair for a mobility device. According to the MDS assessment, Resident #7 had unclear speech and difficulty communicating some words. B. Resident observations and interview On 4/20/26 at 3:59 p.m. Resident #7 was in her bed. Resident #7 had a distressed look on her face. The resident's mouth was open, brow furrowed and her eyes were squinting. Her call light cord was hanging on the far corner of a dresser drawer. Resident #7 was not able to reach the cord and indicated that she needed staff assistance. On 4/21/26 at 10:58 a.m. Resident #7 was in bed asleep. Her call light was under a blanket on top of her wheelchair, approximately four feet from her and on the opposite of her bedside dresser. At 1:29 p.m. Resident #7 was awake in her bed. Her call light was on the right side of her, next to her pillow. She reached for the call light and pushed the button to signal for assistance. She shook her head no when asked if her call light was always within her reach. An unidentified CNA entered Resident #7's room and asked the resident if she needed her brief to be changed and she nodded yes. C. Record review The ADL care plan, revised 9/16/25, documented Resident #7 had an ADL self-care performance deficit related to impaired mobility and a traumatic brain injury (TBI). The care plan directed staff to encourage Resident #7 to use the call light/bell to call for assistance (initiated 1/10/2020). D. Staff interview CNA #1 was interviewed on 4/21/26 at 2:41p.m. CNA #1 said Resident #7 was able to make her needs known but had difficulty speaking. She said the resident was able to say yes, no, nod and make verbalization sounds. CNA #1 said the resident was able to use her call light and would often push it. She said Resident #7 would sometimes sleep with the call light in her hand. -However, observations revealed Resident #7's call light was not always consistently within reach of the resident (see observations above). IV. Resident #8 A. Observation and interview On 4/20/26 at 4:05 p.m Resident #8 was in his wheelchair, next to his bed. Resident #8 said he did not know where his call light was. The resident looked around his bed and found the call light under his bed. He attempted to grab the call light with a reaching device but could not retrieve the call light from the floor independently. He said he tried to keep the call light on his bed but sometimes it would fall on the floor. V. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included chronic kidney disease and chronic obstructive pulmonary disease. The 4/17/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required moderate assistance with ADLs. B. Observations and interview On 4/21/26 at 11:10 a.m. Resident #15 was sitting in her wheelchair in her room. The resident's call light was lying on the bedside table behind the resident and she was unable to reach the call light. On 4/21/26 at 2:05 p.m. Resident #15 was sitting in her wheelchair in her room. Her call light was lying on the bed, out of her reach. Resident #15 said she wanted to lie down in her bed. She said she could not reach her call light. C. Record review Resident #15's fall risk care plan, revised 4/21/26 (during the survey), revealed the resident was at low risk for falls. The resident required a safe environment with a reachable call light. Interventions included ensuring the resident's call light was within reach and encouraging the resident to use the call light for assistance as needed. D. Staff interview CNA #4 was interviewed on 4/21/26 at 2:10 p.m. CNA #4 said residents had to have their call lights next to them to call for staff assistance. She said the residents were checked on every 15 minutes to make sure call lights were next to them. She said Resident #15 was a vulnerable resident and required more assistance with transfers and cares. CNA #4 said Resident #15's call light should be within reach for her. -However, observations revealed Resident #15's call light was not always consistently within reach of the resident (see observations above). VI. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included cerebral infarction affecting his right dominant side, epilepsy and blindness. The 4/16/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required moderate assistance with ADLs. B. Observation On 4/21/26 at 11:06 a.m. Resident #2's call light was observed lying on the floor underneath the bed, out of reach of the resident. C. Record review Resident #2's fall risk care plan, revised 10/17/23, revealed the resident was at high risk for falls due to impaired mobility related to epilepsy, cerebral infarction affecting the right dominant side and blindness. Intervention included ensuring the resident's call light was within reach and encouraging the resident to use the call light for assistance as needed. VII. Resident #13 A. Resident status Resident #13, age less than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included cervical fracture and Huntington's disease (neurological disease of the brain). The 3/21/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required moderate assistance with ADLs. B. Observation and interview On 4/21/26 at 3:00 p.m. Resident #13's call light was on the floor underneath his bed and out of reach of the resident. Resident #13 said he was able to use his call light but he did not know where the call light was. C. Record review Resident #13's fall risk care plan, revised 3/13/26, revealed the resident was at risk for falls related to impaired mobility. Interventions included ensuring the resident's call light was within reach and encouraging the resident to use the call light for assistance as needed. VIII. Additional staff interviews The director of nursing (DON) was interviewed on 4/21/26 at 5:10 p.m. The DON said call lights needed to be within reach of the residents and answered timely to ensure residents' needs were met, such as timely bathroom assistance and to help prevent falls. She said the facility conducted a call light training on 4/21/26 (during the survey) after it was identified that not all residents' call lights were within reach. The NHA was interviewed on 4/21/26 at 5:27 p.m. The NHA said the facility had created a performance improvement plan (during the survey) to address residents' call lights out of reach. IX. Facility follow up A call light education, dated 4/21/26 (during the survey) , was provided by the NHA on 4/21/26 at 6:46 p.m. The education documented all residents should have their call lights within each at all times. According to the education, staff should place call lights on mobile residents' beds and dependent residents should have their call lights clipped to them in a place the resident could easily reach the device. The education documented the staff were informed that they should always tell the resident where the call light was prior to leaving the room and ensure the resident was able to reach the call light.

Based on record review and interviews, the facility failed to timely report an allegation of abuse involving two (#1 and #2) of six residents reviewed for abuse out of 15 sample residents.Specifically, the facility failed to:-Timely report an allegation of physical abuse by Resident #2 towards Resident #1; and,-Timely report an allegation of verbal abuse by Resident #1 towards Resident #2.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. It read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If abuse, neglect, exploitation, or misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and two other officials according to state law. The administrator or other individuals making the allegation immediately reports his or her suspicion to the following person or agencies: The state licensing/certification agencies responsible for surveying/licensings of facility; the local/state ombudsman; the residents' representative; adult protective services; law enforcement officials; and, facility medical director. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents.According to the policy, the facility should report within two hours if the allegation involved abuse or resulted in serious bodily injury or within 24 hours of an allegation that did not involve abuse or resulted in serious bodily injury.II. Allegation of physical abuse by Resident #2 towards Resident #1 Record review and interviews during the survey (see below) identified a 1/30/26 allegation of verbal abuse involving Resident #1 and Resident #2. The allegation was not reported to the State Agency until 2/2/26, three days after the incident occurred.A. Facility investigationA 1/30/26 physical abuse investigation involving Resident #1 and Resident #2 was provided by the NHA on 4/21/26 at approximately 9:30 a.m. The investigation included the incident report to the State Agency, related progress notes (see below) and a witness statement. The incident report identified the incident occurred on 1/30/26 at 9:37 p.m. and the incident report was submitted to the State Agency on 2/2/26 at 6:42 p.m. According to the incident report, the initial report was due on 1/31/26 at 9:37 p.m. The initial report was marked late. The initial report documented that on 2/2/26 at 5:00 p.m the nurse management team was made aware of an incident between Resident #1 and Resident #2 that occurred on 1/30/26 at approximately 9:00 p.m. The investigation identified a certified nurse aide (CNA) heard arguing in the room of Resident #1 and Resident #2. The CNA entered the residents' room and discovered one of the residents (Resident #2) hitting another resident (Resident #1). The CNA intervened and separated the residents. The CNA alleged that she reported it to the nurse but the nurse did not report it to the facility management. The facility notified police, conducted a head-to-toe assessment, attempted to change resident rooms, and began conducting resident abuse surveys on 2/2/26. A 2/2/26 witness statement, included in the 2/2/26 investigation of the incident and documented by licensed practical nurse (LPN) #1, identified that on 1/30/26 she heard yelling in the hallway. CNA #5 told LPN #1 that Resident #2 was yelling at Resident #1. CNA #5 separated the residents and the yelling stopped. According to the witness statement, CNA #5 did not inform LPN #1 that there was physical hitting between the residents during the argument. The statement documented CNAs were instructed to report any additional yelling so proper protocols could be initiated.The facility investigation documented the alleged victim (Resident #1) did not feel threatened or unsafe and was refusing to change rooms. The facility substantiated the allegation. A. Resident #1 (alleged victim)1. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included anoxic brain damage, personal history of traumatic brain injury, insomnia due to other mental disorders, restlessness and agitation, chronic systolic congestive heart failure and major depressive disorder, recurrent. The 2/19/26 minimum data set (MDS) assessment identified Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out 15. The MDS assessment indicated Resident #1 had lower extremity impairment on both sides with no upper extremity impairment. According to the MDS assessment, Resident #1 had verbal behavioral symptoms directed toward others.2. Record reviewA 2/2/26 nursing note documented LPN #2 received a statement on 2/2/26 from an overnight CNA indicting another resident (Resident #2) punched Resident #1 and CNA #2 had intervened by removing the other resident away from Resident #1. According to the note, LPN #2 interviewed Resident #1. Resident #1 said he was yelling and cursing at Resident #2 and Resident #2 punched him three times in the arm before the CNA entered the room and intervened. Resident #1 said he was not scared of the other resident and did not want to move rooms. The note indicated Resident #1 would inform staff immediately if he felt uncomfortable or wanted to move rooms. -Review of progress notes did not reveal documentation of the resident-to-resident altercation on 1/30/26. B. Resident #2 (alleged assailant)1. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included legal blindness, hemiplegia with hemiparesis (motor impairment on one side) following cerebral infarction (stroke) affecting right dominant side, muscle weakness and personal history of malignant neoplasm (cancerous tumor) of the brain.The 2/7/26 MDS assessment identified Resident #2 was cognitively intact with a BIMS score of 15 out 15. The MDS assessment indicated the resident's vision was severely impaired. He had upper and lower extremity impairment on one side. He used a walker and a wheelchair for mobility. According to the MDS assessment, Resident #2 did not have physical or verbal behavioral symptoms directed toward others. 2. Resident interview Resident #2 was interviewed on 4/21/26 at 10:50 a.m. Resident #2 said he did not get along with Resident #1. He said they had gotten into a physical fight. He said they were not offered to change rooms after the fight. He said Resident #1 would tell him that he would kick his (expletive) and was very rude to him. He said he just tried to ignore Resident #1 until he was moved to another room.3. Record reviewA 2/2/26 at 5:38 p.m. nursing note, documented by the former director of nursing identified Resident #2 was involved in a resident-to-resident altercation. According to the note, a resident (Resident #1) made a statement that Resident #2 did not like so Resident #2 hit Resident #1 in the upper right arm three times.-The note did not identify when the altercation occurred.A 2/2/26 at 6:17 p.m. nursing note, documented by LPN #2, identified she received a statement from the overnight shift CNA that on 1/30/26 at approximately 9:00 p.m. Resident #2 became aggressive with another resident and punched the resident (Resident #1) three times. Resident #2 said Resident #1 kept cursing at him and threatening to hit him so Resident #2 approached Resident #1 and hit him three times before the CNA entered the room and removed him from Resident #1. According to the note, there were no injuries to either resident. The note documented LPN #2 educated Resident #2 that the behavior was inappropriate and he could not put his hands on other residents. III. Allegation of verbal abuse between Resident #1 and Resident #2Record review and interviews during the survey (see below) identified a 2/13/26 allegation of verbal abuse involving Resident #1 and Resident #2 which was not reported timely to the State Agency.An email, provided by the NHA on 4/22/26 at 2:49 p.m., documented the facility reported the 2/13/26 allegation of potential verbal abuse to the State Agency on 4/21/26 at 7:39 p.m. (after the survey exit). A. Resident #1 (alleged assailant) 1. Record reviewThe 2/13/26 behavior note documented LPN #2 was walking past Resident #1's room when she heard him yelling aggressively and inappropriately at his roommate (Resident #2). The note documented Resident #1 told Resident #2 I hate you, shut your stupid mouth and I will (expletive) you up. According to the note, LPN #2 entered the room and told Resident #1 that he was being inappropriate. Resident #1 told LPN #2 that he hated Resident #2 and did not want to be in the room. The note documented LPN #2 offered to change his room and Resident #1 agreed. The note documented LPN #2 would discuss the room change with the interdisciplinary team and notify the resident's representative. The behavior care plan, initiated on 4/20/26 (during survey), documented Resident #1 had the potential to be verbally aggressive. Interventions, dated 4/20/26, identified staff should analyze key times, places, circumstances, triggers and what de-escalated Resident #1's behavior and document accordingly, ensuring his needs were being promptly met to reduce risk of agitation and giving him as many choices as possible about care and activities. According to the care plan, staff should intervene before his agitation escalated by directing him away from the source of distress and calmly engaging him in conversation. 2. Resident observationObservations on 4/20/26 and 4/21/26 identified Resident #1 and Resident #2 no longer shared the same room. B. Resident #2 (alleged victim)1. Record reviewThe behavior care plan, initiated 4/20/26, documented Resident #2 had the potential to be physically aggressive. Interventions, initiated 4/20/26, included administering medications as ordered and monitoring and documenting for side effects and effectiveness; analyzing time of day, places, circumstances, triggers and what de-escalated behavior and documenting; assessing and addressing contributory sensory deficits; offering the resident as many choices as possible about care and activities; modifying the resident's environment by adjusting room temperature, comfort level, reducing noise, dimming lights, placing familiar objects in his room and keeping his door closed; monitoring for and anticipating the resident's needs, such as food, toileting, comfort level, body positioning and pain; providing physical and verbal cues to alleviate anxiety giving positive feedback; assessing verbalization for source of agitation; assisting the resident to set goals for more pleasant behavior and encouraging him to seek out staff members when agitated. According to the care plan, Resident #2 was provided education to notify staff when he was agitated with other residents. The care plan documented a room change was offered to Resident #2 but he declined to move. IV. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 5/21/26 at5:27 p.m. The NHA said physical abuse could be anything physical in nature or impeded on a resident's personal space that created a discomfort, an unsafe environment or safety risk or actual harm. He said neglect could also be a form of physical abuse. The NHA said verbal abuse could be demeaning and/or threatening language that could make a resident feel discomfort, undignified and/or unsafe. He said threatening language could also be a form of physical abuse. The NHA said he was the facility's abuse coordinator. He said when he received a report of a potential abuse allegation, whether written or verbal, he would start building the investigation by identifying who was involved and who potentially witnessed the incident that led to the allegation. The NHA said he would conduct interviews identifying how the resident(s) felt, if they felt safe, and looked to see if a room move would be appropriate. He said he would report the allegation to the State Agency and all other appropriate parties. He said the facility would implement frequent checks on the resident, identify if there were any changes to their baseline behaviors, update their care plans and ensure they were safe. The NHA said the 1/30/26 incident between Resident #1 and Resident #2 was substantiated that it occurred. He said the incident began as an argument that then escalated into a physical altercation. He said Resident #2 was punching Resident #1 but Resident #1 brushed it off and said it did not hurt. He said Resident #1 did not want to change rooms but he eventually moved to another room. The NHA said the resident-to-resident physical abuse altercation between Resident #1 and Resident #2 should have been submitted within 24 hours of the incident and there was some confusion on the timeline of the events. He said the administration was not notified of the 1/30/26 incident right after it occurred. The NHA said the former NHA made the initial report to the State Agency after management was notified of the incident. The NHA said he was not made aware of the 2/13/26 verbal altercation between Resident #1 and Resident #2 that was identified in Resident #1's 2/13/26 nurse note, therefore he did not report it to the State Agency. He said he should have been notified right away of the incident so it was reported and investigated timely. He said there should have been a heightened level of sensitivity and timely reporting of any incidents between Resident #1 and Resident #2 because the residents had just had a punching altercation a couple weeks prior to the verbal altercation. He said he was aware that Resident #1 moved to another room but he believed it was because there was a need to accommodate room changes for other residents and Resident #1 was asked again if he wanted to move and he agreed. The DON said she had heard there was a fight between Resident #1 and Resident #2 (on 1/30/26), but she was a floor nurse at the time and she was not the DON. She said she was not aware of all the circumstances of the incident. The NHA and the DON said staff received frequent abuse training with online modules. The NHA said the facility would implement an abuse performance improvement plan that included increased staff training. The DON and the NHA said the facility had scheduled an all staff in-service on 4/22/26 and they would review the protocol for reporting abuse and the performance improvement plan. V. Facility follow upA performance improvement plan was provided by the NHA on 4/21/26 at 6:46 p.m. The performance improvement plan identified the improvement plan was initiated on 4/21/26 (during the survey) to address the concern that not all staff were aware of the importance of reporting abuse/neglect immediately. The plan included resident interviews to identify if there were additional resident concerns on abuse, education to all staff and the interdisciplinary team (IDT) regarding the definitions of abuse, federal and state reporting requirements and expectations to immediately report potential abuse to the NHA. The performance improvement plan identified the facility would implement an abuse allegation checklist and leadership would review the 24-hour communication log five days a week to ensure all unreported incidents of abuse were identified.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#7) of three residents reviewed for accident hazards out of 15 sample residents. Specifically, the facility failed to ensure staff utilized a mechanical lift, as was care planned, when transferring Resident #7 from her wheelchair to her bed.Findings include: I. Facility policy and procedure The Lifting Machine, Using a Mechanical Lift policy, revised July 2017, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. The policy read in pertinent part, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions.At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.Mechanical lifts may be used for tasks the require lifting a resident from the floor, transferring a resident from bed to chair, lateral transfers, lifting limbs and toileting or bathing or repositioning. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Before using a lifting device, assess the resident's current condition, including physical. Determine if the resident's weight and medical condition are appropriate for the use of a lift.II. Observation and staff interview On 4/21/26 at 12:30 p.m. Resident #7 was observed being wheeled into the resident's room by certified nurse aide (CNA) #2. CNA #2 left the room and left the resident with CNA #1, who was already in the room, and CNA#1 shut the door. At 12:40 p.m. CNA #1 opened the resident's door and exited the room carrying a bag of soiled linens. Resident #7 was observed lying on her bed.-However, CNA #1 was the only staff member present in the resident's room at the time of the resident's transfer. Additionally, there was no mechanical lift observed in the resident's room or in the vicinity outside the resident's room.CNA #1 was immediately interviewed upon exiting Resident #7's room (at 12:40 p.m.) CNA #1 said she used a mechanical lift to transfer the resident into bed. She said CNA #2 had assisted her. When prompted, CNA #1 said Resident #1 used the mechanical lift as needed and sometimes she was just a two-person transfer. She said CNA #2 assisted her after lunch to get the resident into bed without the use of the mechanical lift. She said she did use the mechanical lift to transfer Resident #7 before lunch. -However, CNA #2 did not remain in the room to assist with the transfer after wheeling the resident's wheelchair to her room after lunch (see observation above).III. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included cerebrovascular disease, other symptoms and signs involving musculoskeletal system, repeated falls and traumatic brain injury. The 3/20/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required maximum assistance with activities of daily living (ADL). The MDS assessment indicated the resident was a high fall risk and required a mechanical lift for all transfers. B. Record Review The ADL care plan for mobility and transfers, revised 11/12/25 revealed Resident #7 used the wheelchair and was able to self propel at times. The resident did not ambulate and she required a hoyer lift (mechanical lift) for all transfers.Review of Resident #7's April 2026 CPO revealed the following physician's order: Mechanical lift for all transfers, ordered 1/20/26. The physical therapy note, dated 1/16/26, revealed Resident #7 was non-ambulatory and demonstrated severe mobility limitations. It was recommended the nursing staff utilize the hoyer lift (mechanical lift) to ensure safety. The resident exhibited impulsive and unsafe behaviors, including intentionally lowering herself from the wheelchair and the bed, resulting in a high risk for injury. Due to impaired safety awareness, dependence for mobility and inability to perform functional transfers, mechanical lift use was medically necessary to reduce risk of injury to both the resident and the nursing staff. IV. Staff interviews CNA #3 was interviewed on 4/21/26 at 1:15 p.m. CNA #3 said he assisted CNA #1 with using a mechanical lift to transfer Resident #7 today (4/21/26) before lunch. He said his resident assignment list documented what residents needed, a mechanical lift or just a one- or two-person transfer. He said he misplaced the assignment sheet and was not sure if Resident #7 was a lift or not off the top of his head. He said he would check with other CNAs to find out. The director of rehabilitation was interviewed on 4/21/26 at 1:30 p.m. The director of rehabilitation said Resident #7 used the mechanical lift for all transfers. She said the resident was evaluated by the physical therapist back in May 2025 and it was recommended the resident use the mechanical lift for safety concerns. She said the care staff were educated on how to use the mechanical lift and the resident's care plan reflected the use of the mechanical lift. She said there was another physical therapy evaluation completed this year (2026) with the same recommendations. CNA #4 was interviewed on 4/21/26 at 2:10 p.m. CNA #4 said Resident #7 used a mechanical lift for all transfers. She said as of today (4/21/26), the facility would be implementing a white board in the residents' rooms to write down how to transfer the residents. She said the transfer information was on the residents' Kardex (a tool utilized to provide consistent care) but not all staff looked at the Kardex. She said if the mechanical lift was not used when transferring Resident #7, it would be dangerous for staff and the resident could be harmed. The director of nursing (DON) was interviewed on 4/21/26 at 5:10 p.m. The DON said she thought Resident #7 used a mechanical lift at times and was a two-person transfer at other times. She said she was not sure, but she said a mechanical lift was used for safety to transfer a resident from bed to chair or chair to bed. She said she had not educated staff on the use of a mechanical lift but implemented the training today (4/21/26) after she was made aware of the concerns regarding Resident #7's transfers from staff. She said a mechanical lift was safer for the resident versus a two-person transfer without the mechanical lift. She said there was a potential that staff could drop the resident or cause harm without the use of the mechanical lift during transfers. The NHA was interviewed on 4/21/26 at 5:27 p.m. The NHA said the facility started a performance improvement plan (PIP) as of today (4/21/26), which included staff training on mechanical lifts and a full-house audit of residents who used a mechanical lift. The NHA said the PIP would be implemented to start immediately for the safety of residents and staff. V. Facility follow-up On 4/22/26 at 11:58 a.m. (after the survey exit) the NHA provided additional information which included documentation of an in-service to care staff to reinforce safe transfer practices and proper use of resident care information on the Kardex. Education was completed on 4/21/26 with eight direct care staff members.

Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible developement and transmission of infectious diseases. Specifically, the facility failed to offer COVID-19 vaccinations and provide COVID-19 vaccination information to Resident #28, Resident #12, Resident #5 and Resident #17. Findings include: I. Facility policy and procedure The Coronavirus Disease (COVID-19) - Vaccination of Residents policy, revised May 2023, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part, Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. The resident or resident representative has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision. COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee. Residents are screened for contraindications to the vaccine, medical precautions, and proper vaccination before being offered the vaccine. II. Record review A review of Resident #28's electronic medical record (EMR) revealed no documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #28's mEMR revealed no documentation that the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. A review of Resident #12's EMR did not reveal documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #12's EMR revealed no documentation that the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. A review of Resident #5's EMR did not reveal documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #5's EMR revealed no documentation indicating the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. A review of Resident #17's EMR did not reveal documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #17's EMR revealed no documentation indicating the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. III. Staff interviews The director of nursing (DON) was interviewed on 10/17/24 at 11:39 a.m. The DON said that there was no documentation indicating the COVID-19 vaccinations was offered to Resident #28, Resident #12, Resident #5 and Resident #17. The DON said the facility had not offered Resident #28, Resident #12, Resident #5 and Resident #17 the COVID-19 vaccination or COVID-19 vaccination education in the last calendar year. The infection preventionist (IP) was interviewed on 10/17/24 at 2:13 p.m. The IP said she had been in the IP role for two months. The IP said she was not involved in managing vaccinations in the facility and resident vaccination tracking was being completed by the DON. The IP said she did not know if any COVID-19 vaccinations had been offered to residents in the facility. The IP said it was important to provide vaccine education to residents so they could understand the side effects and benefits of that medical decision. The DON was interviewed again on 10/17/24 at 4:11 p.m. The DON said she had identified that the facility needed to do more to offer vaccines to residents in the facility and had begun the process of discussing flu and pneumonia vaccines with residents. The DON said the facility had not initiated a performance improvement plan regarding offering residents COVID-19 vaccinations. The DON said she was not aware of medical contraindications to the COVID-19 vaccine for Resident #28, Resident #12, Resident #5 or Resident #17.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the pantry; and, -Ensure hand hygiene was conducted appropriately. Findings include: I. Failure to store food items appropriately in the the dry storage area A. Professional reference According to the United States Department of Agriculture (USDA) Is Food In Dented Cans Dangerous? (9/18/24) was retrieved on 10/22/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous, food from cans that were leaking, bulging, or badly dented should never be eaten. The damaged cans could contain clostridium botulinum (a toxic bacteria). B. Facility policy and procedure The Food and Nutrition Services Staff policy, undated, was provided by the dietary manager (DM) on 10/17/24 at 6:21 p.m. The policy read in pertinent part, The food service department is staffed by food and nutrition service personnel who have demonstrated the skills and competency to carry out functions of the department. Food and nutrition service staff under the supervision of the dietitian and or the food and nutrition service manager, will safely and effectively carry out all functions of the food and nutrition services department. C. Observations On 10/14/24 at 10:50 a.m. a can of garbanzo beans, a can of jalapeno peppers and two cans of tropical fruit were stocked on the first row and second rows of the can goods rack in the kitchen dry storage room. Each of the four cans of food had a dent on the side of the can. On 10/16/24 at 4:10 p.m. the dented can of jalapeno peppers remained on the shelf ready for use. The DM removed the can from the supply stock after she observed it. II. Failure to perform hand hygiene properly A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/22/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings (2/27/24), retrieved on 10/22/24 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, read in pertinent part, Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients. According to the CDC, hand washing should occur before preparing or eating food, before touching the eyes, nose or mouth, and after touching potential contaminated surfaces. B. Observations During a continuous observation of the dinner meal service in the main kitchen on 10/16/24, beginning at 3:55 p.m and ending at 5:22 p.m., the following was observed: At 4:00 p.m. cook (CK) #1 performed hand hygiene, donned (put on) gloves and scooped chocolate pudding into dessert bowls. He wrapped the dessert bowls in plastic wrap to cover the top of the bowl. CK #1 removed his gloves and touched the back of his pants with his left hand, adjusted his face mask by touching the front surface of the mask, retrieved a marker, placed his left hand over each cover bowl to hold the plastic wrap tight as he dated each bowl with the marker in his right hand. -CK #1 did not perform hand hygiene after removing his gloves and prior to touching the pudding bowls. Between 4:36 p.m. and 5:05 p.m. CK #1 touched his face multiple times while preparing the meals. Without performing hand hygiene while he plated ready-to-eat resident meals of hamburgers, burritos and vegetable pot pie. At 4:52 p.m. CK #1 left the service line with gloved hands and opened and closed the walk-in refrigerator. With the same gloved hands he retrieved a block of plastic wrapped pre-sliced cheese. CK #1 unwrapped the cheese and removed a slice with the same gloved hands and placed the slice of cheese on a hamburger patty for a resident meal. CK #1 did not perform hand hygiene or change his gloves before he touched the slice of cheese. At approximately 5:00 p.m., CK #1 removed two tortillas from a bag. He placed one tortilla on the grill. CK #1 held the second tortilla in his hand as the tortilla touched the front surface of his apron before placing it on the grill. At 5:12 p.m. CK #1 used the index finger of his gloved left hand to push his glasses closer to his face, without performing hand hygiene, he continued to plate meals III. Staff interviews CK #1 was interviewed on 10/16/24 at 4:05 p.m. CK #1 said all the cans of food in storage should be free from dents and punctures because of the risk of potential food poisoning. CK #1 was interviewed on 10/16/24 at 5:35 p.m. CK #1 said the garden salad was kept on ice until it was placed to make sure it was served at a safe and palatable temperature. He said the salad had cheese on it and he did not want the salad to have a chance to grow bacteria if it was not kept at or below 41 degrees F. He said the garden salad should have been kept cold. He said he hoped staff would not set the hot box food cart on the highest setting or plug in the hot box so the salad temperature would not rise too high while in the hot box with warm food. CK #1 said hand hygiene should be done every time he touched surfaces that were not food related. He said he should not open the refrigerator door and then touch food without hand hygiene. The registered dietitian (RD) was interviewed on 10/17/24 at 12:26 p.m. The RD said she had not provided education for the dietary staff or kitchen oversight in the two months she had been at the facility but would welcome the opportunity. The DM was interviewed 10/17/24 at 5:21 p.m. The DM said CK #1 needed to have something put in place so his glasses so he would not continue to adjust them during meal service with his gloved hands. The DM said hand hygiene should be conducted every time a potentially contaminated surface touched gloved hands during meal preparation and service. She said she would review the facility ' s hand hygiene protocol with CK #1. She said food she not touch potentially contaminated surfaces such as CK #1 apron. The DM said she was the one who would usually put away food cans on the supply shelf and make sure there were no dents on the cans. She said for a short time she was not available to put away the cans on the shelf so the other dietary staff placed the food cans on the shelf after the cans were delivered to the facility. The DM said she had not provided education to staff not to put away cans with dents on the shelf because she was usually the one who did it. She said she would create an education, informing the dietary staff of risk of food borne illnesses to the residents from dented cans. She said dents in the can could break the seal of the can causing potential contamination of the food inside the can. The DM said she would establish a routine check of the food can stock.

Based on resident interviews, staff interviews, and observations, the facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature. Specifically, the facility failed to consistently serve foods at a palatable texture. Findings include: I. Facility policy and procedure The Critical Temperatures for Safe Food Handling policy, undated, was provided by the dietary manager (DM) on 10/17/24 at 5:44 p.m. The policy read in pertinent part, Temperature should be taken periodically to assure hot food stays above 135 degrees Fahrenheit (F) and cold food stays below 41 degrees F during the serving process. Maintain a cold enough holding temperature to assure foods are maintained at or below 41 degrees F until they leave the service area. The Food and Nutrition Services Staff policy, undated, was provided by the DM on 10/17/24 at 6:21 p.m. The policy read in part, Food will be palatable, attractive and served in a timely manner at proper temperatures. II. Resident interviews Resident #28 was interviewed on 10/14/24 at 3:50 p.m. He said the food was not palatable. He said he ate in the dining room and the food was often served cold when it should be warm. He said he would eat a lot of sandwiches because he did not like being served cold food. Resident #39 was interviewed on 10/14/24 at 3:58 p.m. She said she ate in her room and food was often delivered to her cold. Resident #15 was interviewed on 10/14/24 at 5:17 p.m. He said he always ate his food in his room and was served cold food often. He said he was served cold food for breakfast on 10/14/24 and cold food for lunch on 10/13/24. III. Resident group interview A group interview was conducted on 10/16/24 at 10:32 a.m. with five alert and oriented residents (#2, #8, #15, #16 and #21) through facility and assessment. Four (#2, #8, #15, and #21) of the residents in the group interview said the food was served cooler than their preference. Resident #21 said he felt the dinner meals tended to be cold when he received the meal tray in his room. Resident #2 said she frequently saw the hot box mobile food cart door left open when staff served room trays. She said the food was served covered in plastic wrap instead of hard cover lids to maintain the heat. IV. Observations During a continuous observation of the dinner meal service on 10/16/24, beginning at 3:55 p.m and ending at 5:22 p.m., the following was observed: At approximately 4:35 p.m. cook (CK) #1 placed a container of garden salad on top of a container filled with ice and took the temperature of the salad. The garden salad registered a temperature of 41 degrees F. CK #1 said 41 degrees was the highest temperature the salad could be held at. At 4:43 p.m. meal service began and staff proceeded to cover room tray plates with plastic wrap and place them into the hot box mobile food cart. At 5:01 p.m. the hot box cart left the dining room for the room tray meal service. Between 5:02 p.m. and 5:08 p.m. the hot box cart door was left open while staff served room trays. The hot box cart was not plugged into an electrical outlet to maintain the heat of the meals trays left in the cart. A test tray for a regular diet was evaluated by two surveyors immediately after the last resident had been served their room tray for dinner on 10/16/22 at 5:23 p.m. The test tray consisted of vegetable pot pie and a garden salad with cheese, tomatoes and lettuce. The salad was served on the same plate as the pot pie. -The lettuce and tomatoes were slightly warm in touch and taste. The salad was 85.2 degrees F. -The vegetable pot pie was lukewarm. The vegetable pot pie was 107 degrees F. V. Staff interviews CK #1 was interviewed on 10/16/24 at 5:35 p.m. CK #1 said the garden salad was kept on ice until it was served to make sure it was served at a safe and palatable temperature. He said the salad had cheese on it and he would not want the salad to have a chance to grow bacteria if it was not kept at or below 41 degrees F. CK #1 said he would not want to eat a warm salad. He said the garden salad should have been kept cold. He said he hoped staff would not set the hot box food cart on the highest setting or plug in the hot box so the salad temperature would not rise too high while in the hot box with warm food. The DM was interviewed on 10/17/24 at 5:21 p.m. The DM said food could not be held in the danger zone to prevent bacteria growth. She said the temperature danger zone was a range of over 41 degrees F and under 135 degrees F. The DM said she wanted food to be held at between 145 degrees F and 165 degrees to make sure food was served warm. The 10/16/24 observations were reviewed with the DM. She said placing the garden salad in the hot box for room service would raise the temperature of the salad. She said the staff should have placed the salad in a container on ice during room service to help maintain the temperature for a cold salad. She said the cheese on the garden salad was dairy which could quickly become compromised with an increased temperature. The DM said hot foods such as the vegetable pot pie should be served at a warm palatable table. She said the hot box should be plugged in during room tray delivery and the door should be closed after each retrieval of a room tray and kept shut to maintain the temperature of the hot food items.

Based on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to answer call lights in a timely manner for residents requesting staff assistance. Findings include: I. Facility policy The Staffing policy, revised October 2017, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. The policy read in pertinent part, Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Other support services are also staffed to ensure that resident needs are met. II. Resident council meeting minutes The July 2024 resident council meeting minutes documented call lights were addressed as a concern. According to the meeting minutes, call lights were not always timely. The action item on the meeting minutes, the resident council was informed by the facility that some residents required two staff members for transferring, potentially taking the certified nurse aides (CNA) a little longer to answer the call lights. -The July 2024 resident council meeting minutes did not identify what the facility was going to do to address the residents' concern of untimely call light times. Cross reference F565 for failure to follow up on group grievances. III. Facility assessment The facility assessment, dated 10/1/24, was provided by the nursing home administrator (NHA) on 10/14/24 at 10:08 a.m. The facility assessment documented the care needs of 40 residents in the facility. The facility assessment documented that the 100 and 200 halls required one licensed nurse and two CNAs to care for the 18 residents residing on both halls during the day shift. It documented that the night shift on 100 and 200 halls also required one nurse and one CNA. It documented the 300 and 400 halls required one nurse and two CNAs to care for the 22 residents residing on both halls during the day shift. It documented the night shift on the 300 and 400 halls also required one nurse and one CNA. The facility assessment documented that 18 residents required moderate assistance with personal hygiene and 14 residents required maximal assistance or were dependent on nursing staff for personal hygiene care. The assessment documented 21 residents required moderate assistance with bathing and 14 residents required maximal assistance or were dependent on nursing staff for bathing assistance. The assessment documented six residents required moderate assistance with their toileting program and 17 residents required maximal assistance or were dependent on staff for assistance with their toileting program. IV. Nursing staff time card and pay stub record review Nursing staff time cards and pay stubs were reviewed on 25 working days between 4/6/24 and 9/1/24. The review revealed the facility had only one bedside nurse working during the day shift on 4/6/24, 4/7/24, 4/21/24, 4/23/24, 5/20/24, 5/21/24, 5/27/24, 6/1/24, 6/9/24, 6/11/24, 6/29/24, 6/30/24, 8/30/24, 8/31/24 and 9/1/24. -However, the facility assessment documented the facility required two bedside nurses working during the day shift. -Additionally, the director of nursing (DON) said the facility required two bedside nurses working during the day shift (see DON interview below). V. Resident interviews Resident #8 was interviewed on 10/14/24 at 11:14 a.m. Resident #8 said she often had to wait 30 minutes to over an hour for her call light to be answered. Resident #8 said she and her roommate often requested help at the same time to get a more timely response from staff. Resident #8 said she waited most frequently in the afternoon for assistance. Resident #8 said she and many other residents had complained about slow call light response times to administration in the past but nothing had been done to improve call light response times. Resident #8 said she felt she was forgotten and unimportant to nursing administration. Resident #8 said the bedside nursing staff were working as hard as they could but they could not keep up with the residents' needs during the day. Cross-reference F565 for failure to follow up on group grievances. Resident #5 was interviewed on 10/14/24 at 2:12 p.m. Resident #5 said she often had to wait more than 30 minutes for staff to respond to her call light. Resident #5 said the nursing administration knew call light response times were slow but they were not doing anything to improve staffing in the facility. Resident #5 said she stopped using her call light as often if she felt she could do something independently. Resident #5 said she felt conflicted asking for help knowing other residents would not be cared for when she was offered assistance instead. Resident #28 was interviewed on 10/15/24 at 8:55 a.m. Resident #28 said he often waited more than 30 minutes for assistance from staff. Resident #28 said he required maximum assistance with most of his cares throughout the day. Resident #28 said he sometimes called for assistance before he actually needed it because he knew he would have to wait for a long time for the staff to come assist him. Resident #28 said he felt frustrated that nursing staff was always short staffed. Resident #23 was interviewed on 10/15/24 at 9:22 a.m. Resident #23 said she had sometimes waited more than 30 minutes for assistance from staff on many occasions in the past month. Resident #23 said she thought the facility was purposely staffed with as few nurses and CNAs as possible. Resident #23 said she felt less important than a nickel when it took staff so long to assist her. Resident #6 was interviewed on 10/16/24 at 9:09 a.m. Resident #6 said she often waited more than 30 minutes for assistance from staff. Resident #6 said she did not like waiting more than 30 minutes for assistance. Resident #6 said waiting long periods of time for staff assistance happened more frequently at night for her. VI. Call light records from 10/2/24 to 10/16/24 Call light records were provided by the nursing home administrator (NHA on 10/16/24 at 6:11 p.m. A 14 day sample of call light response times, from 10/2/24 to 10/16/24, identified the following: On 10/2/24, a total of 200 resident call lights were turned on for resident assistance Bedside nursing staff required more than 15 minutes to respond to 40 of those call lights, representing 20% of all call lights turned on by residents for the day. On 10/3/24, a total of 150 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 32 of those call lights, representing 21.3% of all call lights turned on by residents for the day. On 10/4/24, a total of 126 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 23 of those call lights, representing 18.2% of all call lights turned on by residents for the day. On 10/5/24, a total of 141 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 23 of those call lights, representing 16.3% of all call lights turned on by residents for the day. On 10/6/24, a total of 162 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 14 of those call lights, representing 8.6% of all call lights turned on by residents for the day. On 10/7/24, a total of 163 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 32 of those call lights, representing 19.7% of all call lights turned on by residents for the day. On 10/8/24, a total of 144 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 19 of those call lights, representing 13.2% of all call lights turned on by residents for the day. On 10/9/24, a total of 167 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 16 of those call lights, representing 9.6% of all call lights turned on by residents for the day. On 10/10/24, a total of 162 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 29 of those call lights, representing 17.9% of all call lights turned on by residents for the day. On 10/11/24, a total of 169 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 35 of those call lights, representing 20.7% of all call lights turned on by residents for the day. On 10/12/24, a total of 122 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 21 of those call lights, representing 17.2% of all call lights turned on by residents for the day. On 10/13/24, a total of 144 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 19 of those call lights, representing 13.2% of all call lights turned on by residents for the day. On 10/14/24, a total of 147 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 11 of those call lights, representing 7.5% of all call lights turned on by residents for the day. On 10/15/24, a total of 207 resident call lights were turned on for resident assistance. Bedside nursing staff responded to all call lights in 15 minutes or less on this day. On 10/16/24, a total of 130 resident call lights were turned on for resident assistance between midnight and 5:36 p.m. Bedside nursing staff required more than 15 minutes to respond to three of those call lights, representing 2.3% of all call lights turned on by residents during that time period. VII. Staff interviews The DON was interviewed on 10/17/24 at 10:27 a.m. The DON said it was normal to have two nurses working during the day and one nurse working at night. The DON said all of the nurses and CNAs in the facility were agency staff except for a few that were full time at the facility. The DON said she had experienced many difficulties in hiring staff at the facility.The DON said the cost of living where the facility was located presented a significant challenge for hiring staff. The DON said finding nursing coverage on all days and nights had been difficult for the facility. She said several administration staff, including herself, had worked night shift recently to ensure the facility had nursing coverage. The DON said the facility had seen an increase in the use of overtime hours for bedside staff recently. The DON said she had reviewed the resident call light logs provided to the survey team. She said call lights had been long recently and this was something the facility had been working on for several months. The DON said there was not an active and identified performance improvement plan regarding call light response time. The DON reviewed the resident call light log data for 10/15/24 and said she did not know why the facility recorded zero call lights over 15 minutes in length on that day. The DON said it was possible that additional administrative personnel, present for the survey, could have had a positive impact on call light response times seen during the recertification survey. The NHA was interviewed on 10/17/24 at 6:32 p.m. The NHA said he knew call light response times were contributing to falls in the facility. The NHA said if a resident had to wait too long for help, they might get impatient and attempt to get up unassisted. Cross reference F689 for failure to prevent accidents/hazards.

Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for four of ten resident rooms and one (#6) of two residents reviewed for accidents out of 26 sample residents, received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically the facility failed to: -Ensure tap water in the facility was kept within a safe temperature range; -Initiate a timely fall care plan and interventions to prevent falls for Resident #6; and, -Ensure Resident #6's neurological assessments were completed after the resident sustained an unwitnessed fall in her room on 8/21/24. Findings include: I. Failure to ensure safe water temperatures A. Professional reference According to the Consumer Product Safety Commission (CPSC) Safety Alert, Avoiding Tap Water Scalds, retrieved on 10/23/24 from https://www.cpsc.gov/s3fs-public/5098-Tap-Water-Scalds.pdf, The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five. The U.S. Consumer Product Safety Commission (CPSC) urges all users to lower their water heaters to 120 degrees Fahrenheit (F). B. Facility policy and procedure The Water Temperatures, Safety Of policy, revised December 2009, was provided by the nursing home administrator (NHA) on 10/17/24 at 4:17 p.m. The policy read in pertinent part, Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 112 degrees Fahrenheit (F) or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic water temperature checks and record the water temperature in a safety log. C. Observations and resident interviews The tap hot water temperatures from resident rooms were obtained on 10/17/24 between 10:05 a.m. and 10:23 a.m. The hot water in each resident room ran for approximately one minute prior to taking the water temperature. The hot water temperatures were as follows: -At 10:17 a.m. the water temperature from the sink in room [ROOM NUMBER] was 131 degrees F. The temperature gauges for the two facility hot water heaters were reviewed with the maintenance service director (MSD) at 3:42 p.m. The first hot water heater was located in the 100 hall. The hot water heater serviced the 100 hall (six) resident rooms. The temperature gauge of the hot water heater read 138 degrees F. The second hot water heater was located in the 400 hall and serviced the remainder of the facility rooms. The temperature gauge of the hot water heater read 140 degrees F. The tap hot water temperatures from resident room sinks and the one facility shower room were obtained on 10/17/24 between 3:50 p.m. and 4:00 p.m. The hot water temperature were as follows: -The shower room temperature registered 110 degrees F after one minute. -room [ROOM NUMBER] registered a hot water temperature of 130.8 degrees F after one minute. One resident who resided in room [ROOM NUMBER] said the water was hot and she was able to adjust the temperature with cold water, however, she said the staff usually helped her with everything she needed to do at the sink. The second resident who resided in room [ROOM NUMBER] said she had not had any problems with the hot water temperature from the sink. She said the water got warm but she was able to adjust the water temperature as needed. -room [ROOM NUMBER] registered a hot water temperature of 131 degrees F after one minute. The resident who resided in room [ROOM NUMBER] was bed bound. The resident said she did not use the sink in her room and the staff helped her with all of her activities of daily living (ADL) care. -room [ROOM NUMBER] registered a hot water temperature of 131.5 degrees F after one minute. The resident who resided in room [ROOM NUMBER] said he did not use the sink by himself. He said the staff would help him at the sink. D. Record review The resident room water temperature log was provided by the NHA on 10/17/24 at 4:17 p.m. The water temperature log documented water temperatures were taken weekly in random resident rooms, one to two rooms on each hall. Review of the resident room water temperatures from 9/19/24 to 10/14/24 revealed hot water temperatures ranged from 104 degrees F to 117 degrees F, excluding 10/2/24 when the hot water temperatures were documented as 75 degrees F (see interview below). E. Staff interviews The maintenance services director (MSD) was interviewed on 10/17/24 at 3:42 p.m. The MSD said hot water temperatures in resident rooms and the shower room should range between 100 degrees F and 112 degrees F. The MSD said he had limited training on the hot water heaters. He said if he had questions with the hot water heaters, he would contact the regional plant operations director. The MSD said he would not usually look at the temperature gauge of the water heaters. He said he mainly just made sure the water pressure was not too high or too low. He said he used resident room temperatures to determine the facility's hot water temperature range. The MSD was interviewed a second time during the above observations on 10/17/24 between 3:50 p.m. and 4:00 p.m. He said when he checked the hot water temperatures in the residents' rooms during his weekly audit, the temperatures were within an appropriate temperature range. He said he did not know what had changed since his last audit on 10/14/24. The MSD said he did not adjust anything with hot water temperatures and no one had expressed any concerns to him regarding the water temperatures being too hot. The MSD said he would immediately turn the hot water temperature down on the facility's hot water heaters based on 10/17/24 observations. The NHA was interviewed on 10/17/24 at 4:20 p.m. The NHA said the regional plant operations director was contacted and felt the mixing valve on the hot water heaters had gone out. The NHA said there was only one incident that was reported to him regarding the hot water heaters being too cold, not too hot. The NHA was interviewed a second time on 10/17/24 at 4:51 p.m. He said the MSD had temporarily shut the water off to the 100 hall. He said the MSD was in the process of draining the water and then would refill the hot water heater. The NHA said the hot water heater temperature setting would be lowered. He said a vendor was contacted but could not fix the mixing valve until 10/23/24. The NHA said the MSD would conduct frequent checks of the hot water until all repairs could be made. The NHA said the residents on the 100 hall were either bed bound, dependent on staff to assist them at the sink, or physically and cognitively able to adjust the water temperature to a safe and comfortable temperature. The operation manager (OM) was interviewed on 10/17/24 at 4:53 p.m. The OM said the facility had had some problems with the hot water heaters. He said one of the hot waters was not working but the other two were operational. He said the pilot light to one of the heaters was going out about once a month. He said a vendor was not contacted. He said the regional plant operations manager looked at the hot water heaters and did not see a concern. The OM said when the pilot light went out, the facility just relit it. He said the focus of the hot water heaters had been making sure the water was not cold, not that it was too hot. The OM and the DON were interviewed together on 10/17/24 at 6:32 p.m. The OM said he had not had any reports of hot water concerns. The DON said hot water temperatures over the recommended value increased the risk of burns to older adults. 50314 II. Failure to initiate a timely fall care plan and interventions to prevent falls and complete neurological assessments after a fall for Resident #6 A. Professional reference According to [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1780, retrieved on 10/21/24, In the event of a fall, perform a post-fall assessment to identify possible causes. Monitor patients closely for 48 hours after a fall. B. Facility policy The Fall Management System policy, dated June 2022, was obtained from the director of nursing (DON) on 10/17/24 at 10:57 a.m. It documented in pertinent part, A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force, such as a resident pushing another resident, whether the event was witnessed or unwitnessed. The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without an injury is still a fall. The distance to the next lower surface is not a factor in determining if a fall occurred. If a resident rolled off a bed or mattress that was close to the floor, it is still a fall. When a fall occurs, the resident is assessed for injury by the nurse. In the event a resident has a fall, and it has been determined they hit their head, or it cannot be determined if they hit their head (the fall was unwitnessed or the patient cannot verbalize if they hit their head), the nurse initiates the following actions: neurological checks are completed and documented per instructions. C. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included stroke, chronic obstructive pulmonary disease (COPD), and chronic kidney disease stage three. The 7/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was independent while eating, required substantial assistance with oral hygiene and was dependent on nursing staff for all other cares. D. Record review The fall care plan, initiated 8/26/24, documented that Resident #6 was a high fall risk. Interventions included anticipating resident needs, ensuring the resident's call light was within reach, educating the resident on what to do if a fall occurred, encouraging a helmet, which the resident frequently refused, encouraging the resident to participate in activities that promoted exercise, ensuring the resident was wearing appropriate footwear, placing a fall mat beside the resident's bed, providing a transfer pole beside the resident's bed and following the facility's fall protocol. Fall risk evaluation dated 2/5/24 documented the resident was at a high risk for falls. An interdisciplinary team (IDT) post fall review dated 2/5/24 documented Resident #6 experienced an unwitnessed fall on 2/5/24 at 1:24 a.m. -However, the facility failed to initiate a fall prevention plan of care and fall interventions until after the resident fell again on 8/21/24 (see care plan above). A fall risk evaluation dated 7/2/24 documented the resident was at a high risk for falls. A nurse progress note dated 8/21/24 documented that, at 4:10 p.m., Resident #6 was found on the floor and had reported she hit her head while trying to self-transfer. The progress note documented the DON and two certified nurse aides (CNA) asked Resident #6 if she hit her head and Resident #6 responded yes. The note documented the resident was able to express her concerns without issue. -Review of Resident #6's electronic medical record (EMR) did not reveal documentation which indicated neurological assessments were completed for the resident following her unwitnessed fall on 8/21/24. E. Staff interviews CNA #1 was interviewed on 10/15/24 at 3:41 p.m. CNA #1 said if a resident had an unwitnessed fall, she would get the nurse immediately to assess the resident while she obtained vital signs on the resident. CNA #1 said it was normal for nurses to perform neurological assessments frequently for 48 hours after a fall to ensure nothing happened to the resident. Registered nurse (RN) #1 was interviewed on 10/16/24 at 8:58 a.m. RN #1 said if a resident had an unwitnessed fall, the nurse would complete a neurological assessment and obtain vital signs. RN #1 said if a head injury was suspected or confirmed, neurological assessments would be performed on a regimented schedule for 48 hours. The DON was interviewed on 10/17/24 at 10:41 a.m. The DON said she was the nurse that responded when Resident #6 fell on [DATE]. The DON said ongoing neurological assessments were not completed for Resident #6 as part of the post-fall assessment. The DON said the ongoing neurological assessments should have been completed. The DON said that the facility had call light logs that were reviewed daily by the administration. The DON said longer call lights could contribute to an increase in the chance for falls. The DON said obtaining sufficient nurse staffing had been a difficulty for the facility. The DON said the facility was issuing more overtime to current nursing staff than before and administration had been covering night shifts on the floor to ensure appropriate nurse staff coverage. Cross-reference F725 for failure to provide sufficient nursing staff. The DON and the nursing home administrator were interviewed again on 10/17/24 at 6:32 p.m. The NHA said he knew call light response times were contributing to falls in the facility. The NHA said if a resident had to wait too long for help, the resident might get impatient and attempt to get up unassisted.

Based on record review and resident interviews, the facility failed to promptly address and attempt to resolve resident group complaints and grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to ensure residents felt their concerns with call light timeliness resulting in long waits for staff assistance were addressed and resolved. Findings include: I. Facility policy and procedure The Resident Council policy, undated, was provided by the nursing home administrator (NHA) on 10/17/24 at 6:04 p.m. The policy read in pertinent part, The purpose of the resident council is to provide a form for: residents families and resident representatives to input in the operation of the facility; discussion of concerns and suggestions for improvement; consensus building and communication between residents and facility staff; and, disseminating information and gathering feedback from interested residents. A resident council response form will be utilized to track issues and their resolutions. The facility department related to any issues will be responsible for addressing the items of concern. The quality assurance and performance improvement committee (QAPI) will review information and feedback from the resident council as part of their quality review. Issues documented on council response forms may be referred to the committee, if applicable. II. Resident group interview A group interview was conducted on 10/16/24 at 10:32 a.m. with five residents (#2, #8, #15, #16 and #21) the facility assessed and deemed as alert, oriented and interviewable. According to the group, the residents did not feel the facility addressed their concerns of long call light times. Resident #8 said she recently had to wait over an hour and a half before her call light was answered. She said she had to use the restroom and lay down in bed. She said she had horrible back pain but laying down usually helped. She said because she had to wait so long for assistance, it took a day for her to recover from the pain. Resident #2 said some of the nurses did not help answer call lights and relied on the certified nurse aides (CNA) to answer the call lights. She said last month (September 2024) she had to wait over an hour for her call light to be answered. Resident #16 said last Thursday (10/10/24) he had to wait from 4:15 a.m. to 6:00 a.m. for his call light to be answered. The group said the longest waits were usually during the night. III. Resident council minutes The July 2024 resident council minutes documented call lights were addressed as a concern. According to the minutes, call lights were not always timely. The action item on the minutes indicated the resident council was told some of the residents required two staff for transferring, potentially taking the CNAs a little longer to get to the call light. -The July 2024 council minutes did not identify what the facility was going to do to address the concern of inconsistent call light times. The July 2024 resident council grievance form for call light timeliness was requested but was not provided by the facility. The August 2024 and September 2024 resident council minutes did not document the July 2024 concern of inconsistent call light was reviewed with the resident council to determine whether the concern was resolved or not. IV. Call light record The electronic call light log between 10/2/24 and 10/15/24 was provided by the operations manager (OM) on 10/16/24 at 6:21 p.m. A five day sample of call light response time, from 10/1/24 to 10/14/24, identified the following: On Wednesday 10/2/24, a total of 200 total call lights were turned on for resident assistance. -40 of the call lights were activated for over 15 minutes before they were answered; -Six of the call lights were answered between 20 and 29 minutes; -14 of the call lights were answered between 30 and 39 minutes; -Two of the call lights were answered between 40 and 49 minutes; -Two of the call lights were answered between 50 and 59 minutes; and, -Three call lights were activated for over an hour before the resident's call light was answered. On Thursday 10/3/24, a total of 150 total call lights were turned on for resident assistance. -32 of the call lights were activated for over 15 minutes before they were answered; -Seven of the call lights were answered between 20 and 29 minutes; -Three of the call lights were answered between 30 and 39 minutes; -Seven of the call lights were answered between 40 and 49 minutes; and, -Two of the call lights were answered between 50 and 59 minutes. On Sunday 10/6/24, a total of 162 total call lights were turned on for resident assistance. -14 of the call lights were activated for over 15 minutes before they were answered; -Seven of the call lights were answered between 20 and 29 minutes; -One call light was answered between 30 and 39 minutes; and, -One call light was activated for over an hour (one hour and 33 minutes) before the resident's call light was answered. On Monday 10/7/24, a total of 162 total call lights were turned on for resident assistance. -32 of the call lights were activated for over 15 minutes before they were answered; -12 of the call lights were answered between 20 and 29 minutes; -Two of the call lights were answered between 30 and 39 minutes; and, On Monday 10/14/24, (the first day of the survey period) a total of 200 total call lights were turned on for resident assistance. -11 of the call lights were activated for over 15 minutes before they were answered; -Three of the call lights were answered between 20 and 29 minutes; -One call light was answered between 30 and 39 minutes; -One call light was answered between 40 and 49 minutes; and, -Two call lights were activated for over an hour before the resident's call light was answered. V. Staff interviews The activity director (AD) was interviewed on 10/17/24 at 5:00 p.m. The AD said during resident council, the prior resident council concerns were reviewed each month to determine if the concern was resolved or still an ongoing concern. She said the status of the concern would be documented in the minutes. The AD said if the resident council had a new concern or an unresolved concern that was ongoing, she would add the concern to a grievance form. She said the grievance would be submitted to the appropriate department to address the council. The completed grievances would be turned in to the social service director (SSD). The AD said she was not in her position in July 2024 when the resident council brought up the concern of inconsistent call light timeliness. The AD said she would not have known of the call light concern in July 2024 to review in the August 2024 resident council because she was new to her position and was not aware of the July 2024 call light concern. She said she did not review the July 2024 resident council concerns prior to the August 2024 council meeting. The social service director (SSD) said was responsible for filing all grievances from residents and resident council. The SSD said she had not received a call light grievance from the July 2024 resident council meeting. The operations manager (OM) and the NHA was interviewed on 10/17/24 6:32 p.m. The OM said resident feedback was how the facility determined if resident council concerns were appropriately addressed and resolved. He said the concern would be brought up the following to determine if the concern was resolved. He said if the resident council felt the concern remained unresolved, a new grievance would be submitted and addressed for resolution until the resident said they were satisfied. The NHA said call light timeliness was reviewed in QAPI on 10/17/24 (during the survey). The NHA said interdisciplinary team (IDT) reviewed the electronic call light logs and determined more the facility needed to do call light spot audits.

Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents reviewed out of 26 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically, the facility failed to: -Accurately obtain and document Resident #6's weights; and, -Weigh Resident #6 per physician's orders. Findings include: I. Facility policy and procedure The Nutritional Assessment policy, revised October 2017, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part, As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. II. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included stroke, chronic obstructive pulmonary disease (COPD) and chronic kidney disease stage three. The 7/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was independent while eating, required substantial assistance with oral hygiene, and was dependent on nursing staff for all other cares. The assessment documented Resident #6 had no rejections of care. The assessment documented the resident was 65 inches (5 foot, 5 inches) tall. The assessment documented the resident weighed 253 pounds (lbs). The assessment documented the resident had not experienced weight loss in the last six months. B. Record review The nutrition care plan, initiated on 8/26/16 and revised 1/11/2020, revealed Resident #6 and Resident #6's family were non-compliant with diabetes management and had received education previously. The care plan documented interventions included avoiding exposure to extreme heat or cold, to check the body for breaks in skin and provide treatment promptly, providing diabetes medications as ordered by the physician, providing a dietary consult for nutritional regimen and ongoing monitoring, discussing meal times and portion sizes, educating Resident #6 regarding the importance of dietary compliance, and educate Resident #6 and family as to the correct protocol for glucose monitoring and insulin injections. Resident #10's weights were documented in the electronic medical record (EMR) as follows: -On 4/28/24, the resident weighed 253.2 lbs; -On 5/6/24, the resident weighed 252.0 lbs; -On 6/2/24, the resident weighed 253.0 lbs; -On 9/18/24, the resident weighed 213.5 lbs; -On 9/27/24, the resident weighed 213.0 lbs; and, -On 10/7/24, the resident weighed 214.5 lbs. -The facility failed to accurately subtract the weight of the wheelchair on 4/28/24, 5/6/24 and 6/2/24 (see facility follow-up below). A review of physician's orders in the EMR revealed a physician's order to obtain Resident #6's weight weekly on Sundays for four weeks, then to obtain Resident #6's weight per facility protocol, ordered on 4/7/24 and discontinued on 10/14/24. -The facility failed to obtain and document Resident #6's monthly weight per physician's order in July 2024 and August 2024 . The 1/4/2020 comprehensive nutritional assessment documented Resident #6's admission weight was 257 lbs and Resident #6's usual body weight was 250 pounds. The 4/12/24 nursing at risk review note, dated 4/12/24, documented the resident was consistently eating less than 25% of all meals. The 6/20/24 nutritional assessment documented there were no significant changes with Resident #6's weight recently. The assessment documented the resident was consistently eating 75% to 100% of all meals. -The facility failed to accurately subtract the weight of the wheelchair on 4/28/24, 5/6/24 and 5/2/24 (see facility follow-up below). The 9/18/24 nursing at risk review note documented Resident #6 weighed 213.5 pounds. The note documented this was a weight gain from July 2024. -However, a review of the resident's EMR did not include documentation indicating the facility weighed the resident in July 2024. Facility weight performance improvement plan (PIP) documentation, dated 9/6/24, was provided by the director of nursing (DON) on 10/16/24 at 3:19 p.m. It documented that the facility identified a need to improve the accuracy of documented weights. It documented that education was provided to bedside nursing staff regarding appropriate equipment usage and documentation. III. Staff interviews The registered dietitian (RD) was interviewed on 10/17/24 at 11:46 a.m. The RD said she had been in her role for two months. The RD said that she was present in the building every other week on Wednesdays. The RD said that she created nutritional recommendations by interviewing staff on how the resident is doing, interviewing residents themselves, and by reviewing the electronic health record. The RD said when a resident experienced weight loss the care plan should be updated, the dietitian and family should be notified, and new interventions to reduce or prevent the weight loss should be put into place. The RD said she had an internal spreadsheet that tracked residents for which she had concern for weight loss or weight gain in the facility. The RD said Resident #6 was not identified as having a concern with weight loss. The director of nursing (DON) was interviewed on 10/17/24 at 12:20 p.m. The DON said she expected all residents to be weighed monthly unless there was a physician's order that indicated otherwise. The DON said Resident #6's weight loss was expected and the physician was aware of the weight loss. The DON said Resident #6 was not identified as having weight loss in interdisciplinary (IDT) team meetings. The DON said the facility had implemented a performance improvement plan for obtaining and documenting accurate resident weights in the facility on 9/6/24. -However, the facility provided additional documentation indicated t the weight discrepancy was because nursing staff inaccurately obtained and recorded Resident #6's weight on 4/28/24, 5/6/24, and 6/2/24 (see facility follow-up below). IV. Facility follow-up Additional documentation was received from the DON on 10/21/24 at 2:09 p.m. (after the survey). The facility documentation documented that Resident #6 had not experienced severe weight loss because the weights were obtained and recorded inaccurately. The facility documentation indicated Resident #6's wheelchair weighed 43.5 lbs and this was not correctly subtracted from weights recorded on 4/28/24, 5/6/24 and 6/2/24. The facility documentation indicated an additional weight was obtained in the month of July 2024. -However, no verification that this was completed was included in the submitted documentation. No verification of Resident #6's wheelchair weight was included in the submitted documentation or in the resident's EMR.

Based on observations, record review and interviews, the facility failed to ensure one (#15) of three residents reviewed for activities out of 26 sample residents received individualized activities in accordance with standards of care. Specifically, the facility failed to offer Resident #15 activities in Spanish, which was his preferred language. Findings include: I. Resident #15 A. Resident status Resident #15, age greater than 65, was admitted on [DATE] and readmitted [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included kidney failure, bipolar disorder and type 2 diabetes. According to the 7/17/24 minimum data set (MDS) assessment, Resident #15 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent in completing all activities of daily living. According to the 1/15/24 MDS assessment, it was very important for Resident #15 to have books, magazines and newspapers to read., listen to music he liked., do his favorite activities, go outside and get fresh air when the weather was good and participate in religious services. B. Resident interview and observation Resident #15 was interviewed, in Spanish, on 10/14/24 at 3:18 p.m. Resident #15 said he was raised speaking Spanish only and his preferred language was Spanish. Resident #15 said he understood some phrases and words in English, but he was not fluent in English. Resident #15 said he had not been provided with activities in the Spanish language. Resident #15 said he was given word finding books but they were all in English. Resident #15 presented four different word finding books from his bedside table that were written in the English language. Resident #15 said he enjoyed speaking Spanish with the housekeeping staff when he could but they were often too busy to talk to him. Resident #15 said he had no memory of any activity being provided to him in the Spanish language. Resident #15 said he often felt forgotten because he was the only resident who spoke Spanish primarily at the facility. C. Additional observation The posted facility activity board for the month of October was observed on 10/16/24 at 11:04 a.m. The activity board did not include any activities in the Spanish language for the month of October 2024. D. Record review Resident #15's activity plan of care, initiated on 7/5/21 and revised 10/24/23 revealed a goal for Resident #15 to participate in activities three to five times per week. It documented Resident #15's in-room interests were television and crossword puzzles. Other activity interests included bingo, movies, church, yahtzee and memory card games. The activity plan of care documented Resident #15 spoke the Spanish and English language, but preferred Spanish. Resident #15's activity participation record was reviewed for 30 days, between 9/16/24 and 10/16/24. The facility had initiated activity participation records including spiritual activities, outings, sensory activities, social activities, one on one visits, visits from friends and family, cognitive activities and creative activities. -The activity participation record failed to reveal any resident-centered Spanish activities were provided to Resident #15 between 9/16/24 and 10/16/24. II. Staff Interviews Certified nurse aide (CNA) #1 was interviewed on 10/15/24 at 10:11 a.m. CNA #1 said Resident #15 spoke Spanish and English. CNA #1 said Resident #15 did not need language services or activities in Spanish because he spoke English. Registered nurse (RN) #1 was interviewed on 10/16/24 at 8:41 a.m. RN #1 said there was no communication barrier between Resident #15 and staff because Resident #15 spoke English fluently. -However, despite CNA #1 and RN #1 indicating Resident #15 spoke English fluently and therefore did not need language services and activities in Spanish, the resident expressed that he preferred to receive activities in his preferred language of Spanish (see resident interview above). The activity director (AD) was interviewed on 10/17/24 at 1:14 p.m. The AD said her role was to engage the residents in activities that gave them purpose and meaning and kept them from being bored. She said she would ask the residents what they enjoyed doing and add their interests onto the activity calendar. She said she tried to find activities that were similar to the residents' past leisure pursuits. The AD said the activity program did not have activities specific for Spanish-speaking residents. She said once a year the facility celebrated Spanish heritage month. The AD said Resident #15 could speak, read and write in English. She said an activity for Spanish-speaking residents could have been created, however, she said nobody had expressed to her that it was a need. The AD said she had access to Resident #15's care plan but she was not aware that he would want activities that were Spanish specific. She said she did not ask him if he wanted activities and/or reading materials in Spanish. She said he attended bingo, resident council meetings and Catholic church services. The AD said the activities Resident #15 attended were in English and he participated without concern. The director of nursing (DON) was interviewed on 10/17/24 at 10:27 a.m. The DON said there was no documentation that the facility had provided Resident #15 with activities in the Spanish language. The DON said she thought Resident #15 spoke fluent English. The DON said she was not aware Resident #15 wanted activities provided to him in the Spanish language. The DON said the facility had a language interpreter line available to staff if they needed to reach an interpreter for resident communication needs.

Based on observation and interviews, the facility failed to ensure one (#12) of one of 26 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #12's blood pressure was measured appropriately in accordance with medical standards of practice. Findings include: I. Professional reference How to measure your blood pressure at home fact sheet, dated 2020, was retrieved on 10/21/24 from the American Heart Association medical archives at https://www.heart.org/-/media/Files/Health-Topics/High-Blood-Pressure/measuringbpathome.pdf It documented that the blood pressure cuff should be positioned on the bare arm above the elbow in the middle of the arm. II. Facility policy and procedure The Blood Pressure, Measuring policy, revised September 2010, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part, Expose the resident's arm by rolling the sleeve up about five inches above the elbow. II. Observation On 10/17/24 at 8:42 a.m. registered nurse (RN) #2 was taking Resident #12's blood pressure. Resident #12 was wearing a pink fleece sweater and offered to roll up her sleeve for the blood pressure measurement. RN #2 declined Resident #12's offer and said that she could take a blood pressure over the clothing items because she had good ears. RN #2 then placed the blood pressure cuff on Resident #12's upper arm over the pink fleece sweater to obtain the blood pressure measurement. RN #2 then documented the blood pressure measurement in the electronic medical record (EMR). III. Staff interviews RN #2 was interviewed on 10/17/24 at 8:51 a.m. RN #2 said that it was normal and acceptable to obtain a resident's blood pressure over clothing. RN #2 said obtaining a blood pressure in this manner would not affect the accuracy of the blood pressure measurement. The director of nursing (DON) was interviewed on 10/17/24 at 4:08 p.m. The DON said that a blood pressure device could be placed over resident clothing to obtain an accurate blood pressure if the clothing was thin. The DON said she did not know if Resident #12's pink fleece sweater would be thick enough to affect the blood pressure measurement. The DON reviewed the American Medical Association and American Heart Association recommendations for obtaining an accurate blood pressure reading (see professional reference above). The DON said she did not know the American Heart Association recommendations included placing the blood pressure measurement device on the bare arm for accurate measurement.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#1) of three residents reviewed for pressure ulcers out of 39 sample residents. Resident #1, who was known to be at risk for pressure injuries, was admitted on [DATE] and readmitted on [DATE]. The resident had diagnoses of multiple sclerosis (disabling disease of brain and spinal cord), neurogenic bladder and metabolic encephalopathy (brain disorder caused by chemical imbalance of the blood). Hospital documentation recommended treatment for the wounds which were present to the Resident #1's sacrum, right lower extremity and left lower extremity upon the resident's readmission to the facility on [DATE]. The recommendations further indicated the resident was to follow up with outpatient wound care. However, the facility failed to initiate a care plan and interventions to prevent the development of pressure injuries until 5/11/24. On 5/6/24, Resident #1 developed a stage 2 pressure injury to the right heel which worsened to a stage 4 pressure injury on 6/28/24. The resident developed a second stage 2 pressure injury to the right lateral (outside) heel on 5/17/24 which worsened to a stage 4 pressure injury on 7/2/24. Resident #1's pressure injury care plan was not updated until 7/2/24, despite the resident having developed a second stage 2 pressure injury to her right lateral heel. Review of the resident's electronic medical record (EMR) did not reveal documentation to indicate the physician was notified when the resident's two stage 2 pressure injuries worsened to stage 4 pressure injuries. Additionally, the facility failed to assess Resident #1's wounds weekly between 5/6/24 to 5/17/24 and again between 6/19/24 to 6/28/24. Due to the facility's failure to implement timely interventions to prevent the development of pressure injuries and the facility's failure to implement additional interventions following pressure injury development, Resident #1 developed two facility-acquired stage 2 pressure injuries, which worsened to stage 4 pressure injuries. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 8/5/24 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin Management policy and procedure, dated June 2022, was provided by the nursing home administrator (NHA) on 7/30/24 at 1:43 p.m. It read in the pertinent part, Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new pressure injuries from developing. In accordance with CMS guidelines, 'unavoidable' means that 'the resident developed a pressure injury even though the center had evaluated the resident's clinical condition and pressure injury risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.' All of this must be clearly defined in the resident's medical record. Upon admission or readmission, residents are assessed for skin integrity by completing a head-to-toe physical assessment of skin condition and completing the Braden scale for predicting pressure sore risk under defined assessment (UDA) in conjunction with the new admission nursing data collection set (UDA). Following admission, the braden scale for predicting pressure sore risk will be completed weekly for 3 (three) additional weeks (for a total of 4 (four) weeks, including admission), quarterly, annually, and with a significant change of status to determine the risk for development of pressure injuries. Appropriate preventative surfaces (beds, wheelchairs) will be implemented for residents identified at risk. Interventions are documented on the care plan. Residents admitted with skin impairment will have interventions to promote healing. A care plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis and neurogenic bladder. The 7/12/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident was dependent on staff for dressing, toileting hygiene, personal hygiene, bathing, and putting on/taking off footwear. The assessment documented the resident required maximal assistance with turning side to side in bed. The assessment indicated the resident was at risk for pressure ulcers and had stage 2 and stage 4 pressure ulcers that were not present on admission/readmission. The assessment indicated the resident did not reject care. B. Resident observations On 7/30/24 at 10:38 a.m. Resident #1 was lying in her bed. Resident #1 had a wrapped dressing on her right foot. She did not have compression stockings or shoes on her feet. On 7/30/24 at 2:37 p.m. Resident #1's wound care was observed with the director of nursing (DON), the assistant director of nursing (ADON) and certified nurse aide (CNA) #1. The resident's right heel had an open wound with visible white bone measuring 2.8 cm (centimeters) long, 2.0 cm wide and 1.0 cm deep. The resident had a second wound visible on the bottom of the foot which was not open. The second wound on the bottom of the foot was dark purple in color and was nonblanchable on assessment. The second wound on the bottom of the foot measured 1.2 cm long and 1.0 cm wide. Resident #1 was not observed to exhibit verbal or nonverbal signs of pain or discomfort during the wound dressing change. C. Resident Interview Resident #1 was interviewed on 7/30/24 at 10:41 a.m Resident #1 said she had developed two pressure ulcers at the facility that she felt were avoidable. Resident #1 said she did not always receive weekly skin assessments and the facility did not provide her with the specialty shoes she was promised by nursing staff. Resident #1 said a few months ago she was walking and able to perform several complex self care activities. Resident #1 said she developed the first pressure ulcer on her right heel a few months ago (May 2024) and lost the ability to stand and perform her self-care activities in April 2024. Resident #1 said she felt very angry that she had lost so much of her independence in such a short period of time. Resident #1 was interviewed again on 7/30/24 at 3:58 p.m. Resident #1 said she did not feel pain or discomfort during the wound dressing change earlier today (7/30/24). Resident #1 said she did not normally need pain medication during her foot wound dressing changes because she could not always feel pain in her feet. Resident #1 said she did not reject care. Resident #1 said she did not refuse to exit her wheelchair but had fallen asleep in her wheelchair frequently with her shoes on in the past few months because she could not stand with her heel pressure wounds and staff did not always wake her up to assist her in transferring back into her bed. Resident #1 said she wished staff had tried to wake her up and assisted her with removing her shoes. Resident #1 said this had not been a problem for the last month or so because she did not currently have any shoes to wear for any situation. Resident #1 said she had been bed and wheelchair bound for the last month (July 2024). Resident #1 said she required assistance from staff and a mechanical lift to get in and out of bed. Resident #1 said she had not refused to remove her compression stockings because it was important for her to wear them to help her legs with swelling. Resident #1 said the swelling in her legs is what created leg wounds for her and it had been identified by a doctor in the hospital in March 2024 as a way to prevent pressure sores from occurring. D. Record review Hospital documentation, dated 3/12/24, revealed Resident #1 had wounds on her sacrum, left lower extremity, and right lower extremity. The documentation recommended cleansing sacral wounds daily and as needed for soiling and covering the wound with an optifoam sacral dressing. The documentation recommended wearing tubigrip compression wrappings daily for the left lower extremity wound. The documentation recommended silvasorb covered with a foam dressing over partially open wounds and tubigrip compression wrappings to the right lower leg. The documentation further recommended that Resident #1 elevate her lower extremities with pillows, turn frequently to offload pressure from her sacrum, and follow up with outpatient wound care. -Review of Resident #1's EMR did not reveal documentation to indicate the resident had been scheduled to follow up with outpatient wound care per the physician's recommendations. -Review of the resident's EMR further revealed there was no head to toe skin assessment conducted on 3/17/24 upon the resident's readmission to the facility. A head to toe skin assessment, dated 3/24/24, documented Resident #1 had intact skin. -However, according to hospital documentation prior to the resident's readmission on 3/17/24, Resident #1 had wounds on her sacrum, right lower extremity and left lower extremity (see hospital documentation above). A head to toe skin assessment, dated 3/31/24, documented the resident had intact skin. It documented the resident had blanchable redness to the coccyx and a treatment was in place to an area on Resident #1's right leg. -The assessment failed to document the skin condition on Resident #1's right leg. -The facility failed to implement a pressure ulcer prevention plan of care after identifying an area of redness on the resident's coccyx (see care plan below). Resident #1's pressure ulcer care plan, initiated on 5/11/24 (after the resident developed the first stage 2 pressure wound on 5/6/24) and updated on 7/18/24, documented the resident had a pressure ulcer related to edema and the resident was refusing to remove her shoes and compression stockings. The identified interventions included adding an air mattress to the resident's bed, compression stockings for edema management, providing the resident with a DARCO boot (specialized footwear designed to promote foot wound healing), educating the resident about proper skin care to prevent skin breakdown, providing education on the importance of elevating extremities, encouraging the resident to elevate legs for edema management, encouraging the resident to avoid lying on her back and rolling side to side as tolerated, evaluating ulcer characteristics, monitoring ulcer characteristics for signs of progression or declination, notifying the provider if no signs of improvement on current wound regimen, offloading shoes as needed, providing wound care per treatment orders, referring the resident to a specialized practitioner for wound management, using enhanced barrier precautions and using a temporary wheelchair with elevating foot pedals. -However, the resident did not receive the DARCO boot (see resident observation and interview above and ADON interview below). A Braden Scale for predicting pressure sore risk assessment was completed on 4/12/24, 6/17/24, and 7/25/24. All three assessments documented the resident was at risk for developing pressure ulcers. All three assessments documented the resident had no sensory deficit which would limit her ability to feel pain or voice discomfort. -However, the resident was diagnosed with multiple sclerosis and metabolic encephalopathy which the facility said could impact the resident's sensation (see interview below) and the resident said she did not normally feel pain in her feet (see resident interview above. Resident #1's progress notes were reviewed for documented rejections of care between 5/6/24 and 7/21/24. The resident was documented to refuse returning to bed on five occasions, refusing to elevate her legs on 14 occasions and refusing to remove her shoes or compression stockings on three occasions. -There was no documentation to indicate the facility had reoffered care to the resident on the occasions she refused care or that education was provided to the resident regarding the potential outcomes to skin integrity related to refusing care. -Additionally, the facility failed to update the resident's pressure ulcer care plan to reflect the reason the resident occasionally refused care or document the reasons the resident refused the care. A skin pressure injury note, dated 5/6/24, documented the resident had a stage 2 pressure ulcer to the right heel measuring 1.5 cm long, 4.0 cm wide and 0.3 cm deep. The note documented interventions included a pressure reducing mattress and a pressure reducing cushion. -However, the facility failed to implement a pressure injury care plan until 5/11/24, five days after the pressure injury was identified. -Additionally, the facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24 when a performance improvement plan (PIP) for wounds was implemented (see interviews below). -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the new pressure injury. A weekly skin pressure injury note, dated 5/17/24, documented the resident had a stage 2 pressure ulcer to the right heel measuring 1.5 cm long, 3.0 cm wide and 0.3 cm deep. The assessment further documented a second pressure wound on the resident's right lateral foot measuring 0.5 cm long, 0.5 cm wide and 0.2 cm deep. The note documented interventions included a pressure reducing mattress and a pressure reducing cushion. -The facility did not conduct the weekly skin assessment until 11 days after the previous assessment on 5/6/24. -The facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24 when a PIP for wounds was implemented (see interviews below) -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the new pressure injury. -The assessment failed to identify new interventions to prevent the deterioration of current skin conditions identified by nursing staff. A weekly skin pressure injury note, dated 5/23/24, documented the resident had a stage 2 pressure ulcer to the right heel that had not improved or worsened. The assessment documented the second pressure wound on the right lateral foot had deteriorated and now measured 0.6 cm long, 0.6 cm wide and 0.2 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. -The facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24. A weekly skin pressure injury note, dated 5/30/24, documented the resident had a stage 2 pressure ulcer to the right heel that had deteriorated and now measured 1.6 cm long, 3 cm wide and 0.3 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was now an unstageable wound measuring 1.0 cm long, 1.3 cm wide and had an unknown depth. The assessment documented the wound on the right lateral foot had approximately 50% eschar. (dead skin tissue) -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. -The facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24. A weekly skin pressure injury note, dated 6/6/24, documented the resident had a stage 2 pressure ulcer to the right heel that had improved and now measured 1.5 cm long, 2.1 cm wide and 0.3 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was now a stage 3 pressure wound measuring 1.5 cm long, 2.8 cm wide and was 0.3 cm deep. The assessment documented Resident #1 would supinate (to face a part of the body upwards) her feet which contributed to the deterioration of the wounds. The assessment documented Resident #1 would sleep in her wheelchair all day and all night, would refuse to elevate her legs, and would refuse to remove her shoes or compression stockings. The assessment documented the resident would often refuse to bathe which resulted in poor skin health. -However, Resident #1 was only documented to refuse to return to bed on five separate occasions between 5/6/24 and 7/21/24 and refusing to remove her shoes on three occasions between 5/6/24 and 7/21/24. -The facility failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. A weekly skin pressure injury note, dated 6/15/24, documented the resident had a stage 2 pressure ulcer to the right heel that had deteriorated and now measured 1.5 cm long, 3 cm wide and 0.3 cm deep. The assessment documented the second pressure wound on the right lateral foot had improved and was a stage 3 pressure wound measuring 1.5 cm long, 1.0 cm wide and was 0.2 cm deep. The assessment documented Resident #1 would sleep in her wheelchair all day and all night, would refuse to elevate her legs, and would refuse to remove her shoes or compression stockings. The assessment documented the resident would often refuse to bathe which resulted in poor skin health. -However, Resident #1 was only documented to refuse to return to bed on five separate occasions between 5/6/24 and 7/21/24 and refusing to remove her shoes on three occasions between 5/6/24 and 7/21/24. -The facility performed the weekly assessment nine days after the previous weekly assessment on 6/6/24. -The facility failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. A weekly skin pressure injury note, dated 6/19/24, documented the resident had a stage 2 pressure ulcer to the right heel that had deteriorated and now measured 2.3 cm long, 3.4 cm wide and 0.5 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was a stage 3 pressure wound measuring 1.2 cm long, 1.2 cm wide and was 0.3 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injuries. A weekly skin pressure injury note, dated 6/28/24, documented the resident had a wound on the right heel that had deteriorated and was now a stage 4 pressure ulcer measuring 4.5 cm long, 4.0 cm wide and 0.7 cm deep. The assessment documented the wound bed was eschar and bone. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was a stage 3 pressure wound measuring 0.7 cm long, 1.5 cm wide and was 0.5 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -The facility performed the weekly skin assessment nine days after the previous assessment on 6/19/24. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the pressure injury deteriorating to a stage 4 pressure injury A weekly skin pressure injury note, dated 7/2/24, documented the resident had a stage 4 pressure ulcer on the right heel that measured 3 cm long, 3.7 cm wide and 1 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was a stage 4 pressure wound measuring 1.2 cm long, 1.2 cm wide and was 0.9 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified Resident #1 now had two stage 4 pressure injuries. A telehealth (virtual) physician's visit note, dated 7/2/24, documented Resident #1 had a stage 4 pressure wound on her right heel and had another wound on the lateral middle part of the foot that was a stage 2 pressure injury. The assessment documented the resident had been in her bed since yesterday (7/1/24) and would not get out of bed. The assessment documented the resident was to receive new shoes and an offloading boot. The assessment further documented the resident was receiving daily dressing changes to the heels and compression stockings were being changed every couple of weeks when the resident would allow a shower. The assessment documented the resident had lower extremity edema (swelling) and required compression with tubigrips and compression wraps. The assessment documented the resident was wheelchair bound but could transfer herself. A weekly skin pressure injury documentation, dated 7/9/24, documented the resident had a stage 4 pressure ulcer on the right heel that deteriorated and measured 2.8 cm long, 4.0 cm wide and 0.5 cm deep. The assessment documented the second pressure wound on the right lateral foot had improved and was a stage two pressure wound measuring 1 cm long, 1 cm wide, and was 0.2 cm deep. The assessment identified new interventions to include nutritional supplements, and a plan of care discussion that included Resident #1, the nursing home administrator (NHA), the MDS resource nurse, and the corporate consultant (CC). The discussion included education to Resident #1 that her compression stockings were causing increased pressure to her heels, the importance of turning side to side in bed, and the importance of accepting showers. -The facility failed to document weekly skin pressure injury documentation between 7/10/24 and 7/30/24. A telehealth physician visit note, dated 7/10/24, documented a referral for Resident #1 to see wound care to assist with wound debridement (removal of damaged tissue from the wound). -However, there was no documentation to indicate Resident #1 was seen by a wound care physician for wound debridement between 7/10/24 and 7/30/24. A Performance Improvement Plan (PIP) for wounds, dated 7/10/24, was provided by the DON on 7/31/24 at 8:46 a.m. The PIP documented the facility had an opportunity to improve several areas of wound care management in the facility, including the accuracy and timeliness of pressure ulcer assessment, appropriately identifying pressure ulcer wounds, appropriately changing treatment orders, implementing interventions as needed, and holding care conferences with a resident's decision maker as needed. The PIP documented the facility experienced communication breakdown in shift-to-shift report, nursing management assessments and follow-up was inadequate, and a lack of communication with outside resources such as wound clinic specialists. The PIP documented the facility would intervene with several new interventions on 7/10/24. The PIP documented all residents in the facility would have an accurate and in depth skin assessment completed within 24 hours, and all residents would have a head-to-toe skin assessment that was accurate, on time, and thorough. The PIP documented all nursing staff members would receive education on pressure injury prevention, the Braden scale and reporting requirements of skin conditions. -The facility failed to identify when the PIP would be re-evaluated for effectiveness. E. Staff interviews The DON was interviewed on 7/30/24 at 12:10 p.m. The DON said she was previously the facility's NHA and transitioned into the role of DON on 7/29/24. The NHA was interviewed on 7/30/24 at 1:34 p.m. The NHA said the facility did not have documentation indicating the facility notifying a physician when either of Resident #1's wounds progressed to stage 4 (see documentation above). LPN #1 was interviewed on 7/30/24 at 3:58 p.m. LPN #1 said Resident #1 sometimes did not want to shower. LPN #1 said she did not personally have this issue because she and Resident #1 had a good relationship and Resident #1 did not refuse showers for her. LPN #1 said Resident #1 did not often refuse cares for her as long as she took her time with Resident #1 and made the care enticing by explaining that the resident would feel better afterwards. The DON was interviewed again on 7/30/24 at 4:23 p.m. The DON said Resident #1 had a stage 4 pressure wound on her right heel and an unstageable pressure wound on the resident's right lateral foot. The DON said both wounds were currently improving. The DON said the facility's previous DON no longer worked at the facility. The DON said the facility's previous DON had been solely responsible for wound care in the facility, but she had been on vacation since late June 2024 and had not worked in the building in July 2024 at all before she left the facility. The DON said the facility had identified concerns with resident wound care in July 2024 and implemented a PIP to address these concerns. The DON said the facility did not implement new interventions for Resident #1's plan of care after wound deterioration was documented on 5/30/24, 6/6/24, 6/15/24, 6/19/24, or 6/28/24. The DON said she was not aware that the facility did not implement new interventions because she was in the NHA role at the time. The DON said the facility should have implemented new interventions to prevent deterioration of Resident #1's foot wounds. The DON said the facility should perform weekly wound skin assessments every seven days consistently. The DON said the facility failed to consistently assess Resident #1's wounds weekly. The DON said she did not have documentation of weekly wound assessments being completed between 7/10/24 and 7/30/24. The medical director (MD) was interviewed on 7/30/24 at 4:58 p.m. The MD said Resident #1's wounds were facility-acquired and avoidable. The MD reviewed documentation regarding the resident's wounds and said he could not tell if or when any physician was told about Resident #1's stage 4 pressure wounds. The MD said that his physician's office performed assessments of Resident #1's wounds on 7/2/24 and 7/10/24 and issued recommendations only on those occasions. The MD said the first time he assessed the wounds they were already stage 4 pressure wounds. He said a physician should be alerted that a resident had a wound before the wound reached the status of a stage 4 pressure wound. The MD said if he had been notified earlier he would have reassessed the resident's medications and treatments to further prevent the development of the facility-acquired pressure ulcers. The MD said he was unsure if sufficient education was provided to Resident #1 early enough to help prevent pressure injuries. The MD said the facility had one discussion with Resident #1 in July 2024 regarding care plan adherence and since that time Resident #1 had not had rejections of care. The MD said he had evaluated Resident #1's compression stockings and was unsure if they contributed to any specific pressure development for the resident. The MD said it was important for Resident #1 to wear compression stockings to prevent the development of wounds due to swelling. The MD said the facility failed to identify Resident #1's skin concerns in a timely manner. The MD sa[TRUNCATED]

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure appropriate hand washing and glove usage in the main kitchen; -Ensure cooked food items were monitored and cooled properly; -Ensure the handwashing sink was only used for handwashing; -Ensure food was labeled, dated and disposed of timely; -Ensure ice pack for human use were not stored with food; and, -Ensure food was cooked to the appropriate temperature. Findings include: I. Ensure appropriate hand washing and glove usage in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. -Ready-to-eat is considered a food without further washing, cooking, or additional preparation and that is reasonably expected to be consumed in that form. -Single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. (Retrieved [DATE]). B. Facility policy and procedure The Handwashing/ Hand Hygiene policy, undated, was provided by the registered dietitian (RD) on [DATE] at 3:54 p.m. It revealed in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used: before aseptic procedures, when anticipating contact with blood or body fluids; and when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. Perform hand hygiene before applying non-sterile gloves. The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated [DATE], was provided by the RD on [DATE] at 3:54 p.m. It revealed in pertinent part, All employees who handle, prepare or serve food will be trained in practices of [NAME] food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or service food to residents. 'Employees must wash their hands' after personal body functions (toileting, blowing/wiping nose, coughing, sneezing), after using tobacco, eating or drinking, whenever entering or reentering the kitchen, before coming in contact with any food surfaces, after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food, after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and/or after engaging in other activities that contaminate the hands. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. The General HACCP (hazard analysis critical control points) Guidelines for Food Safety policy and procedure, dated 2019, was provided by the RD on [DATE] at 3:54 p.m. It revealed in pertinent part, Use one staff person to load dirty dishes and another to pull clean dishes. C. Observations During a continuous observation on [DATE] beginning at 11:03 a.m. and ending at 12:48 p.m. the following was observed: -DC #1 had gloves on his hands. He put his hands into pot holders and took a pan of chicken out of the oven and placed it onto the preparation table. He then took the pot holders off and kept the gloves on his hands. He grabbed a piece of parchment paper, folded it and placed it in the bottom of a metal pan. He took off the gloves and placed them in the trash can. He used tongs and put a couple pieces of the chicken into the food processor. He ground the chicken. He put the whole chicken into the pan with the parchment paper. He used a spatula and put the ground chicken into a metal pan. He covered the pans of chicken and placed them into the steam table. DC #1 did not wash his hands after taking the gloves off. -DC #1 began wiping dirty dishes off in the three compartment sink. He took the rinsed dishes to the dish room. DC #1 did not wash his hands after touching the dirty dishes. -DC #1 got a towel out of a sanitizer bucket and sanitized the preparation table. DC #1 put the pot holders back on his hands and took a pan of potatoes out of the oven. He put the potatoes in the steam table. DC #1 got a drink of Sprite. He then got a thermometer and sanitized it. DC #1 had not washed his hands. -At 11:26 a.m. DC #1 took the temperature of the corn, potatoes, ham and chicken. -DC #1 uncovered the ham that was on the steam table. He took a few pieces of ham with tong and ground them in the food processor. He put the ham into a metal pan and placed it into the steam table. DC #1 put on an N95 face mask. He took a few plates and placed them onto the steam table. He then opened up the drawer and grabbed serving utensils. DC #1 did not wash his hands. -DC #1 took the trash out to the dumpster. Upon re-entering the kitchen he adjusted his face mask. He touched the meal tickets and then washed his hands for the first time during the continuous observation. He then put gloves on. -DC #1 went into the walk-in refrigerator and got a package of sliced cheese and a plated salad. With the same gloved hands, he reached into a bag of bread and grabbed two slices. He put butter on the bread and placed the two slices on the flat top to cook. He put two slices of cheese on the bread. When he flipped a bread slice onto the other to form a sandwich he touched the bread with the same gloved hands. He took the sandwich off the flat top and cut-it in half. He used the same gloved hands to pick the sandwich up and put it onto a plate. He picked up a knife and took it to the three compartment sink and rinsed it off. He took the gloves off and went into the walk-in refrigerator. He brought out a tray of plated desserts. He went back to the walk-in refrigerator and closed the door. DC #1 put on a new pair of gloves without performing hand hygiene. DC #1 went to the basement dry storage room. Upon re-entering the kitchen DC #1 no longer had gloves on. He put a new pair of gloves on without performing hand hygiene. He began plating food. He reached into the bag of bread and grabbed a slice. He cut it in half and put it onto a plate with his gloved hands. -DC #1 cracked an egg onto the flat top. He removed the glove that he cracked the egg with and threw it away. He placed a new glove onto his hand without performing hand hygiene. DC #1 reached into the bag of bread and placed two slices of bread onto the flat top. DC #1 went into the walk-in refrigerator with gloves hands. He got a metal container of hamburgers out of the refrigerator and placed it on the flat top. With the same gloved hands he used a spatula and his hand to put the cooked egg onto one of the slices of bread on the flat top. He used a spatula and his hand to flip the other piece of bread on top of the other. He then used a spatula and his hand to move the sandwich to the cutting board. He cut the sandwich in half and used the same gloved hands to put the sandwich onto a place. -DC #1 put a hamburger onto the flat top. He then went to the walk-in refrigerator to get a plate of condiments for a hamburger. He opened the bag of buns and used the same gloved hands to place the bun onto the flat top to toast. He used the gloved hands to put a slice of cheese onto the hamburger. He plated a resident's meal and handed it to dietary aide (DA) #2. DC #1 picked up the bun off the flat top with the same gloved hands and formed the cheeseburger. He cut the cheeseburger in half and put it onto a plate with the same gloved hands. DA #2 had not washed his hands. -DC #1 entered the walk-in refrigerator with gloved hands. He gathered a cutting board, cheese and a slice of bread. He put the cheese on top of the slice of bread and cut it into quarters. He picked up the sandwich with gloved hands and placed it onto a plate. He handed the plate to the resident. DC #1 continued to serve resident meals. -At 11:59 a.m. DC #1 wrapped a resident's meal in plastic wrap and put it into the walk-in refrigerator. Without changing his gloves or performing hand hygiene, DC #1 placed two slices of bread onto the flat top with bread. He used the same gloved hands and reached into a bag of potato chips and placed a handful of chips onto a plate. He used a spatula and the same gloved hands to form the sandwich and take the sandwich off the flat top. He cut the sandwich in half and then used the same gloved hands to place the sandwich onto a plate. -At 12:00 p.m. DC #1 picked up an egg shell and threw it out. He took off his gloves and threw them out. He then readjusted his mask and his beard net. DC #1 touched his mouth and took a drink. He then took dirty dishes to the dish pit. He began putting away clean metal pans. He went back to the dish room and took clean utensils and placed them onto the preparation table. DC #1 adjusted his mask and then put on gloves without performing hand hygiene. He began serving resident meals. -At 12:12 p.m. DC #1 dropped a meal ticket onto the floor. He picked the meal ticket up and went back to serving without changing gloves or performing hand hygiene. He put a hamburger onto the grill. He took a bun out of the bag with the same gloved hands and put the bun onto the flat top to toast. DC #1 went into the walk-in refrigerator and got a plate with hamburger condiments on it. He picked up the tomato, onion, pickle and lettuce with the same gloved hands. He threw the lettuce away and placed the rest of the items back onto the plate. He put a slice of cheese onto the burger. He reached into the bag of chips with the same gloved hands and put a handful of chips onto a plate. He took his gloves off and did not perform hand hygiene. He adjusted his mask. He put new gloves on without performing hand hygiene. He took the bun off the flat top and assembled the cheeseburger. He used the same gloved hands and put the cheeseburger onto the plate. DC #1 went into the walk-in refrigerator and got a container of sour cream and salsa. -DC #1 put a hamburger onto the grill. With the same gloved hands, he took a bun out of the bag and put it onto the flat top to toast. He served more resident meals. He opened a bag of chips and used the same gloved hands to place a handful of chips onto the plate. He then used the same gloved hands and a spatula to form the cheeseburger and place it onto a plate. DC #1 took off his gloves. -At 12:26 p.m. DC #1 said he was done serving lunch to the residents. He adjusted his mask. Without performing hand hygiene, he put new gloves on and reached into a bag of sliced bread. He took two slices of bread and handed it to a resident. DC #1 put a hamburger onto the flat top. He adjusted his mask. He took a bun out of the bag and put it on the flat top to toast. He went into the walk-in refrigerator and came out holding a couple slices of onion with the same gloved hands. He put the onions onto a plate. He used a spatula and the same gloved hands to assemble the cheeseburger. He reached into the bag of chips with the same gloved hands and put a handful of chips onto the plate. DC #1 cut up a jalapeno with the same gloved hands and put the jalapeno on top of the cheeseburger. D. Staff interviews The dining manager (DM) and the registered dietitian (RD) were interviewed on [DATE] at 2:05 p.m. The DM said hands should be washed frequently in the kitchen. She said hands should be washed upon entering and exiting the kitchen, between tasks, between handling dirty and clean dishes and after adjusting a face mask. The DM said gloves should be worn when handling ready-to-eat foods. The RD said hands should be washed before and after glove usage. She said gloves did not replace hand washing. The DM said the infection preventionist had completed a hand washing training on [DATE]. DA #1 was interviewed on [DATE] at 10:43 a.m. She said she had been instructed to wash her hands frequently and in-between tasks when working in the kitchen. II. Ensure cooked food items were monitored and cooled properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, Maintain the records required to confirm that cooling and cold holding refrigeration time/temperature parameters are required as part of the HACCP (hazard analysis critical control point) plan. (Retrieved [DATE]) B. Facility policy and procedure The General HACCP (hazard analysis critical control points) Guidelines for Food Safety policy and procedure, dated 2019, was provided by the RD on [DATE] at 3:54 p.m. It revealed in pertinent part, Cool from 135 F (degree Fahrenheit) to 70 F in two hours and from 70 F to 41 F in four hours (not to exceed six hours). If food is not cooled to 41 F within six hours, reheat to 165 F for at least 15 seconds (within two hours) and discard if not served immediately. This includes mechanically altered foods. Take temperatures frequently to determine if altered methods are needed. C. Observations On [DATE] at 1:00 p.m. the initial kitchen tour was conducted and the following was observed: -In the freezer in the main kitchen there was a bag of turkey labeled [DATE], the turkey was warm to the touch. Dietary cook (DC) #2 said he cooled the turkey to 37 F. DC #2 said he did not have a log of when food was cooled and placed into the refrigerator or the freezer. -In walk-in refrigerator, a container of cooked bacon labeled ,d+[DATE], a container of cooked sausage labeled ,d+[DATE], a container of cooked scrambled eggs labeled ,d+[DATE], a container of cooked chicken chili labeled ,d+[DATE] and a container of cooked mushroom gravy labeled ,d+[DATE]. The facility did not have a monitoring log to ensure food was cooled properly (see DM interview below). On [DATE] at 11:05 a.m. in the main walk-in refrigerator a container of cooked hamburgers that were steaming. -At 11:59 a.m. DC #1 took a resident meal, wrapped it in plastic wrap, labeled it and placed it into the walk-in refrigerator. -At 12:39 p.m. the leftover containers of ham, chicken and potatoes were on the preparation table. DC #1 said he left the food on the counter for a little while until it reached 100 F. DC #1 said he then would put the food into plastic bags and place the food in the walk-in refrigerator. He said he had to wait for the food to cool to 100 F or the bags would steam really bad. D. Record review A request was made for the documented cooling monitor system on [DATE] at 2:10 p.m. The DM said the facility did not have a documented cooling monitor system in place (see interview below). E. Staff interviews DC #1 was interviewed on [DATE] at 11:05 a.m. He said he was not aware of a food cooling monitoring log. He said he typically let food cool on the counter until it was 100 F. DC #1 said he then placed the food into plastic bags and would put the food into the walk-in refrigerator for leftover use. The RD and the DM were interviewed on [DATE] at 2:05 p.m. The DM said the dining department often saved leftover foods. She said at times residents would ask for the lunch menu items for dinner or they would use the leftover foods in different applications. The DM said food was cooled differently depending on the food item. She said food should be cooled off to the correct temperature within 30 minutes. She said if food was not cooled properly it increased the risk of food borne illness. The DM said foods should not be steaming when placed into the refrigerator. The RD said she provided an in-service to the dietary staff a few weeks ago regarding cooling foods properly. The DM said they did not utilize a food cooling log. III. Ensure the handwashing sink was only used for handwashing A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; A handwashing sink shall be maintained so that it is accessible at all times for employee use. A handwashing sink may not be used for purposes other than hand washing. A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees. (Retrieved [DATE]). B. Observations On [DATE] at 11:07 a.m. DA #2 placed a pitcher into the handwashing sink to make fruit punch. -At 11:27 a.m. DA #2 placed another pitcher into the handwashing sink to make another pitcher of fruit punch. DA #2 filled a third pitcher with water from the handwashing sink. C. Staff interviews The DM and the RD were interviewed on [DATE] at 2:05 p.m. The DM said they typically utilized the handwashing sink to fill pitchers to make drinks for the residents. She said they did not use the three compartment sink to fill drinks because it was dirty. The nursing home administrator (NHA) was interviewed on [DATE] at 3:12 p.m. He said he understood that handwashing sinks should only be used for hand washing. IV. Ensure food was labeled, dated and disposed of timely A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved [DATE]). B. Facility policy and procedure The Accepting Food Delivers policy and procedure, dated 2019, was provided by the RD on [DATE] at 3:54 p.m. It revealed in pertinent part, Perishable foods will be properly covered, labeled and dated and promptly stored in the refrigerator or freezer as appropriate. The Food Production and Food Safety policy and procedure, dated 2019, was provided by the RD on [DATE] at 3:54 p.m. It revealed in pertinent part, All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftover) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. C. Observations On [DATE] at 1:00 p.m. the initial kitchen tour was conducted and the following was observed: -In the resident refrigerator in the main dining room, there was a container of two pieces of sushi that did not have a use-by-date and an opened container of honey thick apple-juice that did not have an open or use-by-date. -In the main walk-in refrigerator there were two plastic bags of hot dogs labeled ,d+[DATE], a container of refried beans labeled ,d+[DATE]. On [DATE] at 11:03 p.m. the following was observed: -In the main walk-in refrigerator there were two plastic bags of hot dogs labeled ,d+[DATE]. -At 2:31 p.m. in the resident refrigerator in the main dining room, an opened container of honey thick apple-juice did not have an open or use-by-date, a frozen bean and cheese burrito that expired on [DATE] and three slices of pizza in a plastic bag without a date. The DM said the honey thick apple-juice, burrito and pizza needed to be discarded. In the resident freezer in the main dining room there was a frozen opened Gatorade bottle. The DM disposed of the frozen Gatorade. D. Staff interviews The DM and the RD were interviewed on [DATE] at 2:05 p.m. The DM said since the hot dogs had been taken out of their original package and placed in a plastic bag, they should have been disposed of on [DATE]. The DM said after food was prepared or taken out of the original package it should be disposed of within three days. The DM said she was unsure how long thickened liquids could be left open before being discarded. V. Ensure ice packs for human use were not stored with food A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Food shall be protected from contamination by storing the food: In a clean, dry location and where it is not exposed to splash, dust, or other contamination. (Retrieved [DATE]). B. Observations On [DATE] at 1:00 p.m. the initial kitchen tour was conducted and the following was observed: -In the resident freezer in the main dining room, there were two ice packs stored next to resident food. On [DATE] at 2:31 p.m. the following was observed: -Four resident ice packs. The DM took the ice packs out of the freezer and said the ice packs should not be stored with resident's food. C. Staff interviews The DM and the RD were interviewed on [DATE] at 2:31 p.m. She said ice packs for resident use should not be stored in the same freezer as resident's food. She said she often found them in the freezer and would take them out and put them on top of the freezer. VII. Food was cooked to the appropriate temperature A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, 165 F or above for 15 seconds for poultry. B. Facility policy and procedure The Critical Temperatures for Safe Food Handling policy and procedure, dated 2019, was provided by the RD on [DATE] at 3:54 p.m. It revealed in pertinent part, Stuffed pasta, meats, fish or stuffing containing meat, fish or poultry, reheat leftovers, food reheated in microwave should reach 165 F. Heat throughout to minimum temperature for a minimum of 15 seconds. C. Observations During a continuous observation on [DATE] beginning at 11:03 a.m. and ending at 12:48 p.m. the following was observed: -DC #1 had gloves on his hands. He put his hands into pot holders and took a pan of chicken out of the oven and placed it onto the preparation table. He then took the pot holders off and kept the gloves on his hands. He grabbed a piece of parchment paper, folded it and placed it in the bottom of a metal pan. He took off the gloves and placed them in the trash can. He used tongs and put a couple pieces of the chicken into the food processor. He ground the chicken. He put the whole chicken into the pan with the parchment paper. He used a spatula and put the ground chicken into a metal pan. He covered the pans of chicken and placed them into the steam table. -At 11:26 a.m. DC #1 took the temperature of the corn, potatoes, ham and chicken. The chicken was 160 F. He said he did not take the temperature of the chicken when he took it out of the oven. He said he did not need to rewarm the chicken to ensure the correct temperature, as he knew he had cooked the food long enough. He said it should be 165 F. D. Staff interviews The DM and the RD were interviewed on [DATE] at 2:05 p.m. The DM said chicken and poultry should be cooked to 160 F. -However, chicken and poultry should be cooked to 165 F. The DM said DC #1 should have taken the temperature of the chicken when it came out of the oven and again when he put it in the steam table. The NHA was interviewed on [DATE] at 5:07 p.m. He said they had educated the dining staff on proper food temperatures recently.

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on four of four units. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene practices; -Ensure appropriate use of personal protective equipment (PPE) such as masks and gloves; and, -Ensure houskeeping staff cleaned resident rooms appropriately. Findings include: I. Facility policy and procedure The Handwashing/Hand Hygiene policy, revised August 2019, was provided by the nursing home administrator (NHA) on 3/30/23 at 2:21 p.m. According to the hand hygiene policy, the facility considered hand hygiene the primary means to prevent the spread of infections. The policy was read in pertinent part: All Personnel should be trained regularly and in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy identified when staff should perform hand hygiene, including before and after direct contact with the residents; before donning sterile gloves; after removing gloves; before and after entering isolation precautions settings; before and after eating or handling food; and, before and after assisting a resident with meals. According to policy, the use of gloves does not replace hand hygiene and the integration of glove use along with routine hygiene was recognized as the best practice for preventing healthcare-associated affections. The policy identified single-use disposable gloves should be used before antiseptic procedures; when anticipating contact with blood or body fluids; and, when in contact with the resident, or the equipment or environment of a resident who was on contact precautions. The Personal Protective Equipment policy for COVID-19, revised 2021, was provided by the facility on 3/29/23. The policy identified the general procedures for donning and doffing masks. The policy indicated staff should ensure the face mask covered the nose and the mouth while wearing it; staff should perform hand hygiene after touching their mask; and staff should not remove their mask while performing a treatment or service or a resident. II. Observations During a continuous observation on 3/27/23 beginning at 4:31 p.m. and ending at 5:26 p.m. the following was observed: -At 4:31 p.m. six residents were in the dining room. An unidentified nursing staff member offered hand hygiene to the six residents. -At 4:44 p.m. six more residents had entered the dining room. These residents were not offered hand hygiene. One resident who was not offered hand hygiene received two grilled cheese sandwiches and chips for dinner. He ate his meal with his hands. During the initial kitchen tour on 3/27/23 at 1:00 p.m. dietary cook (DC) #2 did not have a face mask upon entering the kitchen. On 3/27/23 at 4:46 p.m. certified nurse aide (CNA) #5 walked to the PPE cart. He donned PPE of gloves, gown, and eye protection. He was already wearing an N95 mask. CNA #5 entered room [ROOM NUMBER] on isolation precautions for COVID. The CNA did not perform hand hygiene prior to donning PPE. The CNA attended to the resident, doffed his PPE and exited the room. He used alcohol based hand rub (ABHR) when exiting the room. -At 4:58 p.m. the activity director (AD) donned PPE and entered isolation room [ROOM NUMBER]. She did not perform hand hygiene prior to entering the room. The AD dropped off mail for the resident, doffed her PPE and exited the room. She used ABHR on exit from the room. Observations of room tray delivery was conducted on 3/27/23 during the dinner meal. -At 5:08 p.m. the meal cart with resident room trays arrived in the 300 hall. -At 5:09 p.m. the dietary aide (DA) #3 entered room [ROOM NUMBER] and room [ROOM NUMBER] with room trays. She did not perform hand hygiene before entering the rooms. She dropped off the room trays and exited the room. She did not perform hand hygiene on exit of the room. -At 5:10 p.m. DA #3 dropped a condiment packet on the floor in the hallway. She pick up the item off the floor, threw the packet away, collected a room tray and entered room [ROOM NUMBER]. She did not perform hand hygiene after picking up the item off the floor. She did not perform hand hygiene before collecting the resident's tray and entering the room. -At 5:12 p.m. DA #3 delivered the second room tray to room [ROOM NUMBER]. She did not perform hand hygiene before entering the room and on exit. Observations of room tray delivery was conducted on 3/27/23 during the dinner meal. -At 12:08 p.m. CNA #3 donned PPE and entered room [ROOM NUMBER] and delivered her room tray. He did not perform hand hygiene prior to donning PPE. The CNA set the tray by the resident and used ABHR on exit. -At 12:14 p.m. DA #2 was observed wearing gloves as she collected a room tray from the meal tray cart and entered room [ROOM NUMBER]. She unwrapped the plastic wrapping over a dessert bowl and placed all meal tray items near the resident. The DA exited the room. She did not doff her gloves or perform hand hygiene after exiting the room. -At 12:16 p.m. DA #2 went back to the meal cart, collected the room tray for room [ROOM NUMBER] using the same gloves as she used in room [ROOM NUMBER]. The DA delivered the room tray and exited the room without doffing her gloves or performing hand hygiene. -At 12:29 p.m DA #2 delivered a covered drink to a resident in room [ROOM NUMBER]. She wore gloves and did not perform hand hygiene prior to entering the room. She did not perform hand hygiene or doff her gloves after exiting the room. -At 12:30 p.m. DA #2 collected a room tray from the cart wearing gloves. She delivered the tray to room [ROOM NUMBER]. She exited the room without doffing her gloves and performing hand hygiene. The DA exited the hallway. Housekeeper (HSKP) #1 was observed on 3/28/23 at 9:10 a.m. She cleaned room [ROOM NUMBER] and exited the room with the resident's trash bag. She put the bag into her housekeeping cart trash and pushed the cart to room [ROOM NUMBER]. She opened the door to room [ROOM NUMBER], entered the room and collected the trash bags from the resident's room and bathroom. She exited room [ROOM NUMBER], put the bags into her cart trash and then entered room [ROOM NUMBER]. HSKP #1 entered and exited the rooms and touched door handles to the rooms and bathrooms and her housekeeping cart. She was observed continuously and did not remove her gloves or perform hand hygiene. HSKP #1 entered room [ROOM NUMBER] with her broom, swept the room, returned the broom to the cart, then entered room [ROOM NUMBER] with her mop and mopped the floor. She was continuously observed and failed to change her gloves or perform hand hygiene between tasks. HSKP #1 failed to wipe surfaces she touched with her gloved hands (door handles and door knobs and her housekeeping cart). HSKP #1 was observed at 11:30 a.m. HSKP #1 was observed as she exited room [ROOM NUMBER] with the resident's trash bag in her hand. HSKP #1 put the trash bag in her cart trash, removed the toilet cleaning supplies from her cart, entered room [ROOM NUMBER] and cleaned the toilet. She exited the room, replaced the toilet cleaning supplies on her cart, removed the broom and swept the room. She exited the room, returned to the room with her mop and mopped the floor. She was observed to exit the room with her mop, place it in the mop bucket and then she opened the door on the clean linen closet in the 200 hallway. She removed items from the closet and then entered room [ROOM NUMBER]. HSKP #1 was continuously observed and she did not remove dirty gloves or perform hand hygiene between tasks and after she exited room [ROOM NUMBER] and before she entered room [ROOM NUMBER]. HSKP #1 was observed continuously as she cleaned room [ROOM NUMBER] in the same manner. She entered and exited the room, removed and replaced items on her housekeeping cart without changing her gloves or performing hand hygiene. Dietary aide (DA) #1 was observed at 4:40 p.m. The DA passed dinner trays to residents on the 100 hallway. She was observed continuously as she removed trays from the food warming cart, entered the resident's room, cleaned bedside tables for the food trays, exited rooms and closed doors, and returned to the food warming cart and removed the next tray. The DA did not perform hand hygiene after touching door handles or resident personal items on their bedside tables. The residents were not offered or assisted with performing hand hygiene prior to eating their meal. Rooms observed were #103, #101 and #205. On 3/29/23 at 9:14 a.m. the regional nurse consultant (RNC) crossed the lobby containing five residents not wearing a face mask. -At 9:45 a.m. housekeeper (HK) #3 was in resident room [ROOM NUMBER] with two residents. She was speaking to the residents and did not have her N95 face mask covering her nose and mouth. -At 10:37 a.m. an unidentified staff was passing out snacks. She gave a resident animal crackers and did not offer hand hygiene prior to the resident eating his snack. -At 10:39 a.m. an unidentified staff member donned gloves without performing hand hygiene. She then opened the drawer to get a gown. She put the gown on and entered the isolation room. Upon exiting the room she did not change her N95 mask. -At 11:03 a.m. DC #1 was observed not wearing a face mask in the kitchen. -At 11:26 a.m. DC #1 placed a N95 face mask on. HSKP #1 was observed on 3/30/23 at 9:18 a.m. as she exited room [ROOM NUMBER] and entered room [ROOM NUMBER]. The HSKP did not remove her gloves or perform hand hygiene when she exited room [ROOM NUMBER] and before she entered room [ROOM NUMBER]. She emptied the trash in room [ROOM NUMBER], exited the room, placed her trash in her cart trash, returned to the room with toilet cleaning supplies, cleaned the toilet, replaced the toilet supplies on her cart, entered the room with her broom, swept the floor, cleaned the residents bedside table, exited the room with the broom and entered with her mop. She exited the room and moved to room [ROOM NUMBER]. HSKP #1 was continuously observed. She did not remove her gloves or perform hand hygiene after she exited room [ROOM NUMBER]. After HSKP #1 cleaned room [ROOM NUMBER], she opened the door to the clean linen closet on the 100 hallway, removed items and closed the door. She accessed the closet with her dirty gloves and did not perform hand hygiene after closing the door. HSKP failed to clean the door handles and door knobs or other surfaces she touched with her dirty gloves. The HSKP moved to room [ROOM NUMBER] and repeated the same process of entry and exit with continuous observation; she failed to complete hand hygiene before she entered or exited room [ROOM NUMBER]. DA #1 was observed at 5:10 p.m. She was observed passing dinner trays to residents on the 200 hallway. She opened the door for room [ROOM NUMBER], cleared items on the resident's bedside table, exited the room, closed the door, and returned to the tray warming cart for the next tray. She repeated the process and delivered the dinner tray to the resident in room [ROOM NUMBER]. She was observed continuously and did not perform hand hygiene after touching door handles and personal items on the resident's bedside tables. III. Record review The 2/24/23 all-staff in-service agenda was provided by the nursing home administrator (NHA) on 3/30/23. The in-service agenda indicated that hand hygiene, including for residents at meal time and cross-contamination was reviewed with the staff. The review of the facility's surveillance log with the assistant director of nursing (ADON) identified one resident was COVID positive on 3/8/23 and was now off COVID precautions. She said the second resident tested positive on 3/21/23. IV. Staff interview The nursing home administrator (NHA) was interviewed on 3/27/29 at 12:55 p.m. He said there was one resident on isolation precautions for COVID. The NHA said she was asymptomatic. He said the facility was currently using N95 masks throughout the facility. CNA #3 was interviewed on 3/29/23 at 12:11 p.m. He said he should have performed hand hygiene before donning PPE and after doffing PPE. The assistant director of nursing (ADON) was interviewed on 3/30/23 at 10:00 p.m. She said the best way to prevent the spread of transmission based infections was hand hygiene. She said hand hygiene should be conducted by staff before and after entering resident rooms and before donning and doffing PPE. She said hand hygiene prevents potential risk of cross-contamination. She said it was important to perform hand hygiene before donning PPE to prevent potential contamination of the clean PPE. The NHA was interviewed with the ADON on 3/30/23 at 10:15 a.m. He said masks should be worn throughout the facility, including in the kitchen. Observations were shared with NHA. He said the facility would continue to provide on-going training and reminders to staff. HSKP #1 was interviewed 3/30/23 at 11:17 a.m. HSKP #1 was unable to recall specific training that she had regarding hand hygiene between tasks. She stated that she was unaware she needed to change her gloves or perform hand hygiene between tasks and as she entered or exited the resident's room. HSKP #1 stated that she did not assist with direct resident care and felt that she provided good cleaning service. CNA #4 was interviewed on 3/30/23 at 5:00 p.m. He was caring for residents on the 200 hallway and stated that it was his first day working in the facility. He said that he received some education on infection prevention and stated he would follow stand precautions when he entered a resident's room prior to delivering a meal tray. He said he did not receive education to help residents perform hand hygiene prior to eating in their rooms. He stated he was unaware residents should be offered hand hygiene prior to eating meals and denied receiving education to offer and assist with hand hygiene when residents are eating in their room. The NHA was interviewed again on 3/30/23 at 5:08 p.m. He said staff received infection control training in February 2023 at the all staff meeting. He said the facility would continue to focus on making sure staff had clear comprehension of infection control practices. DA #1 was interviewed on 3/30/23 at 5:10 p.m. She said she has worked at the facility for six months and when hired she completed required computer based training and received handouts with information regarding infection prevention. She did not recall the education included the need to offer hand hygiene to residents prior to eating their meals. DA #1 said that residents were not offered hand hygiene prior to eating in their room because they have previously been cleaned up and changed for the day by the certified nursing aides. 46022 47536

Based on observations, record review and interviews the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, the facility failed to educate the dietary staff about the type of dishwasher, the correct temperature and the correct parts per million (PPM). Findings include: I. Professional reference The Colorado Retail Food Establishment Rule and Regulations, revised January 2019 (pg. 24, 113-124, 133-137), read in pertinent part, Cleaning and sanitizing may be done by spray-type, immersion ware washing, or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. Chemical sanitizing ware washing machines (single-tank, stationary-tank, door-type machines and spray-type glass washers) may be used provided that: 1) The temperature of the wash water shall not be less than 120 Fahrenheit (F) (49 Celsius (C)); 2) The wash water shall be kept clean; and 3) Chemicals added for sanitization purposes shall be automatically dispensed; and 4) Utensils and equipment shall be exposed to the final chemical sanitizing rinse in accordance with the manufacturer's specifications for time and concentration; and 5) The chemical sanitizing rinse water temperature shall not be less than 75 F (24 C) nor less than the temperature specified by the machine's manufacturer. When used for warewashing, the wash compartment of a sink, mechanical warewasher, or wash receptacle of alternative manual warewashing equipment, shall contain a wash solution of soap, detergent, acid cleaner, alkaline cleaner, degreaser, abrasive cleaner, or other cleaning agent according to the cleaning agent manufacturer's label instructions. The wash, rinse, and sanitize solutions shall be maintained clean. A test kit or other device that accurately measures the concentration in MG/L of sanitizing solutions shall be provided. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified in accordance with the EPA- registered label use instructions The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 F. II. Facility policy and procedure The Dishwashing Machine Use policy, revised March 2010, was provided by the nursing home administrator (NHA) on 3/28/23 at 5:23 p.m. It revealed in pertinent part, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine 50-100 ppm (parts per million) and 10 seconds. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. III. Observations On 3/27/23 at 1:13 p.m. dietary aide (DA) #3 started a load of dishes. The dishwasher was 105 degrees fahrenheit ( F) during the rinse cycle. On 3/28/23 at 12:55 p.m. the regional maintenance director (RMD) ran a test load in the dish machine. The rinse cycle was 142 F. He tested the PPMs of the dishwasher and said it was 300 PPM. He said the dishwasher was sanitizing dishes appropriately. -However, the PPM should be 50-100 PPM (see facility policy). IV. Record review A request was made for in-services related to the dishmachine on 3/29/23. The dining manager (DM) said she had conducted an in-service a couple weeks ago verbally, but did not have any documentation that the in-service was held. IV. Staff interviews DA #3 was interviewed on 3/27/23 at 1:13 p.m. She said she frequently washed dishes in the main kitchen. She said she was not sure if the dish machine was a high temperature or low temperature dishwasher. She said she was not sure how to check the dishwasher to ensure that it was sanitizing dishes properly. Dietary cook (DC) #2 was interviewed on 3/27/23 at 1:15 p.m. DC #2 said he often washed dishes in the main kitchen. He said he was not sure what type of dish machine the kitchen had. DC #2 said he was not sure how to check to ensure the dish machine was sanitizing dishes properly. The RMD was interviewed on 3/28/23 at 12:55 p.m. He said the dish machine in the main kitchen was a low temperature dish machine. He said they had replaced a part on the dish machine on 3/27/23 (during the survey). He said prior to replacing the part the temperature of the dishwasher was often fluctuating too low. The RMD said the dishwasher was running properly on 3/28/23 when the sanitizer was checked at 300 ppm. The NHA was interviewed on 3/28/23 at 1:13 p.m. He said the dish machine had not been working properly and they had instructed staff to use the three compartment sink. He said the facility had noticed fluctuations in the PPM. DA #2 was interviewed again on 3/29/23 at 12:38 p.m. She said the rinse temperature of the dish machine should be at least 120 F. She said the PPM should be between 200 and 400. She said she was not aware of any recent issues with the dish machine. She said had not been instructed to not use the dish machine recently. The DM and the registered dietitian (RD) were interviewed on 3/29/23 at 2:05 p.m. The DM and the RD said they were unsure of what type of sanitizer the dish machine used. The DM was interviewed on 3/29/23 at 2:31 p.m. She confirmed the dish machine used a chlorine based sanitizer. She said the sanitizer should be at 200 ppm. She said if the sanitizer was too strong it could cause chemical burns and make the residents sick. -However, chlorine based sanitizer should be 50-100 PPM (see facility policy). The DM said she had conducted a verbal in-service on how to use the dish machine a couple weeks ago, but did not document the in-service. DA #1 was interviewed on 3/30/23 at 10:43 a.m. She said the dishwasher rinse cycle should be 120 F or above. She said the ppm should be between 100 and 150. She said she had received training on the dishwasher, but was not sure of the specifics. The NHA was interviewed again on 3/30/23 at 3:12 p.m. He said it was not an issue if the PPMs were too high in the dishwasher.

Based on observation, record review and interviews, the facility failed to ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity which included proper licensure or certification. Specifically, the facility failed to ensure certified nurse aide (CNA) #1, who had medication authority in the facility, was certified in the State registration system to ensure the training was aligned with the requirement of the State. Findings include: I. Review of schedules Review of the working schedules for October 2022, November 2022, December 2022, January 2023, February 2023 and March 2023 identified CNA #1 with medication authority. October 2022: -CNA #1, worked for 10 days: 10/12, 10/11, 10/12, 10/17, 10/18, 10/19, 10/24, 10/25, 10/26 and 10/31/22. November 2022: -CNA #1, worked for 14 days: 11/1, 11/2, 11/7, 118, 11/9, 11/14, 11/15, 11/16, 11/21, 11/22, 11/23, 11/28, 11/29 and 11/30/22. December 2022: -CNA #1, worked for 14 days: 12/2, 12/3, 12/4, 12/9, 12/10, 12/11, 12/16, 12/17, 12/18, 12/23, 12/24, 12/25, 12/30 and 12/31/22. January 2023: -CNA #1, worked for 15 days: 1/2, 1/3, 1/4, 1/9, 1/10, 1/11, 1/16, 1/17, 1/18, 1/23, 1/24, 1/25, 1/29, 1/30 and 1/31/23. February 2023: -CNA #1, worked for 15 days: 2/1, 2/3, 2/6, 2/7, 2/8, 2/9, 2/13, 2/14, 2/15, 2/20, 2/21, 2/22, 2/23, 2/27 and 2/28/23. March 2023: -CNA #1, worked for 11 days: 3/1, 3/6, 3/7, 3/8, 3/13, 3/14, 3/15, 3/21, 3/22, 3/27 and 3/28/23. -CNA #1 was also scheduled on 3/29/23. -It was identified that CNA #1 did not have medication authority on 3/28/23 and was pulled off the medication cart and did not work administering medications on 3/29/23. The schedules identified a licensed nurse on duty at the same time when the CNA #1 was working. CNA #1 started at the facility with medication authority on 7/31/22 through a contract agency. CNA #1 was hired by the facility on 12/13/22. II. Record review On 3/29/23 at 9:13 a.m. the nursing home administrator (NHA) provided a copy of CNA #1 ' s qualified medication administration person (QMAP) license that identified her as a QMAP. -However, QMAPs are not authorized to pass medications (see NHA interview). According to Colorado Division of Professions and Occupations, CNA #1 had a current CNA license in the State of Colorado. III. Staff interviews CNA #1 was interviewed on 3/28/23 at 4:29 p.m. She said she was a medication technician for approximately three years. She said she was able to pass all medications except for intravenous medications and medications through a gastric tube. The social services director (SSD) was interviewed on 3/28/23 at 4:31 p.m. She said she helped complete the nursing schedule. She said CNA #1 was the only CNA with medication authority. She said a licensed nurse had to be scheduled at the same time as CNA #1. The NHA and the regional nurse consultant (RNC) were interviewed on 3/28/23 at 6:05 p.m. The NHA said CNA #1 did not carry a license with medication authority. He said they contracted with an agency for an individual with medication authority. He said the facility was told CNA #1 had medication authority prior to her start date. The NHA said the facility had not verified that CNA #1 had a license with medication authority in the State of Colorado. He said CNA #5 had a QMAP license. He said QMAPs were not authorized to provide medications in nursing homes per the State Operations Manual. The NHA said they immediately pulled CNA #1 off the unit and she will no longer be working as a medication technician. The NHA said the facility did not have any other non licensed nursing staff or QMAPs employed. The NHA was interviewed again on 3/3/23 at 5:07 p.m. He said going forward the human resource (HR) would be trained in different licenses. He said all licenses for agency and hired staff would be checked prior to the individual working.

Based on observations, record review and staff interviews, the facility failed to provide services for seven out of nine sample residents according to professional standards of practice. Specifically, the facility failed to clarify physician's orders with dose information for the administration of diclofenac gel. Findings include: I. Professional reference The diclofenac gel drug information was accessed on 3/29/23 on the Physicians Drug Reference website at https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. Diclofenac is a nonsteroidal anti-inflammatory (NSAID) medication that can be prescribed in intravenous, oral, topical, and ophthalmic formulations. The use of analgesic and antipyretic properties increases the risk of serious gastrio-intestinal events and may increase serious cardiovascular events; use the lowest dose of the shortest time. The topical dosage of diclofenac gel is prescribed as 4 grams (4.5 inches) topically 4 times a daily, with a maximum of 16 grams a day per lower extremity joint) and/or 2 grams (2.25 inches) topically 4 times daily per upper extremity joint. Do not exceed a total dose of 32 grams over all affected joints. II. Facility policy The Medication Administration policy, undated, was received by the nursing home administrator on 3/29/23. The policy stated in pertinent part: Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration; d. Date and time of administration; e. Reason why medication was withheld or refused; f. Signature and title of the person administering the medication; g. Resident response to the medication. III. Observation On 3/29/23 at 10:15 a.m. registered nurse (RN) #2 prepared to administer diclofenac gel. The RN referred to the physician order which directed to apply to the affected area. RN #2 was unaware the medication required a measured dose prior to application and did not seek to clarify the physician order. IV. Record review A list of residents with prescribed diclofenac gel was requested and received on 3/29/23. The list revealed nine residents had diclofenac gel ordered. Each physician order for the diclofenac gel was reviewed and seven of the nine orders did not include a medication dose. V. Interviews Registered nurse (RN) #2 was interviewed on 3/29/23 at 3:10 p.m. She said that she was unaware diclofenac gel required a measured dose. She said she followed the physician's orders and if an order was not clear she would contact the physician for clarification. RN #2 was unable to locate a dosing guide that was provided with the medication and used to measure the gel medication. Licensed practical nurse (LPN) #1 was interviewed on 3/29/23 at 2:30 p.m. She said when she administered the medication, she removed the gel tube from the resident's medication supply, took the tube of medication to the residents room, applied the gel and then returned it to the medication storage. She said she did not measure the gel for dosing and was unaware that the gel should be measured. She said she referenced the physician order which indicated the medication was to be applied to an affected area. LPN #2 was unaware what the medication dosage guide for diclofenac gel was or where to find one. The regional nurse consultant (RNC) was interviewed on 3/30/23 at 2:37 p.m. She said she was unaware the physician orders for diclofenac did not contain dose instructions. The RNC acknowledged the dosage was not present and should be used for diclofenac gel. She said that she would coordinate and follow up to obtain dosing for the applicable orders. She said that a measured dose was necessary to ensure the correct dose was applied.

Based on interviews and record review the facility failed to honor resident choices for three (#22, #12 and #15) of four reviewed for self-determination out of 24 sample residents. Specifically, the facility failed to ensure Resident #22, Resident #12 and Resident #15 received showers consistently according to their choice of frequency. Findings include: I. Facility policy and procedure The Personal Care policy and procedure, revised February 2018, was provided by the nursing home administrator (NHA) on 3/30/23 at 2:21 p.m. It revealed in pertinent part, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of resident's skin. Documentation: the date and time the shower was performed, the name and title of the individual(s) who assisted the resident with the shower/tub bath, all assessment data obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath and the signature and title of the person recording the data. Reporting: notify the supervisor if the resident refuses the shower/tub bath, notify the physician of any skin areas that may need to be treated and report other information in accordance with facility policy and professional standards of practice. II. Resident #22 A. Resident status Resident #22, over the age of 90, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included nondisplaced fracture of right radial styloid process (fracture of the wrist), dementia with agitation and adult failure to thrive. The 12/27/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of two out of 15. She required limited assistance of one person for bed mobility. She required extensive assistance of one person for transfers, walking, tressing, toileting, bathing and personal hygiene. She required supervision set-up assistance for eating and locomotion on and off the unit. B. Record review The personal choice care plan, initiated on 1/2/23, revealed in pertinent part Resident #22 liked to shower two or three times a week. The activities of daily living (ADL) care plan, initiated on 9/28/22, revealed Resident #22 had an ADL self-care performance deficit related to dementia, impaired balance and limited mobility. The interventions included in pertinent part: avoid scrubbing and pat dry sensitive skin, check nail length and trim and clean on bath day and as necessary and provide sponge bath when a full bath or shower cannot be tolerated. The shower documentation from 12/27/22 to 3/30/23 for Resident #22 was provided by the NHA on 3/30/23 at 3:30 p.m. It revealed Resident #22 received a shower on 1/13/23 and 3/9/23. Resident #22 received two showers in a 90-day look back period. III. Resident #12 A. Resident status Resident #12, over the age of 90, was admitted on [DATE]. According to the March 2023 CPO, the diagnoses included adult failure to thrive, anxiety, dementia and depression. The 3/7/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The 12/5/22 MDS assessment documented choosing to shower was very important. B. Resident interview Resident #12 was interviewed on 3/28/23 at 9:34 a.m. She said she could not recall the last time she was offered a shower. She said she preferred to shower twice a week, but was lucky if she was offered one shower a week. Resident #12 was interviewed again on 3/30/23 at 9:32 a.m. She said she was not offered a shower on 3/29/23. She said she had refused one shower recently. She said she refused the shower, because the staff offered for her to shower very early in the morning and she was not awake yet. C. Record review The personal choice care plan, initiated on 5/9/19 and revised on 4/28/21, revealed in pertinent part that Resident #12 preferred to shower two to three times a week in the morning by a female caregiver. The interventions included in pertinent part: providing Resident #12 with a shower on Monday and Thursday mornings by a female caregiver. The ADL care plan, initiated on 12/3/17 and revised on 7/14/2020, revealed Resident #12 had an ADL self-care performance deficit related to limited mobility and history of a stroke. The interventions included, in pertinent part: Resident #12 required total dependence of one staff member for showers on Mondays, Thursdays and as needed by a female caregiver. The staff task sheet indicated Resident #12 preferred showers on Wednesdays and Saturdays. The shower documentation from 1/1/23 through 3/25/23 was provided by the NHA on 3/28/23 at approximately 5:00 p.m. It revealed Resident #12 did not receive a shower on her scheduled shower days on 1/4/23, 1/25/23, 2/1/23, 2/8/23, 2/15/23, 3/1/23, 3/11/23 and 3/22/23. The shower documentation revealed Resident #12 refused a shower on 1/7/23, 1/11/23, 1/14/23, 1/18/23, 1/21/23, 2/22/23, 3/8/23 and 3/22/23. The NHA provided three shower sheets for Resident #12 for a 90-day review period on 3/28/22 at approximately 5:00 p.m. The 1/11/23, 2/8/23, 3/11/23 shower sheet did not document if the resident had refused or accepted a shower. The shower documentation revealed the resident was not offered showers on eight days during the review period. It documented Resident #12 refused eight showers during the review period. -Review of the resident's record did not have documentation indicating why Resident #12 had refused her showers. The resident said she had refused a shower due to the staff coming too early in the morning (see above). IV. Staff interviews Certified nurse aide (CN)A #3 was interviewed on 3/28/23 at 4:01 p.m. He said when he provided a resident with a shower he was responsible for documenting it in the resident's electronic medical record. CNA #3 said Resident #12 preferred showers on Saturdays and Tuesdays. CNA #3 was interviewed again on 3/29/23 at 3:33 p.m. He said when a resident refused their shower he would attempt to offer the shower one more time and then notify the nurse of the refused shower. He said Resident #12 had refused a couple showers. The minimum data set coordinator (MDSC) and the assistant director of nursing (ADON) were interviewed on 3/29/23 at 4:29 p.m. The MDSC said the staff were responsible for documenting in the resident's electronic medical record when residents received and refused showers. The MDSC and the ADON said they were not sure why the shower sheets for Resident #12 did not match the shower documentation in the electronic medical record. The MDSC said there should be documentation that a shower was offered three times prior to staff documenting the resident refused their shower. The MDSC said she was going to implement a new shower program to help ensure all residents received their shower per their preference. The regional nurse consultant (RCR) and the ADON were interviewed on 3/30/23 at 11:28 a.m. The RCR said if a resident was frequently refusing showers it should be included on their care plan. The RCR said they had noticed some issues with their shower program, but still had work to do to ensure all residents were receiving showers per their preference. CNA #5 was interviewed on 3/30/23 at 3:40 p.m. She said Resident #22 preferred to shower on Thursdays and Sundays. She said a couple months ago, she went around to each resident to obtain their shower preference days. The social services director (SSD) was interviewed on 3/30/23 at 3:45 p.m. She reviewed Resident #22's shower record and confirmed Resident #22 received two showers in a 90-day look back period on 1/13/23 and 3/9/23. The NHA was interviewed on 3/30/23 at 5:07 p.m. He said the facility had identified concerns with the bathing program in February 2023 and had provided an in-service to the staff on 2/24/23. He said they had experienced frequent call offs and at times showers were missed. 40467 V. Resident #15 A. Resident status Resident #15, age 55, was admitted on [DATE] and readmitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included other symptoms and signs involving the musculoskeletal system, chronic venous hypertension with ulcer of right lower extremity, type two diabetes mellitus with unspecified complications, other specified depressive episodes, unspecified mood disorder, morbid (severe) obesity with alveolar hyperventilation (out of proportion carbon dioxide production). The 1/27/23 minimum data set (MDS) assessment revealed the resident's cognition was intact, with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 required extensive assistance from more than two staff with bed mobility and dressing. The MDS assessment identified Resident #15 needed total dependence of more than two staff physical assistance for transfers. She required extensive physical assistance from one staff member for locomotion. According to the MDS assessment, she needed physical assistance in part for bathing from one staff member. B. Resident interview Resident #15 was interviewed on 3/27/23 at 3:57 p.m. She said she would like to be bathed more often. Resident #15 said she wanted a bed bath over a shower but only was offered showers. She said it was hard for her to get up and she had fallen in the past when she was getting on a shower/bath chair with staff. C. Record review The personal choices care plan, last revised on 5/4/21, read Resident #15 preferred showers two to three times a week. The shower/bath/partial bath record between 12/27/23 and 3/30/23, was provided by the facility on 3/30/23. The record included a key to codes marked on the bathing record. The key read Sh was used for when the resident received a shower, Bb was for bed bath, and Pb was used for partial bath.The key also read No for Did not occur, RR was use for when the resident refused, RA for Resident not available and NA for Not applicable. The bathing record read the resident received a shower on 2/13/23 and on 3/7/23. The record read the resident refused bathing on 2/6/23 and the resident was not available on 3/14/23. The record did not identify other times the resident received or refused a shower. The records between 12/27/23 and 3/30/23 did not show the resident received or refused a bath or a partial bath. All other coding on the bathing record read bathing (in any form) did not occur or was not applicable. The physician notes on 1/27/23 read the resident was still not interested in leaving her room. The note read the resident requested a bed bath but was encouraged to shower to bath(e) and being as active as possible was what was best for her in the long run. The physician notes on 3/16/23 read the resident was mostly bed bound since December (2022). The activity of daily living (ADLs), last revised 3/23/23, identified Resident #15 had a self-care performance deficit related to CHF (congestive heart failure) peripheral vascular disease, diabetes, and morbid obesity. According to the care plan the would refuse showers repeatedly or let staff give her bed baths and had been spoken to by the director of nursing (DON) about the risk of not showering.The bathing interventions, last revised on 3/23/23, read the resident required extensive assistance from one staff with bathing and showers; the resident preferred showers on Monday, Wednesday, and Friday and as necessary; provide sponge bath when a full bath or shower can not be tolerated. D. Staff interview Certified nurse aide (CNA) #5 was interviewed on 3/30/23 at 3:40 p.m. She said Resident #15 was scheduled for showers once a week on Sundays. The social service director (SSD) was interviewed on 3/30/23 at 3:45 p.m. The SSD said she was also a CNA and worked with Resident #15. She said the resident refused showers/bathing. The SSD said they tried to make sure she had clean bedding and wipe her down as best as possible during ADL care. She said staff did give her a bed bath. The SSD reviewed the shower/bath recorded and could not identify when the resident was offered bed baths or when she refused bathing/showers other than on 2/6/23. The regional nurse consultant (RNC) was interviewed on 3/30/23 at 3:47 p.m. She said Resident #15 recently agreed to be seen by mental health services in hopes that it could help with her ADL refusals. VI. Resident council minutes The resident council minutes for January 2023, February 2023, and March 2023 were reviewed. The resident council minutes, dated 3/22/23, read Baths are not happening like they were supposed to. VII. Staff training The 2/24/23 all-staff in-service agenda was provided by the nursing home administrator (NHA) on 3/30/23. The in-service agenda indicated that staff were reminded to provide showers and baths daily. According to the in-service, the residents have the right to refuse a shower/bath and staff should report the refusal to the nurse so it could be documented correctly. -However, the resident still voiced concerns about bathing in the March 2023 resident council.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents physical, mental and psychosocial well-being were provided for two (#40 and #22) of three residents reviewed for activities out of 24 sample residents. Specifically, the facility failed to ensure Resident #40 and Resident #22 were provided activities and developed a comprehensive care plan which addressed each resident's socialization and activity needs. Findings include: I. Facility policy and procedure The Group Programs and Activities Calendar policy, revised June 2018, was provided by the nursing home administrator (NHA) on 3/30/23 at 2:21 p.m. It revealed in pertinent part, Group activities are available in this facility and an activities calendar is completed and maintained to inform residents, families, and staff of the activity opportunities available. Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and physical, mental, and emotional needs. Modifications, time changes, cancellations or substitutions are reflected on all large posted calendars as soon as possible. The Individual Activities and Room Visit Program policy, revised June 2018, was provided by the NHA on 3/30/23 at 2:21 p.m. It revealed in pertinent part, Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them. For those residents whose condition or situation prevents participation in group activities, and for those who do not with to participate in group activities, the activities program provides individualized activities consistent with the overall goals of an effective activities program. It is recommended that residents with in-room activity programs receive, at a minimum, three in-room visits per week. A typically in-room visit is ten to fifteen minutes in length, but may be longer if appropriate for the resident. The Activities and Social Services policy, undated, was provided by the NHA on 3/30/23 at 2:21 p.m. It revealed in pertinent part, As much as possible, the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care. Should a resident be considered to lack sufficient decision making capacity, mental incompetence, or physical capacity to participate in Activity and Social Service Programs, the Activities or Social Services Staff will document the reasons for any limitations in the resident's medical record (chart). The Attending Physician may also be asked to document the physical or medical basis for such limitations or restrictions. The Spiritual and Religious Activities policy, revised June 2018, was provided by the NHA on 3/30/23 at 2:21 p.m. It revealed in pertinent part, A variety of spiritual and religious activities are available and scheduled through local religious organizations. II. Resident #40 A. Resident status Resident #40, age 88, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) the diagnoses included dementia. The 3/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of one out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, personal hygiene and bathing. She required extensive assistance of two people for toileting. The 12/5/23 MDS revealed it was very important to the resident to have visits from her friends and family and somewhat important to listen to music, do things with groups, do her favorite activities and participate in religious services. B. Observations During a continuous observation on 3/29/23 beginning at 10:14 a.m. and ending at 10:45 a.m. the following was observed: -At 10:14 a.m. Resident #40 was in the common area underneath the television with no meaningful activities in front of her. -At 10:43 a.m. no staff had offered for Resident #40 to attend karaoke (see calendar of events below). -At 10:45 a.m. karaoke was not occurring in the facility. At 3:19 p.m. Resident #40 followed an unidentified certified nurse aide (CNA) into another resident's room. -At 3:20 p.m. a resident asked the CNA if Resident #40 went into her room again. At 3:40 p.m. Resident #40 was at the main entrance of the facility. She attempted to open the door, but was unsuccessful. Resident #40 propelled herself backwards through the hallway. -At 3:43 p.m. the front door was opened and Resident #40 propelled herself out the front door of the facility. The minimum data set coordinator (MDSC) went outside and assisted Resident #40 into the dining room. During a continuous observation on 3/30/23 beginning at 9:54 a.m. and ending at 10:40 a.m. the following was observed: -At 9:54 a.m. Resident #40 was sitting in the common area with her head down and eyes closed. -At 10:05 a.m. Resident #40 was sitting in the common area with her head down and eyes closed. -At 10:11 a.m. the television was playing in the common area, but Resident #40 was not watching it. She had no meaningful activities within reach. -At 10:23 a.m. an unidentified CNA took Resident #40 to her room. -At 10:26 a.m. CNA #5 entered Resident #40's room. -At 10:33 a.m. the unidentified CNA and CNA #5 exited Resident #40's room with incontinence supplies and returned Resident #40 to the common area. -At 10:40 a.m. no staff had offered for Resident #40 to attend corn hole (see calendar of events below). C. Record review The personal choice care plan, initiated on 11/17/22, revealed in pertinent part, Resident #40 liked to participate in activities outside her room. The activities care plan, initiated on 11/17/22 and revised on 2/1/23, revealed Resident #40 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits. The interventions included, in pertinent part: ensuring that the activities Resident #40 attends were compatible with physical and mental capabilities, compatible with known interests and preferences, adapted as needed, compatible with individual needs and abilities and age appropriate, introducing Resident #40 to other residents that share similar backgrounds, interests and encourage interaction, inviting Resident #40 to scheduled activities, providing Resident #40 with activities calendar and thanking Resident #40 for attending activities. The cognitive care plan, initiated on 11/22/22, revealed Resident #40 had impaired cognitive function, dementia or impaired thought process. The interventions included: asking yes or no questions to determine the resident's needs, cuing and reorienting the resident as needed, keeping the resident's routine consistent and try to provide consistent care givers as much as possible, monitoring any changes in cognitive function, presenting one thought at a time and using task segmentation to support short term memory deficits. The 11/16/22 Activity Assessment was completed upon admission. The assessment documented the resident thought it was very important to have books, newspapers and magazines to read, do her favorite activities, participate in religious activities, get outside when the weather was good, and music to listen to. It documented the resident said it was not important to be around pets. It documented the resident said it was somewhat important to keep up on the news and keep up with groups of people. The 2/14/23 Activities-Quarterly/Annual Participation Review documented Resident #40 liked all activities. Resident #40 participated in activities passively. Resident #40 liked visits, Bible study, crafts and food activities. The assessment documented activity-related focuses remain appropriate/current as per current care plan and the interventions and approaches have been effective in reaching goals. III. Resident #22 A. Resident status Resident #22, over the age of 90, was admitted on [DATE]. According to the March 2023 CPO, the diagnoses included nondisplaced fracture of right radial styloid process (fracture of the wrist), dementia with agitation and adult failure to thrive. The 12/27/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of two out of 15. She required limited assistance of one person for bed mobility. She required extensive assistance of one person for transfers, walking, tressing, toileting, bathing and personal hygiene. She required supervision set-up assistance for eating and locomotion on and off the unit. The 9/26/22 MDS assessment did not identify the resident's interests. B. Observations During a continuous observation on 3/29/23 beginning at 10:14 a.m. and ending at 10:45 a.m. the following was observed: -At 10:14 a.m. Resident #22 was propelling herself towards her room. -At 10:17 a.m. the MDSC asked the unidentified licensed nurse to assist Resident #12 back to the common area. The nurse asked Resident #12 what she wanted to do. Resident #12 pointed at the newspaper. -At 10:34 a.m. Resident #12 began propelling herself towards the dining room. -At 10:39 a.m. Resident #12 propelled herself back to the common area in front of the nurses cart. -At 10:43 a.m. no staff had offered for Resident #12 to attend karaoke (see calendar of events below). -At 10:45 a.m. karaoke was not occurring in the facility. During a continuous observation on 3/30/23 beginning at 9:54 a.m. and ending at 10:40 a.m. the following was observed: -At 9:54 a.m. Resident #22 was sitting in the common area. -At 9:59 a.m. another resident waved at Resident #22. Resident #22 smiled and waved back. -At 10:31 a.m. Resident #22 remained in the common area with no meaningful activities. -At 10:40 a.m. no staff had offered for Resident #22 to attend corn hole (see calendar of events below). C. Record review The personal choice care plan, initiated on 1/2/23, revealed in pertinent part Resident #22 preferred activities out of her room. The activities care plan, initiated on 1/2/23 and revised on 2/3/23, revealed Resident #22 was dependent on staff for meeting emotional, intellectual, physical and social needs related to her disease process and physical limitations. The interventions included: conversing with Resident #22 when providing care, introducing Resident #22 to residents with a similar background, interests and encourage interaction, inviting Resident #22 to scheduled activities, providing Resident #22 with the activities calendar and notifying her of any changes, providing assistance with activities of daily living as needed during activities, providing one-on-one activities bedside or in room visits if unable to attend out of room events, thanking Resident #22 for attending activities and escorting Resident #22 to activity. The cognitive impairment care plan, initiated on 8/28/22, revealed Resident #22 had impaired cognitive function or impaired thought process related to dementia. The interventions included: administering medications as ordered, asking yes or no questions to determine the resident's need, cueing, reorienting and supervising the resident as needed, keeping the resident's routine consistent and try to provide consistent care givers, monitoring and documenting any changes in cognitive function, presenting one thought, idea, question or command at a time and use task segmentation to support short term memory deficits. The 3/13/23 Activities-Quarterly/Annual Participation Review documented Resident #22 participated in one-on-ones, balloon toss and stuff involving her hands. The assessment documented activity-related focuses remain appropriate/current as per current care plan and the interventions and approaches have been effective in reaching goals. IV. Scheduled activity events The March 2023 activity calendar documented the following activities: On 3/29/23: -8:00 a.m. Current events -10:30 a.m. Karaoke -2:00 p.m. Paper mache -3:00 Ladybug making -7:00 p.m. Triathlon On 3/30/23: -8:00 a.m. Current events -10:30 a.m. Corn hole V. Staff interviews The NHA was interviewed on 3/30/23 at 1:17 p.m. He said the activities director was not working on 3/30/23. He said the activities assistant had recently quit. He said there were no activity staff members at the facility on 3/30/23. The NHA was interviewed again on 3/30/23 at 1:43 p.m. He said no staff had been appointed to conduct activities while there were no activities staff members in the building. He said the activities director put in her notice and was leaving soon. He said they had been conducting interviews to fill several positions in the activities department. He said they had hired a couple staff members that quit immediately. The NHA was interviewed again on 3/30/23 at 3:12 p.m. He said Resident #22 enjoyed bingo, getting her nails painted and arts and crafts. He said she needed to be on the one-to-one program. The NHA said Resident #40 enjoyed looking at the fish tank, finger painting and listening to music. The NHA said he was not sure why karaoke did not occur on 3/29/23 as the activities director was in the building. He said the activities did not occur according to the activities calendar on 3/30/23.

Based on observation, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed for pressure injuries, out of 26 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #11 had a facility acquired unstageable pressure injury which was not identified as unavoidable in the medical record. The review of the resident's progress notes and medical record between 11/11/21 and 1/10/22 did not identify the resident was seen by her primary physician or by a wound physician after it was identified the resident had an unstageable pressure injury/DTI (deep tissue injury). The review of the resident's medical record indicated the resident was not identified to have any skin related issues to her left heel until it was identified as unstageable on 11/11/21. The resident was at risk for developing pressure injuries according to the Braden scale risk assessment and the 10/21/21 minimum data set (MDS) assessment. The last risk assessment completed was on 8/3/21. The resident did not have a risk assessment completed after the 10/21/21 quarter review or after the resident had an identified unstageable pressure injury on 11/11/21. The weekly summary assessment documented by the nursing staff did not identify the resident had pressure injuries or other skin related conditions on 11/2/21 a week before the resident was identified to have an unstageable DTI/pressure injury to her left heel. The nursing staff continued to document the resident did not have a pressure injury or skin conditions each week following the identification of the unstageable DTI/pressure injury to her left heel. A pressure reducing air mattress was not provided until 12/7/21, 26 days after the resident was identified to have an unstageable pressure injury. The care plan was last updated on 10/28/21. The care plan did not include interventions to treat the unstageable DTI/pressure injury discovered on 11/11/21. A change of condition assessment was not conducted after the resident was identified to have an unstageable pressure injury. Observation identified a second area discoloration on her left heel on the outer lateral side. An LPN (licensed practical nurse) described it as a possible old blister from her boot. There was no mention in the medical record regarding the discolored site. Findings include: I. Facility policies and procedures The policy for wound care, dated 11/1/17, was provided by the nursing home administrator (NHA) on 1/10/22 at 10:24 a.m. The policy provided guidelines to promote wound healing. According to the policy, staff were to: -Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Review the resident's care plan to assess any special needs of the resident; -Provide wound documentation weekly; -Document physician wound care notes, if resident was followed by a wound care physician; and, -Report other information in accordance with facility policy and professional standards of practice. The Prevention of Pressure Ulcers/Injuries policy, revised July 2017, was provided by the clinical care coordinator (CCC) on 1/11/22 at 11:34 a.m. According to the policy, its purpose was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. The policy read: Assess the resident on admission for existing pressure ulcer injury risk factors. Repeat the risk assessment weekly and upon any changes in condition Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs). Identify any signs of developing pressure injuries (i.e non-blanchable [CONDITION(S)]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; Inspect pressure points ( sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, ect .Moisturize the dry skin daily; and Reposition resident as indicated on the care plan . Select appropriate support services based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors .Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. II. Resident #71 status Resident #11, age 71, was admitted on [DATE], with an initial admission on 8/8/17. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/21/21 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired, with a brief interview for mental status (BIMS) score of five out of 15. The resident required extensive assistance of one person for bed mobility, transferring, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS indicated the resident was at risk for developing a pressure ulcer and was not on a positioning/turning program. The 1/3/22 annual MDS in progress identified Resident #11 had one unstageable pressure injury presenting as deep tissue injury (DTI). According to the MDS, the resident had a pressure reduction device to her bed. III. Observation On 1/6/22 at 12:50 p.m., Resident #11 was observed in the lobby sitting in her wheelchair. She wore a Lanard boot on her left foot. The social service director (SSD) attempted to assist the resident to her room but the resident could not lift her feet so the wheelchair could be moved forward. The SSD requested the CNA to place foot pedals on the wheelchair so the resident could be taken to her room. On 1/11/22 at 10:25 a.m. Resident #11 was observed in her bed. Two pillows and a folded blanket floated her heels. She wore socks over her feet. The staffing development coordinator (SDC), identified she was a licensed practical nurse (LPN). The SDC removed the resident's left sock and proceeded to wash her foot with a wet cloth. Two separated areas of the left foot were observed. On the backside of the left heel a dark purple large scab hung from the heel. The area was sensitive to touch. The resident said No, no, don ' t touch as the SDC washed her heel. She blotted the wound with gauze. She applied [MEDICATION(S)] to the whole left heel. On the outer lateral side of the heel was a purple discolored mark. The mark was not connected or in the same location as the DTI pressure injury located on the cusp of the resident's heel. The SDC said the discolored mark was considered part of the pressure injury because it was all on the same heel and that was why she applied [MEDICATION(S)] to the entire left heel. The SDC applied A&D ointment to both feet and placed the socks back on the resident. She offered the Lanard boot over the left foot but the resident refused. On 1/11/22 at 12:03 p.m. LPN #2 was observed to measure the area on Resident #11's lateral left heel. The LPN measured the discolored mark at 2 cm (centimeters) x 1 cm. According to the LPN, it appeared to be a triangle sized, old and dried blister, possibly from her Lanard boot. On 1/11/22 at 1:40 p.m. the director of nursing (DON) observed the possible old blister with the registered nurse (RN) surveyor. The DON described the area on the resident's lateral heel as non-blanchable discolored flakey skin. The RN described the area as an old, non blanchable discolored intact site, purplish read in color, with a dry skin flap that was hard and hanging. IV. Record review A. Skin risk assessment The Braden scale for predicting pressure sore risk, dated 8/3/21, identified Resident #11 was at risk for developing pressure injuries. The 8/3/21 was the most recent skin risk assessment completed. A risk assessment was not completed after the resident acquired an actual pressure injury. According to the 8/3/21 risk assessment, the resident was chairfast, identifying her ability to walk was severely limited or non-existent. The assessment indicated friction and shearing was a potential problem. The assessment read the resident moved freely or required minimal assistance where her skin probably slid to some extent against sheets, chairs, restraints or other devices. B. Care plan The care plan for potential/actual impaired skin integrity, revised on 1/4/21, read the resident had the potential/actual impaired skin integrity was related to her falls, limited mobility, blind, incontinence, and DMII (diabetes). Interventions dated 10/28/21 directed staff to: -Maintain or develop clean and intact skin; -Avoid the resident from scratching herself, keeping her fingernails short and her hands and body parts from excessive moisture; -Encourage good nutrition and hydration in order to promote healthier skin; -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan identified the resident had a deep tissue injury (DTI). The care plan did not identify new interventions to treat the DTI/pressure injury/ulcer documented on 11/11/21 to current. (See below) C. Computerized physicians orders The CPO identified Resident #11 had orders on 11/11/21 to monitor the resident's left heel deep tissue injury (DTI) on each shift until resolved. Staff were to offload at all times and document any changes noted to the left heel on every shift for left heel DTI. The CPO on 11/11/21 included orders for a lanard boot on at all times to the left lower leg secondary to the left heel DTI. The orders directed staff to document if the boot was in place on every shift. The CPO on 11/20/21 directed staff to conduct a weekly skin assessment every night shift every Wednesday. According to the orders staff need to document with the following key: D=Dry; I=Intact; NI=Not Intact; N=New; O=Old. The CPO on 11/22/21 with a discontinue date of 12/29/21 (see below), read to paint the left heel with [MEDICATION(S)] to aid in drying out the area and promote healing daily until resolved on every shift for left heel DTI. The CPO on 11/24/21 identified an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The CPO on 12/29/21 read to paint the left heel with [MEDICATION(S)] to aid in drying out the area and promote healing daily on every shift for left heel DTI until resolved. The review of the CPO did not identify the resident had orders for a pressure reduction device/air mattress. D. Treatment administration record The treatment administration record (TAR) was reviewed for November 2021, December 2021, and January 2022. The TAR included the order to conduct a weekly skin assessment every night shift every Wednesday. According to the orders, staff needed to document with the following key: D=Dry; I=Intact; NI=Not Intact; N=New; O=Old. The review on the November 2021, December 2021, and January 2022 TAR, identified staff did not use the ordered key to describe the condition of Resident #11 skin. A check was marked weekly instead of the above code. The key did not indicate what the check meant in relation to the condition of the resident's skin. E. Weekly summary assessment The 11/2/21 weekly summary assessment identified the resident had blanchable redness to her sacrum and upper mid vertebrae. No other skin conditions were identified. The weekly summary assessment between 11/16/21 and 1/9/22 did not identify the resident had a pressure injury/DTI. According to the assessments, the nursing staff marked no for presence of a current pressure injury or other skin conditions. Under the assessment section to identify a site for concern, the section was left blank. According to the weekly assessments, Resident #1's skin was intact and she did not have a current pressure injury or other skin conditions present. F. Wound log The wound log was provided by the DON on 1/10/22. The wound log identified the DTI/pressure injury measurements and treatments. -11/11/21: Acquired in house left heel DTI unstageable measuring 2 cm (centimeters) x 2.5 cm. Interventions were to offload in a Lanard boot and apply [MEDICATION(S)]. According to the log entry the DTI was intact but identified as a new onset as of 11/11/21. -11/21/21: Left heel (DTI/pressure injury) measuring 2.5 cm x 1.8 cm. Interventions were to paint the heel with [MEDICATION(S)], and apply the Lanard boot to offload. According to the log entry, there was a slight improvement and there was no drainage or odor present. -11/24/21: (Left heel DTI/pressure injury) measuring 2.5 cm x 1.8 cm. The heel was painted with [MEDICATION(S)] and applied boot to offload. There was no drainage and hard, intact and decreased in size (from original onset). -11/29/21: (Left heel DTI/pressure injury) measuring 3 cm x 2 cm (an increase in size from original onset). (Provide) [MEDICATION(S)], lanard boot, off load and air mattress. According to the log entry, no drainage was present and the DTI/pressure injury was dry with a hard intact scab. -12/6/21: (Left heel DTI/pressure injury) measuring 2.8 cm x 2.5 cm. The 12/6/21 entry identified it as hard, dry, and an intact scab. No new interventions. -12/12/21: The review on 12/12/21 wound log indicated other residents were seen on 12/12/21 but Resident #11 did not have a log entry. -12/23/21: Unstageable (Left heel DTI/pressure injury) measuring 2.2 cm x 2.6 cm . There were no new interventions. -12/31/21: Left heel (DTI/pressure injury) measuring 1.8 x 2 unstageable. According to the entry log, there was no drainage and the resident had orders for a wound consult. -1/8/22: Left heel (DTI/pressure injury) measuring 2.2 cm x 2 cm without drainage. Interventions included [MEDICATION(S)] daily and a wound consult. The review of the measurements identified the pressure injury had very little improvement between 11/11/21 and 1/8/22. The review of the log did not include identification or measurement of the discolored area on her lateral left heel. G. Progress notes The 11/1/21 physician note read the resident received an office visit with her primary care physician on 11/1/21 for chronic conditions and medication reconciliation. The 11/1/21 was the most recent encounter Resident #11 had with the physician. No skin concerns were identified by the physician on 11/1/21. The resident was not seen by the physician after it was discovered on 11/11/21 she acquired a pressure injury/DTI. The 11/10/21 interdisciplinary team (IDT) note read Resident #11 had no skin related issues noted. The 11/11/2021 skin/wound note read the nurse on duty reported Resident #11 had an injury to left heel. According to the note, the DON completed the assessment and noted left heel DTI. The area of the DTI was dark purple in color and tender to touch upon palpation of the site. There were no signs of infection or drainage noted. Resident #11 stated her heel was sore. A Lanard boot was applied to the site to ensure pressure was offloaded and heels floated while she was in bed. The resident was noted to have three plus pedal [CONDITION(S)] to both of her feet and one plus pitting [CONDITION(S)] to bilateral extremities (BLE). The physician was notified with a pending follow up call regarding [CONDITION(S)] and pressure injury to the left heel. The nurse on duty would monitor daily and document any changes and report and DON to monitor weekly and PRN (as needed) until resolved. The 11/17/21 IDT note met to review new DTI on Resident #11's left heel. According to the note, a Lanard boot was implemented and the facility would initiate Juven once a day for wound healing. The 11/21/2021 skin/wound note read the DON completed wound rounds on 11/21/21. The note identified the area to the left heel was dry and hard with an intact scab. The resident did not verbalize the complaint of pain with palpation of the site. The Lanard boot remained in place without resident complaints of wearing the boot to aid in offloading at all times. According to the note, the area was cleaned and painted with [MEDICATION(S)] as ordered by the physician to aid in drying the area out and eventual goal for the scab to fall off. The note indicated staff would continue to monitor weekly and note any changes. The 11/24/21 IDT note read the resident's DTI to the left heel had a hard dry intact scab to site. Interventions identified in the note included a Lanard boot and Juven once a day. The 12/1/21 IDT note read the resident resided on an air mattress however according to the DON interview (see below), an air mattress for pressure reduction had to be ordered for the resident. -According to the purchase order (see below) a mattress was not ordered till 12/1/21 and did not arrive at the facility till 12/7/21. The IDT note did not note the increase of size of the DTI between 11/24/21 at 2.5 cm x 1.8 cm and 11/29/21 at 3 cm x 2 cm. The 12/6/2021 skin/wound note identified the area to the left heel remained intact with dry hard scab and did not have buoyancy when pressure applied to site and no signs of pain note. According to the note, staff would continue to monitor. The 12/7/21 IDT note read the heal appeared to be healing. The 12/15/21 IDT note read the resident's DTI to the left heel was healing and decreasing in size. According to the note, the left heel was offloaded with the Lanard boot and an air mattress to alleviate pressure. The note identified the resident's heels were floated on pillows when in bed. The resident was frequently turned when in bed. The 12/19/2021 skin/wound note was identified as a late entry note on 12/13/21. According to the note, the left heel unstageable 2.2 x 2.4 cm DTI was decreasing in size and dead tissue was noted to be flaking off with new tissue growth present under dead tissue that came off during cleaning. According to the note, the turning schedule continued. The 12/21/21 IDT note read the DTI to the left heel was now considered unstageable. However, according to the wound log, the DTI was considered unstageable on 11/11/21 when it was first identified. No new interventions were identified in the CPO or the care plan. The 12/29/21 IDT note read Resident #11 had an ongoing left heel unstageable pressure injury. According to the note, the physician was contacted to request orders for a wound care consult. A wound care consult was not requested for the unstageable DTI/pressure injury prior to 12/29/21. The 1/2/2022 skin/wound note read wound rounds were completed on 12/31/21. A dark hard intact callous to the left heel was identified. According to the note, no dramatic changes noted to the site since last the assessment. However the note indicated the area to have a slight amount of buoyancy to the center of callous when the area palpated upon assessment which was not present during prior assessments of the left heel. The note read an appointment would be scheduled with the wound care clinic for further evaluation of the site. The left heel was dry and had sloughing skin which was noted to come off during cleaning of the site. The area was painted with [MEDICATION(S)] as ordered. Both feet remain dry but noted improvement in appearance of feet since both are being moisturized daily with A&D ointment excluding left heel. The left lower leg remained in the Lanard boot to offload pressure to the left heel and both feet are floated on pillows while in bed. Resident #11 continued use of the air mattress with no other skin issues present. The review of the resident's progress notes and medical record between 11/11/21 and 1/10/21 did not identify the resident was seen by her primary physician or by a wound physician after it was identified the resident had an unstageable pressure injury/DTI. The progress notes did not include a second area on her left lateral heel. H. Air mattress A purchase order for an air mattress was provided by the DON on 1/11/21. The purchase for an air mattress was submitted on 12/1/21 and arrived at the facility on 12/7/21. V. Staff interview The SDC was interviewed on 1/11/22 at 11:18 a.m. She said the location of the wound on the heel appeared to be from pressure of her bed. She had no current signs of infection and was starting to dry out. She identified two areas on her heel. The LPN said one was intact, the other was open. She said the left lateral area on the heel was about the size of a quarter. She said the resident prefers to be in bed and would often wiggle her feet potentially causing shearing. LPN #2 was interviewed on 1/11/22 at 11:53 a.m. LPN #2 said the facility was treating a wound to the back of Resident #11's heel, describing it as a quarter sized area with a scab hanging from the site. He said he did not notice any other areas to the resident's heel. She said she would look at her heel again (see above observation). The DON was interviewed on 1/11/22 at 12:10 p.m. with the corporate clinical consultant (CCC). The DON identified preventive measures to prevent pressure injuries. She said the resident would be assessed for risk of pressure injuries. She said if the resident was at a high risk, the resident would be frequently repositioned and toileted. They would be evaluated for nutrition at risk, ensuring adequate fluids and nutritional needs. The resident would have weekly skin assessments. The DON said offloading would be implemented and an air mattress would be put in place if warranted. The DON said Resident #11 had a current unstageable pressure injury that was facility acquired on the cusp of her heel. The DON said she last saw the pressure injury on 1/8/21. She said the injury had a hard center and the skin around the area was sloughing off. The DON said residents should not have a facility acquired pressure ulcer/injury but sometimes they were unavoidable. The DON said if a facility was doing prevention care for pressure injuries, injuries could be potentially avoided. She said they were trying their best to avoid facility acquired pressure injuries. She said prior to the pressure injury, Resident #11 had weekly skin assessments, repositioning, and fluid and nutritional needs were met. The DON said when the deep tissue injury was first reported to her on 11/11/21, the condition of the DTI was determined to be unstageable. The DON said the resident was frequently positioned prior to her facility acquired pressure injury, however, according to the 10/21/21 MDS the resident was not on a repositioning/turning program. The resident's care plan did not direct staff to frequently reposition/turn the resident. The DON said an air mattress to reduce pressure to the heel was implemented in December 2021. She said the air mattress had to be ordered. The DON provided the purchase order for the air mattress, arriving on 12/7/21 (see above). The DON said all resident treatments needed to have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The DON said she was unsure what caused the pressure injury. She said the resident did not use foot pedals because she was able to slightly propel herself with use of her feet. The DON said a Lanard boot was implemented when the pressure injury was identified. The DON reviewed the resident's care plan and confirmed interventions to treat the unstageable pressure injury were not included in the care plan. She said the care plan should have been person centered and included all the interventions they incorporated to treat the pressure injury. She said the plan should have included the air mattress, the Lanard boot, a turning schedule, offloading, floating the heels, physicians orders, and weekly skin monitoring. The DON said the nurses should review the pressure injury daily and document the treatment. She said a weekly summary should be completed and include a review of the resident's skin. The review should include any potential changes in the skin as well as current identified skin conditions such as a pressure injury/DTI. The DON reviewed the weekly summaries prior to the 11/11/21 unstageable pressure injury and the summaries after the pressure injury was identified. The DON confirmed the weekly summaries indicated there were no skin concerns or pressure injuries. She said she did not know why the nurses did not document the resident's skin issues. The DON said she would create an action plan to include a facility audit of weekly summaries with possible corrective actions as needed. She said she would stress the importance of the accuracy of the summaries. She said the nursing staff were responsible for reviewing and promoting good skin integrity on every resident in the facility. The CCC said the facility would investigate why staff were not documenting skin concerns. The DON said she needed the nurses to continue to check on the resident's skin and notify her of new injuries or changes in condition. The DON said a change of condition MDS assessment was not completed after the resident had an identified unstageable pressure injury. She said a change of condition assessment could have possibly identified the missing orders for the air mattress and the lack of interventions on the care plan. The DON confirmed Resident #11 was last seen by her primary care physician on 11/1/21. The DON said Resident #11 had not had an appointment with her physician after she identified on 11/11/21 a pressure injury to her left foot. The DON said Resident #11's primary care physician was located in another town and it was a challenge to see him for appointments. She said the physician does not visit the facility and the resident has not had a telehealth appointment with him. The DON said the physician has not seen the pressure injury but was aware of it. The DON said the resident had not been seen by a wound physician. The DON said she noticed over the holidays, there was buoyancy to the pressure injury and determined a need for a wound consult. She said she set up an appointment on 1/13/21 at the wound clinic but the resident was currently in isolation for COVID and would not be able to go. The DON said she would contact the clinic and request the wound team to visit her at the facility. The DON was asked about the second skin condition on the resident's heel, identified as a possible old blister on the left lateral heel. She said she was not aware of a second skin condition on the resident's heel or had staff communicate any other skin conditions to the resident's left heel. She said she would look at her heel to review (see observation above). The DON said she would do a whole house sweep audit reviewing resident care/treatment. She would review risk assessments, skin documentation, orders for treatment and make sure all interventions were included in residents ' care plans to help prevent skin breakdown.

Based on record review and staff interviews, the facility failed to thoroughly investigate allegations of verbal and physical abuse involving two (#1 and #2) of four sample residents. Specifically, the facility failed to: -Thoroughly investigate the alleged violation; -Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and -Take appropriate corrective action, as a result of investigation findings. The failures resulted in incidents of abuse involving incontinence care with certified nurse aides (CNAs). The first incident resulted in an allegation of verbal and physical abuse by CNA #1 towards Resident #1 on 6/11/21. Although Resident #1 was the victim of an alleged verbal and physical abuse and indicated other staff were aware of the incident; it was not investigated until the following day when she reported feeling angry and fearful. Therefore, since the first incident of abuse was not investigated a second incident occurred with Resident #2 involving CNA #2 on 7/4/21. Although other staff were aware, the incident was not investigated until two days later, when the resident reported being fearful. Cross-reference F600, failure to ensure residents were free from abuse. Findings include: I. Facility policy and procedures The Abuse Prevention policy and procedure, dated 10/1/11, was provided by the director of nursing (DON) on 8/6/21 at 4:00 p.m. The investigation section required in pertinent part the following: All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the administrator and in accordance with state and federal law. An immediate investigation into the alleged incident, during the shift it occurred on, is initiated as follows: 1. Complete resident incident report form at time of incident 2. Interview the resident or other resident witnesses. The interview is to be dated, documented and signed by the nursing supervisor using the sample resident interview form. 3. Interview the staff member implicated. Have the employee document knowledge or version of the incident in a written narrative that is dated and signed using the employee/witness investigation statement. 4. Interview all staff on that unit, as well as other available witnesses. Witnesses are to document their knowledge of the incident in a written narrative, signed and dated, on the employee/witness investigation statement form. Immediate response: -Documentation in the medical record to reflect direct observable facts, i.e. resident's statement about what occurred, physical findings. -An incident report is to be completed, to include the written summary of the investigation and facility actions taken, for quality assurance (QA) review and litigation analysis. -Follow up with appropriate disciplinary action, which may include reinstatement with or without retraining or termination as indicated by investigation results. -When the investigation is inconclusive, written documentation of a monitoring program is completed, reviewed with the employee and implemented. -Once the investigation is completed, the administrator or designee will inform the resident or the resident's representative of the results of the investigation and corrective action taken, if any. II. Resident #1 Resident #1 reported on 6/11/21 that certified nurse aide (CNA) #1 verbally and physically abused her. The incident was not investigated until 6/12/21. When the nursing home administrator (NHA) interviewed Resident #1, the resident said he minimized and unsubstantiated her concerns and did not take proper corrective actions. Comparison of the resident's statement and NHA's documentation revealed he did not accurately document the resident's statements during the interview, and did not conduct detailed interviews with all involved witnesses and parties. As a result, the investigation was not thorough, the outcome was not shared with the resident by the NHA, and the resident continued to feel fearful. The CNA was suspended and later returned to work without written disciplinary action or a monitoring/supervision plan. The facility's most recent abuse training was conducted on 4/7/21, and the above abuse incident occurred on 6/11/21. This event was not thoroughly investigated and there was no staff training after the 6/11/21 event. A second abuse incident occurred on 7/4/21 (see below) which the facility also failed to thoroughly investigated. II. Resident #2 Resident #2 (who was discharged on [DATE]) reported a verbal abuse allegation that occurred on 7/4/21 regarding an interaction with CNA #2. The NHA did not conduct and document a detailed interview with the resident to demonstrate a thorough understanding of her allegations and the abuse she allegedly suffered. He did not thoroughly interview the staff on duty about their knowledge and understanding of the incident, yet unsubstantiated the allegation without thoroughly investigating and gathering sufficient information to make the determination of unsubstantiated. Although the resident alleged abuse, he documented that the resident abused the CNA. The CNA did not return to work after her suspension. Education was not provided to the other staff. -No documentation could be found to show exactly when CNA #1 was suspended, when she returned to work in the facility, and under what limitations and supervision. III. Record review Review of both facility investigations revealed the facility failed to show evidence of thorough interviews where residents were listened to and their concerns were thoroughly documented and investigated. Interviews with Resident #1 revealed a marked difference between what she stated had occurred and what the NHA documented. The NHA's documentation blamed the resident for her response to the CNA instead of thoroughly documenting her reports of abuse by the CNA. The resident reported during interview that CNA #1 had forced her will on her and verbally and physically pushed and injured her but the NHA's report only reflected that the resident hit and kicked the CNA. The NHA also inaccurately documented Resident #3's (the roommate's) statement. The NHA documented Resident #3 reported that CNA #1 was kind to Resident #1 who was abusive to CNA #1. However, when interviewed by the surveyor Resident #3 said CNA #1 was abusive to Resident #1 and she (Resident #3) told her to get the nurse. The NHA's documentation of Resident #2's statement did not encompass the resident's description of the CNA's actions, comments or tone of voice, although the resident was quoted by the NHA as saying the CNA was more worried about her safety rather than the resident's safety while changing her and the resident was fearful of CNA due to not being considerate of her feelings. What exactly was said and what occurred was not documented or explored. The NHA and DON did not initiate immediate investigations, interview the residents in a detailed manner, document incident reports or investigative reports, interview staff in a detailed manner regarding their knowledge of the incidents, follow up with disciplinary action and monitoring/supervision plans for alleged staff assailants, follow up with the residents for their knowledge and approval of corrective actions taken, and ensure all documents were dated and signed by the nurse supervisor throughout the investigative process. Detailed and accurate resident and staff interviews were not documented for either allegation, neither allegation was documented in the residents' medical records, incident reports and investigative reports were not properly completed, corrective action was not documented as discussed with the residents, and follow-up disciplinary actions were not documented for staff. Both allegations involved incontinence care, failure by staff and administration to recognize and properly respond to resident care preferences and requests. V. Regular visitor interview A regular visitor to the facility was interviewed on 8/6/21 at 8:30 a.m., and provided a follow-up email on 8/9/21 at 10:15 a.m. that documented the following: Based on numerous visits and conversations with the residents, my overall impression is that the staff and administration are not providing resident centered care. I sense a lack of empathy for the residents and the understanding that the facility is their home. The administration appears to hold the belief that residents are to fit in with the facility ' s schedule and rules instead of the facility working to meet the needs and wishes of the residents. When issues arise, the administration quickly identifies the cause as something the resident involved has, or has not, done (e.g. the resident didn ' t ask for a shower) instead of talking with the resident and identifying how the facility can better meet that resident ' s needs. The administration ' s response also suggests that they do not believe what the residents have to say. Though I have heard from residents that some of the staff are caring and trying their best, that is not the norm. Perhaps this is due to the attitude of the administration and/or a lack of staff training in resident centered care. I have also been told by residents that they do not voice their complaints because they are concerned that they will experience repercussions if they do. V. Staff interviews The NHA was interviewed on 8/6/21 at 1:35 p.m. He acknowledged this was the second documented abuse allegation within a month regarding incontinence care by CNAs. He said he had forgotten about this second incident, and said the CNA was suspended pending investigation and did not return after her suspension. The DON was interviewed on 8/6/21 at 1:54 p.m. She said she did not know any of the details of the investigation involving Resident #2. She was on vacation that week and it was a conflict of interest because CNA #2 was her daughter and CNA #4 was her daughter's best friend. She said the ADON was involved but she was working nights and they had not been able to contact her. The DON acknowledged there was no resident interview in the investigative documentation, no interviews with other staff working that shift on what specifically happened, and no evidence of follow-up with the resident. She acknowledged there was no system in place to address the facility's multiple conflicts of interest during abuse investigations. IV. Facility follow-up The DON was interviewed on 8/6/21 at approximately 4:00 p.m. The DON said she had developed a process improvement plan (PIP), provided a copy, and said she was still working on it. The PIP, dated 8/6/21, was titled Abuse Investigation Improvement, and contained the following incomplete list of concerns to be addressed: -Lack of thorough documentation in investigation packets -Lack of summary included -Non-specific questions related to investigation -Lack of signatures and dates on interview forms -Lack of follow up with identified victim on investigation findings in abuse packets -Inadequate documentation and lack of flow in abuse investigation process -Lack of insight for outside sources interpretation to investigations. The action plan to correct issues identified listed: -Outline specific questions regarding alleged abuse 8/6/21 -IDT training on new process for abuse investigations going forward 8/9/21 -All staff education on abuse reporting, investigation and follow up 8/9/21 -Provide detailed summary of investigation process and details concluding investigation ongoing -Provide detailed summary of findings discussed with resident and plan of action after completion of investigation - ongoing -Ensure all items in an abuse investigation are dated and signed by appropriate parties relevant to the investigation - ongoing. The DON said they would ensure staff training was conducted so staff were able to recognize different types of abuse, that no means no, and to listen to residents and provide care in the manner they preferred. She said, We will do the training. We try to do investigations to the best of our ability and inform the residents. She said she wanted to have an objective person interview residents in detail to ensure they were being heard, felt free to report abuse, and so they would know their concerns would be thoroughly investigated and action taken.

Based on interviews and record review, the facility failed to provide a safe environment and protect residents from staff-to-resident abuse involving two (#1 and #2) of four sample residents were free from verbal and physical abuse. The facility failed to ensure Resident #1 was free from abuse by certified nurse aide (CNA) #1. The resident reported she was verbally and physically abused by CNA #1 on 6/11/21. Although CNA #1 was suspended and instructed not to provide care for Resident #1, the resident said she was angry at the time of the incident and fearful of retaliation afterward, and felt the nursing home administrator (NHA) minimized her concerns and failed to [MEDICATION(S)]. Residents were not asked during the investigation if abuse had been reported to them by anyone or if they overheard verbal or physical abuse or dignity violations. There was no documentation of the interview with Resident #3, who was Resident #1's roommate, although it was mentioned in the abuse investigation form. Resident #1 said nobody told her the outcome of the investigation. She said she asked the assistant director of nursing (ADON) if she could call the state but the ADON said she would have to call corporate, then the ADON spoke to the director of nursing (DON) and nursing home administrator (NHA). There was no evidence the facility leadership followed up on Resident #1's statement of being physically abused and fearful, whether CNA #1 had provided care for Resident #1 since the reported incident, or whether the facility informed Resident #1 of actions taken, or provided emotional support and reassurance to Resident #1. There was no documentation of follow-up action taken by the facility regarding how Resident #1 would remain free from abuse, or any follow-up interviews with Resident #1 for reassurance that she felt safe and would remain free from further abuse. Moreover, there was no evidence of follow-up with CNA #1 and what corrective actions were taken, other than being instructed not to enter Resident #1's room. There was no evidence of follow-up staff training on identifying, preventing and ensuring residents were free from abuse and neglect. Additionally, former Resident #2 reported she felt unsafe and fearful after a verbal abuse incident by CNA #2 on 7/4/21. The incident was unsubstantiated without benefit of a thorough investigation, and there was insufficient evidence of actions taken to ensure Resident #2 felt safe while she remained in the facility. The NHA did not document detailed interviews with Resident #2, the nurse on duty, all the staff who were working that night and might have witnessed or had knowledge of the incident, and did not document discussing the outcome of the investigation with Resident #2. Cross-reference F610, failure to ensure a thorough investigation of allegations of abuse. Findings include: I. Facility policy and procedures The Abuse Prevention policy and procedure, dated 10/1/11, was provided by the director of nursing (DON) at approximately 4:00 p.m. on 8/6/21. The purpose of the policy/procedure was to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents . and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse. Abuse definitions included, harmful treatment, insulting language, intimidation. The abuse awareness section documented in part the right to report abuse, neglect or mistreatment without fear of reprisal. II. Resident #1 A. Resident status Resident #1, age 79, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 7/9/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no mood symptoms other than appetite concerns, no [CONDITION(S)] or [CONDITION(S)], no behavioral symptoms and no care rejection. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was frequently incontinent of bladder and occasionally incontinent of bowel, with no toileting programs for bladder or bowel. Her balance was not steady but she was able to stabilize without human assistance. She used a wheelchair for ambulation. She had no falls since her prior assessment and no falls per her 4/27/21 MDS assessment. B. Resident interviews Resident #1 was interviewed on 8/5/21 at 4:35 p.m. The resident said facility staff treated her with dignity and respect, Except one time (CNA #1) tried to force her will on mine. She was changing me, removed my soiled (brief), told me to sit down and I kept saying no and she tried to force the issue. I was saying no and was really angry at that point and I said no I'm not, so she said sit on the bed, then and I said not before I put my diaper on. She kept pushing the point. At some point she pushed me. I had a bruise on my chest and hit my head on the wall. She was standing on my oxygen cord and about ripped my nose off so I yelled at her about that. Then she said that she was going to get the nurse so she wouldn ' t have to deal with me, so she left. At that point I managed to get over and put a towel down and noticed I had some stool on me. Anyway the nurse came down and I told her I was very angry. The day that it happened nobody followed up with me. It happened at about 2:00 p.m. more than a month ago. (Resident #3) heard it and she said in a loud voice at the time, 'Just leave her, she's not going to change her mind,' and (CNA #1) didn't listen to her at that point. Anyway the NHA came to interview me and he didn't seem to think the CNA did anything wrong. As far as her pushing me down he kind of pooh-poohed that . I told him she'd pulled my nose so hard that my priority was the pain in my nose and not where she was pushing me. He said he suspended her for three days and he investigated and then he said the allegation of abuse - he didn't tell me that (another staff person did) - the allegations of abuse were unfounded and (CNA #1) returned to work on the other side only. She wasn't to work over here or work with me and she's been working. But my experience with abuse is, she was guilty of abuse when she tried to force her will on me. I'm an ex-director of nurses so I know it was abuse and I don't think it was handled correctly. I told the ADON (assistant director of nursing). She'd been off for several days. Resident #1 said nobody told her the outcome of the investigation. She said she asked the assistant director of nursing (ADON) if she could call the state but the ADON said she would have to call corporate, then the ADON spoke to the director of nursing (DON) and nursing home administrator (NHA). Resident #1 said, Initially I was very fearful, and less so now. We don't speak to each other. I pass her (CNA #1) in the lobby. I think she should've been terminated. It wasn't the first time that she's done that to me or others. I'm concerned about her doing it to others. She's a girl who's very opinionated. The first time she'd tried to get me to sit in the wheelchair naked, I'd done it the first time but not this time, and she didn't like it. She likes to call the shots and be in control. When she worked here during the COVID outbreak we were in isolation and we had to do things when she wanted them done. I worry about her being with other residents and getting away with that. I'm still fearful knowing she's here and seeing her. Resident #1 said nobody had checked back in with her to see how she was feeling. She said nothing like this had happened with any other staff. The trend is that nothing ever goes anywhere, it goes to the NHA. I know why they say that. He pooh-poohed it when he talked to me, so I understand what people (residents) mean when they say it didn't go anywhere because he did it to me. Resident #1 said she spoke with the ADON after the incident and she deferred to the DON, and we didn't speak of it again. I asked her if the DON had talked to corporate. She said she didn't know. Resident #1 said, I got very loud when I was saying no and they heard me down at the nurses' station, I know they did. I overheard someone say they heard me saying no. Knowing that, I figure it was abuse and I think they need an in-service at the very least. In-service the staff on what abuse is, because it can just be forcing someone, trying to get your will (by forcing a resident to do something against their will). I don't remember for sure if she pushed me down because I can't say that, but I do remember a lot of force and I don't think I could have fallen back with that much force. I won't hold her to pushing me. I told her I'm not sitting in my chair. I'm dripping with urine. The (NHA) said 'Did you tell her you were dripping with urine?' No, she (CNA #1) could see it. That was awful. The NHA said, 'You were supposed to tell her. It was your responsibility to tell her.' I got angry with him too. I raised my voice as I was talking to him. And he said 'I'm not the enemy.' I almost said I'm not so sure. Then he said he'd come back and talk to me later and he never came back to me. One thing I said to (CNA #1) was 'I don't sit on my furniture without clothes on.' When I said that to the (NHA) he didn't take that seriously. And then he told me that she didn't know and he wasn't going to tell her who complained, yet he told her she couldn ' t talk to me. It doesn't make sense. Resident #1 said she was initially fearful of retaliation but not now. She works here two days a week and I can handle that. ]However, Resident #1 said she still had a feeling of unrest. I can't let go of it. It was really on my mind for a while. I was afraid. Now I don't think about it very much. Resident #1 said, I don't think she (CNA #1) thinks she did anything wrong, and that was part of Resident #1's concern. Resident #3, who was Resident #1's roommate, was interviewed on 8/5/21 at 5:20 p.m. Resident #3, according to her 8/6/21 MDS, had a BIMS of 14 out of 15, no [CONDITION(S)], no [CONDITION(S)], and no behavioral symptoms including care rejection. Observation revealed Resident #1 and Resident #3 shared a large room, with separate entry doors and a wall partition between them which allowed visual privacy for each bed. Resident #3 said she overheard the incident on 6/11/21 with CNA #1, although she was unable to see what occurred. Resident #3 said CNA #1 asked the resident to do something and Resident #1 said no. They were both angry and pretty soon it got to shoving and pushing . and I told (CNA #1) to go to the nurse. Resident #3 said CNA #1 had in her mind what she wanted to do and that's how it was going to be. She said, When you push a person so far to make them that mad, it's abuse . I made (CNA #1) get out of here. I told her to go on to the nurse because I knew it wasn't going to stop if she didn't. I know (Resident #1) doesn't like people pushing her around and that's what (CNA #1) was doing. C. Record review 1. Facility investigation The Resident Abuse Investigation Report Form, dated 6/12/21, documented a physical abuse incident that occurred 6/11/21 after noon, after lunch was reported on 6/12/21 (no time documented) by Resident #1. Under injuries, an unnamed staff person (different handwriting than NHA's) documented, No s/sx (signs or symptoms) injury noted, skin warm, dry and intact, no bruising noted, no scratch marks or discoloration noted . no injuries noted. The name of the person accused (although details of the allegation were not documented) was CNA #1. No witnesses were documented as present, although a statement from the roommate was documented as follows by the NHA: Roommate (Resident #3) stated the resident was yelling & hitting at CNA. Roommate stated that CNA was kind and left room to get help after she was being hit. The summary of findings documented by the NHA revealed: Investigation finds that no abuse happened . Resident is unable to tell if or where she was pushed. Resident admitted that she was yelling & hitting CNA. Resident stated that she does not like CNA & because it was her she was annoyed. Corrective action taken was documented as: Employee was educated to not enter that resident's room. Employee to inform other staff when that resident needs help. Results of the corrective action were documented as reported to the ombudsman, law enforcement, administrator, DON and corporate regional leadership on 6/12/21. The document was signed by the NHA and referred to the following attachments: According to an unsigned, undated, untimed note, Resident #1 was interviewed by the NHA, who documented the following: I, NHA, went to interview resident about alleged abuse. Resident stated that she does not like CNA and that when she tried to help her change she was yelling and hitting CNA. Resident stated that she could not identify where she was pushed or if she was pushed. Resident stated that CNA was trying to change her, but because she does not like her she was annoyed by CNA. An undated, untimed, unsigned statement further documented, Resident states to writer while administering medications, 'I want to talk to you about what happened yesterday.' Writer asked resident if she could wait until after medication pass was completed. Resident stated 'yes, but please don't forget to come talk to me, that was abuse.' Writer then asked resident to explain, (Resident #1) then stated, 'I will not sit in that chair with no pants on.' Writer asked (Resident #1) who asked her to sit in her chair with no pants on. (Resident #1) stated 'the CNA.' She then went on to state, 'she was mean to me and pushed me down on my bed and then she pulled my oxygen out of my nose, because she was standing on it when she turned to walk away.' Writer asked (Resident #1) to identify the CNA. She named (CNA #1). Writer asked resident if she was scared and her reply was 'no.' Writer then asked (Resident #1) if she was afraid of (CNA #1). Her reply was 'I am now.' Writer notified DON. Staff member on duty this day and were suspended pending investigation. -The name/title of the staff person who conducted this resident interview was not documented, and it was not documented if the interview was conducted before or after the NHA interviewed Resident #1. There was no evidence the facility leadership followed up on Resident #1's statement of being physically abused and fearful, whether CNA #1 had provided care for Resident #1 since the reported incident, or whether the facility informed Resident #1 of actions taken, or provided emotional support and reassurance to Resident #1. A copy of page 11 of 24 of Resident #1's undated care plan was included with the investigation. It could not be determined whether the care plan was documented before or after the resident's abuse allegation. The care plan identified, (Resident #1) has a potential to be physically aggressive and verbally (related to) [CONDITION(S)] disorder and is known to make false allegations at times. The goal was for no episodes of physically aggressive behavior through the next review date. Interventions were: -Administer medications as ordered (Olanzapine). Monitor/document for side effects and effectiveness. -Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. -Assess for and address contributory sensory deficits. -Give (Resident #1) as many choices as possible about care and activities. -Modify environment: adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed, etc. -Monitor every shif]t and document observed behavior and attempted interventions in behavior log. -Monitor for and anticipate (Resident #1's) needs: food, thirst, toileting needs, comfort level, body positions, pain, etc. -Monitor for changes in mood or behaviors and document due to allegations of abuse. -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assess verbalization for source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff when agitated. -Psychiatric/psychogeriatric consult as indicated. A statement by CNA #1 included in the investigation supporting documents did not include a time, interviewer name or whether it was a written statement. There was no signature by CNA #1 or the interviewer. The statement, a computer print-out, documented: The following is (CNA #1's) account of her encounter with (Resident #1) on Friday June 11, 2021: 'When I answered the light, it was (Resident #1) she was in her chair and told me she was wet and needed to be changed. I said Ok let's head to the bathroom. She snapped at me and said No I want to change in here. I said Ok do you need to go to the bathroom? She said No I already went. I said Ok no big deal we can do it in here, I grabbed a brief, wipes and a new pair of pants and she started pushing herself toward the top rail of her bed, I assume to assist her in standing up, I locked the brakes on her chair and put my gloves on, she stood up and I pulled her pants and brief down. I asked her to sit down, she said No I don't want to sit in a wet chair. She had a blue towel on her bedside table so I grabbed that and put it in her chair and said Ok you can sit down now and she said No I want to sit on the bed. I hesitated and said Ok and tried to guide her down as I was attempting to assist her to pivot to the bed, she jerked her arm away and said No I want to change standing up. I said (Resident #1) we can't change you standing up. When I said that she tried to kick me and lost her balance. I guided her to the bed. When she went down on the bed, she screamed you tore my nose off you [OBSCENITY] ing [OBSCENITY] , she was trying to hit and kick me yelling you ripped my nose off you [OBSCENITY] ing [OBSCENITY] . I said (Resident #1) please don't hit me, please stop hitting me. I'm sorry I didn't mean for that to happen (meaning ripping her oxygen off) She was sitting there and I took her brief off and noted her pants were wet, I turned around to get new pants and when I turned back, she was attempting to stand up with no foot wear except socks (not non skid ones) I asked her to please sit back down she said no I don't want to sit. I said let me get you dressed and back in your chair and then I will leave you alone. She said no I wasn't (stet) to stand up, then sit down then put my pants on. I told her it would make more sense to put her pants and shoes on and then transfer, that's when she started screaming it was her right and she gets what she wants repeatedly. She then told me to get out. So, I backed away and asked her to please stay there. I went to the nurse's station immediately and told (CNA #3 and licensed practical nurse #1). I explained the situation so that (Resident #1) could get assistance and to let the nurse know that (Resident #1) was acting out of normal limits today. I then removed myself from the situation. Copies of nine staff questionnaires were included in the investigation packet. Each staff person was asked if they had ever witnessed physical or verbal abuse or neglect, and if so to whom they reported. Licensed practical nurse (LPN) #1 was interviewed and responded NO to every question. Her interview was undated and was signed by the NHA. The NHA did not document that LPN #1 was asked about what CNA #1 and Resident #1 reported to her on 6/11/21 (see CNA #1's statement above), although CNA #1 said she had explained the situation and requested assistance from LPN #1 and CNA #3. The NHA did not document that he asked LPN #1 if abuse had been reported to her by any resident or staff. The other staff interviews the NHA conducted were dated 6/14/21, two days after the abuse incident was allegedly reported (see above, all stated no knowledge of abuse). The ADON was not documented as interviewed although Resident #1 talked with her after the incident, nor were other staff present interviewed although Resident #1 said she yelled loudly enough for other staff to hear her (see resident interview above). -No documentation could be found to show exactly when CNA #1 was suspended, when she returned to work in the facility, and under what limitations and supervision. Copies of nine resident questionnaires were included in the investigation packet. Each resident was asked if they had witnessed physical or verbal abuse or neglect, and if so to whom they reported. All nine residents were documented to have said NO to each of the questions. The questionnaires were dated 6/14/21, two days after the abuse was reported to the facility, and signed by the social services director (SSD). -Residents were not asked if abuse had been reported to them by anyone or if they overheard verbal or physical abuse or dignity violations. -There was no documentation of the interview with Resident #3, who was Resident #1's roommate, although it was mentioned in the abuse investigation form (see above). A copy of an email at the bottom of the investigation packet documented the NHA had emailed the local police department on 6/12/21 at 1:15 p.m. with the following information: Physical abuse . We had a resident report to us today that a CNA was rough with her and she is fearful of this CNA. We suspended the CNA pending investigation. If we can have a case number that would be great. -There was no evidence of a response from the police department, or evidence the email was confirmed as received. There was no summary investigative report, no documentation of how or from whom the NHA learned of the abuse allegation, no determination of whether or not Resident #1's abuse allegation was substantiated, no documentation of follow-up action taken by the facility regarding how Resident #1 would remain free from abuse, or any follow-up interviews with Resident #1 for reassurance that she felt safe and would remain free from further abuse. Moreover, there was no evidence of follow-up with CNA #1 and what corrective actions were taken, other than being instructed not to enter Resident #1's room. There was no evidence of follow-up staff training on identifying, preventing and ensuring residents were free from abuse and neglect. The section in the abuse report form that asked, Did the resident participate in determining the appropriate corrective action that was taken? Yes or no, if no explanation why they did not participate, was left blank. (Cross-reference F610, failure to timely and thoroughly investigate abuse allegations.) 2. Interdisciplinary team (IDT) notes Review of IDT notes provided by the DON on the afternoon of 8/6/21 revealed no documentation of the 6/11/21 incident or follow-up with Resident #1. D. Interviews The NHA, DON and social services director (SSD) were interviewed on 8/6/21 at 9:15 a.m. Regarding their investigation and what was not included: investigative summary report, dated and/or signed documents, evidence of follow-up with Resident #1 regarding action taken; counseling, training, monitoring/supervision of CNA #1, training of all staff related to abuse/neglect. The NHA said he would gather the information. (See below for additional information provided.) CNA #1 was interviewed at 10:20 a.m. on 8/6/21. She said of the incident on 6/11/21, It breaks my heart because (Resident #1) is one of my favorite people. She wanted to be changed but the way she was explaining it to me, I told her (Resident #1), honey, if we do it that way you could fall, let's do it this way. And she started getting agitated. Looking back, I didn't give her enough space and re-approach her. She stood up and refused to sit on the bed. I said okay honey, and she went to hit me and let go of what she was holding on to. I held her under her arm transferring her from the chair to the bed and in the middle of standing and telling her she needed to sit, she let go and tried to hit and kick at me, and started to fall, and I gently helped her to the bed. Then she said 'you ripped my face off' and started trying to kick and hit me. I was sitting in front of her and asked what happened, what happened, she went to hit me again and I said 'don ' t hit me, you can't hit me.' That's not normal; she's never been (like that). CNA #1 said, I could've backed off. I must have been in a rush or something, but I made sure she was safe and made sure I did all my stuff correctly. She denied stepping on Resident #1's oxygen tubing or physically pushing the resident. CNA #1 said she was suspended while management investigated the abuse allegation, and she was followed up with by the NHA and DON, and given training on abuse and neglect. They've asked me to stay out of that room and there have not been any incidents since. CNA #1 said she should have taken a step back, listened to what (Resident #1) said, and gotten someone else to assist. It was fast going and I wanted to make sure she was safe. It shouldn't have turned out that way. She said the DON and NHA told her Resident #1 felt scared and bad about the situation, and said, In the long run, I guess it was abuse. The only thing I regret is not backing up and stepping out. Just being in a rush and not evaluating the situation fully is something I regret not doing. I definitely evaluate and take my time a lot more since then. I feel bad. It shouldn't have happened the way it happened. I could've approached it way differently. LPN #1 was interviewed on 8/5/21 at 12:07 p.m. She said she had not witnessed or heard of any abuse, and abuse had not been reported to her by any residents. (However, she was one of the nursing staff that CNA #1 allegedly went to for assistance.) The SSD was interviewed on 8/6/21 at 2:03 p.m. She said she had not witnessed abuse, neglect or dignity issues. She said she did check in on (Resident #1) once after her incident. She heard there was some yelling, (Resident #1) yelling at (CNA #1) but that's about all I'd heard about that. She said (Resident #1) didn't want to talk about it, and was just glad to know (CNA #1) wouldn't be providing care for her anymore. She said she did not want to make Resident #1 relive the incident, and could not imagine how hard that must be for residents. Other staff who had knowledge of the incident were not on duty and were not interviewed. Resident #1 was interviewed a second time on 8/6/21 at 2:47 p.m. She said, I was angry because she was telling me what to do and I actually refused to do it, and I was angry when she refused to listen. I did feel fearful. I was concerned that if she couldn't get at me she'd get another one of the aides to get at me. But she didn't. I just wanted to make sure they understood there are different types of abuse. And 'no' means 'no.' A regular visitor to the facility was interviewed on 8/6/21 at 8:30 a.m., and provided a follow-up email on 8/9/21 at 10:15 a.m. that documented the following: Based on numerous visits and conversations with the residents, my overall impression is that the staff and administration are not providing resident centered care. I sense a lack of empathy for the residents and the understanding that the facility is their home. The administration appears to hold the belief that residents are to fit in with the facility's schedule and rules instead of the facility working to meet the needs and wishes of the residents. When issues arise, the administration quickly identifies the cause as something the resident involved has, or has not, done (e.g. the resident didn ' t ask for a shower) instead of talking with the resident and identifying how the facility can better meet that resident's needs. The administration's response also suggests that they do not believe what the residents have to say. Though I have heard from residents that some of the staff are caring and trying their best, that is not the norm. Perhaps this is due to the attitude of the administration and/or a lack of staff training in resident centered care. In addition, I have heard many complaints from residents related to a lack of follow through with regard to requests and planned care. Medications are late, meal changes are not made, showers are not provided, and call lights are very slow to be answered. Residents often state that they believe part of the reason for their issues is that the facility is short staffed. I have also been told by residents that they do not voice their complaints because they are concerned that they will experience repercussions if they do. III. Resident #2 A. Resident status Closed record review revealed Resident #2, under age 70, was admitted on [DATE] and discharged on [DATE]. According to the July 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 7/28/21 MDS assessment, she was cognitively intact with a BIMS score of 15 out of 15. She had no [CONDITION(S)], [CONDITION(S)] or behavioral symptoms including rejection of care. She needed extensive assistance for transfers, dressing, toilet use and personal hygiene. She was occasionally incontinent of bladder and always continent of bowel. B. Record review 1. Abuse allegation and facility investigation Review of facility abuse investigations revealed a Resident Abuse Investigation Form regarding an abuse incident that occurred on 7/4/21 and reported on 7/6/21 by the resident. It read in pertinent part, Resident reported that this CNA (#2) was more worried about her safety rather than the resident's safety while changing her. Resident stated that she was fearful of CNA due to her not being considerate of her feelings. -The report did not describe what happened and there was no evidence of a detailed resident interview to determine what occurred, what the CNA said and did to the resident that caused her to be fearful, and what immediate action was taken. The resident did not have a roommate to interview. The NHA documented the investigation found that no abuse occurred. This event was witnessed and fell ow CNA was able to attest that accused CNA (#2) was not abusive. The corrective action was CNA to be educated on appropriate way to voice ideas and concerns to residents. The NHA documented the resident participated in determining the appropriate corrective action, however documented CNA was attempted to be contacted for interview with no return response & CNA did not report back to scheduled shift & was a no call no show & terminated. No other contact has been established with CNA. The NHA did not document that this was discussed with Resident #2. The investigation was signed by the NHA on 7/7/21. There was no documentation of a detailed resident interview other than the summary above. The name of the nurse on duty was not documented, nor was a detailed interview with that nurse documented. A phone interview with CNA #4 (who witnessed the incident) was included in the investigation packet, documented by the NHA as conducted on 7/6/21, no time documented: What happened occurred on Friday night around 8-9 p.m. We had went into room [ROOM NUMBER] to assist her with changing her brief. Once we started, she voiced her opinion of not wanting to be laid fully flat, instead preferred to be in low Fowler's position, which makes it a lot harder for the person rolling to keep the resident on their side, not to mention it is unsafe for the resident. Upon voicing (CNA #2's) concern that she did not want to hurt her back trying to roll her in a low Fowler's, and instead wanting to roll her in a fully flat position, the resident refused to do so, and so we proceeded to change the resident in the position she wanted. (CNA #2) went back into her room about an hour later, and the resident proceeded to yell and become agitated with (CNA #2) because of the concerns she voiced earlier. When (CNA[TRUNCATED]

Based on observations, record review and interviews, the facility failed to provide supervision and assistance to prevent falls with injury for one (#2) of three residents reviewed for falls/accidents out of seven sample residents. The facility failed to observe and supervise, anticipate needs and implement fall prevention measures for Resident #2, who was impulsive, had a history of [REDACTED]. The facility failed to complete accurate fall risk assessments on two occasions. The facility's interdisciplinary team (IDT) failed to determine the actual root cause of why Resident #2 continued to fall. The facility failed to implement new fall interventions following each of the resident's ten falls in the facility between 9/30/2020 and 3/11/21. The resident sustained [REDACTED]. The facility's failures contributed to Resident #2 falling and fracturing his hip on 2/3/2021 at 4:02 p.m. and as a result suffered pain, surgical revision of his hip, physical and mental decline and experienced three more falls between 2/20/21 and 2/28/21, following the fall which re-fractured his hip. Findings include: I. Facility policy and procedure The Falls-Clinical Protocol policy, revised September 2012, was provided by the nursing home administrator (NHA) on 3/11/21 at 3:30 p.m. It documented while many falls were isolated individual incidents, a significant proportion of falls occurred among a few residents, It documented the staff should document any risk factors for falls, such as gait disorders and cognitive impairment, in the resident's record and discuss the resident's fall risk. It documented the physician should identify medication conditions affecting the fall risk, such as a previous stroke, and the risk for significant complications of falls, such as a resident having already sustained a [MEDICAL CONDITION] prior to admission. It documented the staff should evaluate and document falls that occur while the resident was in the facility. It documented, for residents who had fallen, staff would attempt to define possible causes within 24 hours of the fall. It documented often, multiple factors, in varying degrees, contribute to falling problems. It documented that after more than one fall, the physician should review the resident's gait, balance and current medications that may be associated with dizziness or falling. The policy stated, Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. It documented the staff, which physician's guidance, would follow up on any fall with associated injury until the resident was stable. It documented the staff and physician would monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. It documented risks of serious adverse consequences could sometimes be minimized even if falls could not be prevented. The policy documented if the individual continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that had already been identified) and would re-evaluate the continued relevance of current interventions. II. Resident #2 A. Resident status Resident #2, age 64, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The 2/9/21 significant change minimum data set MDS assessment (six days after his fall with fracture) documented the resident had a BIMS score of eight, which meant he was moderately impaired for daily decision making. It documented the resident required extensive assistance of two or more for transfers and extensive assistance of one for ambulating in his wheelchair. It documented the resident has sustained a fall with a major injury since the previous MDS assessment. B. Record review Previous MDS The 12/23/2020 MDS documented the resident required supervision with set up for both transferring and ambulation with his walker. It documented the resident had sustained two or more falls in the facility since admission with one of those falls resulting in injury According to his 10/6/2020 minimum data set (MDS) assessment (prior to his fall with fracture), he was cognitively intact for daily decision making with a brief interview for mental status (BIMS) cognition score of 13 out of 15. It documented the resident required supervision with no set up for transferring. This MDS documented the resident usually ambulated with a walker, but ambulation did not occur during this MDS look-back period. It documented the resident has sustained a fall in the past two to six months prior to admission to the facility. 1. Fall risk assessments The fall risk assessments completed by the facility documented Resident #2 was a high fall risk on 10/7/2020, 11/11/2020, 11/17/2020, 1/5/21, 1/6/21, 2/28/21 and 3/1/21. The assessments of 12/31/2020 and 2/20/21 documented the resident was a low risk for falls. -The fall risks assessment, dated 12/31/2020, was inaccurate as Resident #2 sustained a fall on 12/30/2020 (see below). The fall risk assessment dated [DATE] was also inaccurate as Resident #2 sustained a fall on that same date, 2/20/21. 2. Falls sustained prior to February 2021: Fall #1: An unwitnessed fall occurred on 10/7/2020 at 6:30 p.m. Resident #2 was found on the floor in his room. He spilled his dinner tray on the floor and was trying to clean it up and slipped on the food. The resident was reported to be confused, agitated and restless. The fall resulted in a skin tear to his elbow, which was cleaned and dressed. The new intervention was resident education to use the call light when he needed assistance, no matter what the need. Fall #2: A witnessed fall occurred on 11/11/2020 at 2:30 a.m. Resident #2 asked for coffee and a certified nurse aide (CNA) jokingly said, No, haven't you had enough? The resident became agitated and threw his empty cup against the wall, picked up the chair he was sitting in and threw it a few feet down the hallway. After throwing the chair, he lost his balance and fell backwards onto the floor in a sitting position, up against another occupied chair in the lobby. The new intervention was to educate staff on redirection of the resident and educate the resident on ways to express needs without behaviors. Fall #3: A witnessed fall occurred on 11/16/2020 at 3:30 p.m. Resident #2 was observed in the common area to stand up and walk without his walker; he lost his footing and fell , landing on his knees. A scab to his left knee came off and a new band-aid was re-applied after the area was cleaned. The resident was observed by the NHA when he fell and did not hit his head. The resident got up before he was assessed and sat in a chair in the common area. The documentation failed to note if the NHA encouraged the resident to use his walker prior to the fall or if he ensured the resident was not moved off the ground prior to the nursing assessment of the fall. The documentation noted the resident tended to drag his left foot when ambulating. The intervention was to remind the resident to always use his walker due to poor safety awareness. Fall #4: An unwitnessed fall occurred on 12/30/2020 at 4:00 a.m. Resident #2 came to the nurse and reported he had fallen out of bed and hit his head on the floor. Resident said he did not turn his light on or tell anyone at the time because he got up and was just fine. The resident was educated that if he did fall, to turn on the call light and wait for the nurse to come and assist him off the floor. Resident #2 said he understood, but stated, I really didn't need any help, I just got up. The resident was educated to report any incident at all times and wait for staff to complete their assessment prior to the resident getting himself up and the resident agreed. The documentation did not include any new interventions following this unwitnessed fall. Fall #5: An unwitnessed fall occurred on 1/5/21 at 8:15 a.m. A dietary aide informed the nurse the resident was found on the floor. When the nurse entered the resident's room, he was lying on his back on the right side of the bed. Resident #2 waited for assessment (no injury) and was assisted from the floor to bed. -There were no new interventions noted for this fall other than PT to evaluate for treatment again. Fall #6: An unwitnessed fall occurred on 1/6/21 at 10:00 a.m. Resident #2 was found on the floor by a nurse, lying flat on his back by the left side of his bed. -There were no new interventions noted for this fall. Resident #2 continued to fall without sufficient supervision or interventions in place by the facility to prevent falls or injuries until he sustained an injury on 2/3/21 and continued to fall afterwards. 3. Fall with major injury sustained on 2/3/21 and subsequent falls thereafter Review of fall investigation reports and interdisciplinary progress notes revealed the following documentation of the resident's falls: Fall #7: Resident #2 fell on [DATE] at 4:02 p.m. This was an unwitnessed fall. A loud bang was heard coming from the hallway, as well as Resident #2 yelling for help and screaming out I broke my hip. The director of nursing (DON) and assistant director of nursing (ADON) immediately ran to assess the situation. It documented Resident #2's neurological examination revealed the resident's neuros were at baseline, but with the left pupil larger than the right at 5 mm and was sluggish to light. Resident #2 verbalized complaints of pain to his right hip. The resident was left lying on his back until emergency medical services (EMS) arrived due to right hip pain rated at nine out of ten. The resident was sent to the local emergency room due to increased complaints of pain in his right hip. The resident's blood pressure was reported at being slightly elevated secondary to pain. No predisposing factors related to the fall were noted on this form. The documentation noted Resident #2 tended to drag his right foot since his [MEDICAL CONDITION] and subarachnoid bleed prior to admission. No new fall interventions were documented following this fall with a [MEDICAL CONDITION]. The facility documented this incident as a witnessed fall even though a loud bang was heard coming from the hallway causing the DON and ADON to run to assess the situation. The facility should have reported this as an unwitnessed fall. ) -The facility did not provide any documentation about neurological assessments for this unwitnessed fall other than what was noted above (i.e., the initial baseline assessment immediately following the fall). Fall #8: Resident #2 fell on [DATE] at 1:13 p.m., which was 17 days following a fall resulting in a [MEDICAL CONDITION] and surgical repair. This was an unwitnessed fall in which the resident was found on his knees in front of his wheelchair, leaning on the bed. The resident said he slid out of his chair trying to get out of bed into his wheelchair without waiting for staff assistance. Predisposing factors were weakness and decline in function. New interventions were resident education not to attempt to transfer without assistance and resident agreed, therapy to screen related to fall, frequent rounding to ensure no attempts to self-transfer, staff to ensure resident needs are met and to monitor for increased complaints of pain and document. Fall #9: Resident #2 fell on [DATE] at 1:39 p.m., which was seven days since his last fall. The fall investigation form documented the resident was found on the floor, but the NHA said the fall was witnessed by a certified nurse aide (CNA) and no neurological examinations were documented. It documented a nurse entered the room to find the resident and CNA in the resident's bathroom with the resident sitting on the floor in front of the sink. Resident #2 stated he used his wheelchair to get into the bathroom when he then tried to stand up at the sink. He could not recall why he was going to the sink. The form documented the resident was alert and oriented times person, place, time and situation, then later noted the resident was confused with a gait balance issue. Weakness and ambulating without assistance were predisposing factors related to this fall. -There were no new interventions noted for this fall. Fall #10: Resident #2 fell on [DATE] at 3:28 p.m., which was the following day since his last fall. It documented Resident #2 was found on the floor at 2:30 p.m. The resident stated he was trying to reach for call light, which was out of reach, and fell from his wheelchair. He sustained a laceration just below his left eyebrow, which was open and bleeding, as the resident hit the corner of his dresser when he fell . His eye was cleaned and steri-strips were put in place. The post-fall documentation noted a gait imbalance was the predisposing factor related to the fall, but Resident #2 was not observed ambulating at the time of the fall; he was seated in his wheelchair, reaching for a call light that was out of his reach. The form also documented ambulating with assist was also a factor, which was also incorrect given the resident was not ambulating at the time of the fall. The interventions for this fall was Resident #2 being educated on using his reaching device to assist in reaching items out of his reach to prevent falls. Resident #2 verbalizing understanding, but it should be noted Resident #2 was unable to locate his reaching device at the time of this fall. Ice was applied to his left eyebrow to reduce swelling and relieve pain. New interventions of monitoring the resident's left eyebrow daily until injury was resolved and resident education on using the reaching device were noted. The interdisciplinary team (IDT) met on 3/2/21 to review the falls sustained on 2/27/21 and 2/28/21. Resident #2 had stated he was trying to do things on his own because he wanted to see if he could do it. The DON re-educated Resident #2 about using his call light and waiting for staff assistance. Resident #2 again agreed to this intervention. No new interventions were noted; only the same interventions were documented again. 3. Care plan The care plan related to falls, originally dated 10/7/2020 and revised on 3/10/2021 documented resident was at risk for falls related to confusion and a history of falls. -The care plan failed to specify if the resident was a high, moderate or low fall risk. It documented the dates and outcomes for the following falls: 10/8/20: minor injury 11/18/20: no injury 11/28/20: no injury 12/30/20: no injury 1/5/21: no injury 1/6/21 times two: no injury 2/3/21: fall with fracture 2/20/21: no injury 2/27/20: self transfer 2/28/21: laceration to left eye The goal was for the resident to be free of minor injury through the next review date. Appropriate interventions for each fall included: Actual fall 11/11/20: Educate staff on redirection of resident. Educate resident on ways to express needs without behaviors. Actual fall 2/20/21: Resident education for self transfers. Frequent rounding. Actual fall 2/27/21: Therapy to screen for falls. Resident education on self-transferring. Frequent reminders to use call light. Actual fall 2/28/21: Therapy to screen for falls. Education to (resident's name) on using reaching device. Actual fall on 1/5/21: PT to evaluate for treatment. Actual fall on 11/16/2020: Educated on the importance of using assistive device for ambulation. Actual fall times two: PT started treatment. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. (Resident's name) needs a safe environment with (SPECIFY:) It should be noted this was a canned care plan and specifications related to a safe environment were not assessed for this resident. Additional interventions on this care plan included assistance of two staff for all transfers, wheelchair for mobility, follow facility fall protocol and PT to evaluate and treat as ordered or as needed (prn). Resident #2 fell on [DATE], 11/18/2020, 11/28/2020, 12/30/2020, 1/5/21, 1/6/21, 2/3/21, 2/20/21, 2/27/21 and 2/28/21. The facility failed to develop new, person-centered interventions following every fall in order to prevent or minimize the risk of falling for Resident #2. 4. Change of condition documentation The change of condition note dated 2/3/21 documented, Resident ambulating down hallway when staff heard loud bang and resident noted to have had fall. Resident stated he hurt his right hip. DON and ADON noted right hip pain which he rated 9/10. Neuro assessment completed and WNL (within normal limits) except for left pupil measuring 5 mm (millimeters) and sluggish to light. Slightly elevated BP (blood pressure related to increased complaints of pain. Resident noted to have head injuries upon assessment. Pillow placed under resident's head for comfort and EMS called. Sent to ER (emergency room ) for evaluation and treatment. admitted for surgery to right hip. 5. Rehabilitation services screenings The rehabilitation services screenings were reviewed from the resident's admission through present. The following was documented: a. Screenings prior to the fall with fracture on 2/3/21: - 10/8/2020: Therapy to address fall in the next therapy session. Resident noted to have fluctuating confusion and agitation since admission, at times non-compliant with therapy. - 11/17/2020: Resident is a frequent faller due to impulsivity and poor carryover with therapy recommendations. Resident attempting to ambulate without a walker. Resident discharged from physical therapy on 11/2/2020 due to frequent refusals and non-compliance. Continues with OT (occupational therapy), who will address in the next therapy session. - 12/31/2020: Resident with a fall out of bed. Resident with several falls over the past month. Resident impulsive and has decreased safety awareness. Previously discharged from PT (physical therapy) and OT due to lack of participation and frequent refusals. Resident refusing PT evaluation at this time, but will re-attempt as new PTA (PT assistant) starting soon. - 1/8/21: Resident with recent falls times two. PT evaluation and treat order placed and resident picked up for PT services due to decreased balance and impulsivity. However, PT previously discharged due to non-compliance and decreased participation. - 2/3/21: Resident with a fall in hallway and transfer to (local hospital) for evaluation. PT/OT/ST (speech therapy) evaluation indicated on return to the facility. - 2/26/21: No changes noted status [REDACTED]. - 2/29/21: Resident with recent falls times two: Currently on PT/OT/ST caseload. It should be noted there was no 2/29/21 this year. - 3/9/21: Resident with fall, no injuries. PT to address in next session. C. Resident interview and observations On 3/10/21 at 3:15 p.m., Resident #2 was observed down in the therapy gym working with the occupational therapist (OT). On 3/10/21 at 3:35 p.m., Resident #2 was interviewed in his room following his OT session. Fall mats were observed on the floor on both sides of the resident's bed. The resident was observed sitting on the left side of the bed at this time. He said he could not recall exactly how long he had been in the facility, but it had been longer than a month. He said he had fallen in the facility and re-broken his left hip, which was still sore, but getting better. Resident #2 denied being impulsive, but said he had tried to do something too fast when he fell . He said 90% of the time, he did not need his pain meds and rated his pain currently at 1 out of 10. He said the worst the pain had been in the past week was 4.5 or 5 out of 10. He said he had sustained a few falls in the facility before the fall which re-injured his hip and had fallen several times since the injury. He said he had fallen out of his wheelchair that he now required since his fracture while trying to pick something up off the floor or trying to clean something up off the floor. He said when he was first admitted to the facility, he was provided a reaching device that helped his pick things up off the ground. He said he had not seen that device for several weeks, but had been through two room changes and it had probably been lost during one of the moves. He said he felt having another reacher to grab things might have prevented some of his tumbles out of his wheelchair. He said he would like to see the reacher device replaced. During the interview with the resident, the resident's call light was not within his reach at this time. It was located on the floor near his bedside table, approximately four feet away from the resident. Immediately following this interview, on 3/10/21 at approximately 4:15 p.m., Resident #2 was getting out of his bed to get his wheelchair, which was on the other side of the room. Resident #2 did not use his call light for staff assistance during this transfer and ambulation across the room. He was observed until he safely sat down in his wheelchair. On 3/10/21 at 4:45 p.m. Resident #2 seated comfortably in his wheelchair, watching television in his room. On 3/11/21 at 8:15 a.m., Resident #2 was lying in bed with his television; fall mats were on the floor on both sides of the bed. On 3/11/21 at 8:50 a.m., Resident #2 was in his wheelchair by the nurse's cart on the 100 hall, waiting for his medications to be administered. He said he did not sleep well due to the soft mattress. He asked for a firmer mattress, if possible. On 3/11/21 at 10:00 a.m., Resident #2 was lying in bed, with fall mats on each side of the bed. His call light was clipped to the front upper left of his shirt and a reaching device was now within his reach for use if he dropped something. This was after the interview with the therapy director (TD) about why the resident was not provided a reaching device to minimize his fall risk. His wheelchair was not within reach, however. On 3/11/21 at11:25 a.m., Resident #2 was to be asleep and snoring at this time. He was under the covers and there were fall mats on both sides of the bed. His reacher was now on the bedside table within reach, as was his call light. D. Family/friend interviews A friend of Resident #2 was interviewed on 3/8/21 at 9:54 a.m. She said the resident fell in the facility on 2/3/21 and re-fractured his hip. She said he was ambulating down the hallway unassisted when the fall occurred. She said the resident had fallen a few times prior to sustaining the [MEDICAL CONDITION] and that he had fallen multiple times since. She said the only intervention subsequent to the fall with fracture she was aware of was the facility placing fall mats around his bed; she said the fall mat placement was not timely, as this just happened a few weeks ago. A family member of Resident #2 was interviewed on 3/9/21 at 12:56 p.m. She said prior to entering the facility, Resident #2 fell on [DATE] and sustained a major brain bleed and was air-lifted to a hospital for surgery. She said the facility was aware of this information prior to accepting the resident into their facility. She said communication with the facility in relation to falls and accidents had been horrible, which was alarming to her. She said, after five months in the facility, the facility staff had never really shared with the family what his care plan goals were in relation to falls. She said typically, Resident #2 was not very aware of his safety. E. Staff interviews The OT was interviewed on 3/10/21 at 3:35 p.m. He said Resident #2 had sustained a lot of falls, both prior to the facility and while a resident in the facility. He said, additionally, the resident had several other close calls for additional falls due to Resident #2's impulsivity and lack of safety awareness. He said the resident was weight-bearing as tolerated (WBAT) following a fall with fracture and need for subsequent hip revision. He said the resident was a high risk for falls, was impulsive and had difficulty remembering about safety awareness due to a prior stroke and subdural bleeds. He said the resident needed frequent reminders and supervision due to his lack of safety awareness. He said the physician had not been pleased with Resident #2's progress in therapy, but understood the resident had refused some therapy sessions due to pain. He said the resident's level of pain had been controlled the past few weeks and he was now doing much better with his transfers and bed mobility. The director of nursing (DON) was interviewed on 3/11/21 at 9:00 a.m. She said Resident #2 had a BIMS score of 15 prior to his hip repair. She said he was more confused following the surgery due to anesthesia. He said his cognition had not returned to baseline yet. The therapy director (TD) was interviewed on 3/11/21 at 9:45 a.m. She said Resident #2 was initially hesitant, fearful and in pain following his broken hip, but had been participating very nicely with therapy the past three or four weeks. She said the resident was provided a reacher when he was in therapy prior to his fall with a fracture. She said she had not seen the reacher recently. She recalled she used to see it in the basket that was on the resident's walker when he was ambulating with a walker prior to the fall. She said his reacher might have disappeared, as the resident had been moved several times recently due to being temporarily housed in the therapy gym when there was COVID-19 in the building. She said Resident #2 was also in another room when placed on isolation precautions after returning from the hospital. She said she would ensure the resident received another reacher. She said a reacher would be important for this resident, as he had numerous falls when trying to pick something up or clean up a spill on the floor. The DON was interviewed on 3/11/21 at 12:58 p.m. She said the facility did not have an official fall program, but they were working on implementing this program. She said the facility did not have an actual target date for the implementation of their falls program. She said falls had been an issue in the facility, especially with people like Resident #2, who were impulsive and had decreased safety awareness. She said a fall program was needed so all staff could know details about his fall risk and appropriate interventions to take to minimize the risk of falls. She said the facility had identified some repeat fallers and they were a big concern to the facility. She said the facility should develop new interventions after each and every fall, if possible. She said, in relation to Resident #2, some of the interventions attempted did not appear on the care plan, but she did not know why. She gave the example of fall mats and a low bed. She said the facility did not think about some interventions to minimize falls, such as encouraging activity involvement for the residents to occupy their time and prevent boredom. She said the facility should not be using canned care plans and should be specifying the resident's fall risk (low, moderate or high) on the care plan. She said, Care plans need to be specific. The DON said the last time she saw Resident #2's reacher was approximately five or six days prior. She said call lights should always be within reach of a resident who had frequent falls. She acknowledged Resident #2's room was quite far away from the main nurse's station, but said Resident #2's friend did not wish to have the resident moved. The DON acknowledged that Resident #2 had fewer falls when his room was closer to the nurse's station. She said she would present a room change again to Resident #2's family and friend. She said an appropriate intervention to assist in minimizing Resident #2's falls would be frequent rounding and said her expectation would be to check on this resident at least hourly. She said she had no ideas why Resident #2's wheelchair was observed out of reach other than staff may be placing it across the room to prevent him from self-transferring. A discussion of the observation on 3/10/21 at 4:14 p.m. (see above) was held and the DON said keeping Resident #2's wheelchair on the other side of the room was probably not a good intervention to minimize Resident #2's falls. She said the IDT team reviewed falls every weekday morning to discuss the falls of the previous day. She said the nurses completed the beginning fall documentation and she did the final IDT summary. She said the IDT team needed to do a better job determining the root cause analysis that made sense for each particular fall. In summary, the DON said the interview was helpful to her and that ensuring Resident #2 always had a reacher nearby could have prevented a few of his falls. The exit interview was conducted on 3/11/21 at 2:30 p.m. with the NHA and DON. The NHA said he had nothing further to add to the above interview with the DON.

Based on resident, family and staff interviews and record review, the facility failed to ensure sufficient staffing on two of two hallways, for nine (#2, #14, #15, #36, #55, #56, #63, #72, #76) of 30 sample residents, to provide daily care and services in a timely manner. Resident and staff interviews revealed the facility failed to consistently provide adequate nursing staffing resulting in delayed call light response, assistance to the toilet, and assistance with bathing. Residents and family members said residents experienced incontinence accidents resulting from short staffing, and residents said they felt helpless and embarrassed. Cross-reference F241 dignity and respect; F281 professional standards of quality; F309 highest practicable quality of care; F311 treatment and services to improve/maintain activities of daily living; 312 activities of daily living provided for dependent residents; F314 pressure ulcers; F323 supervision and safety equipment to prevent falls; F325 weight loss and F327 dehydration. The findings included: 1. Facility policy The facility policy on staffing, revised April 2007, included, Our facility provides adequate staffing to meet needed care and services for our resident population. The facility policy was that the facility would maintain adequate staffing on each shift to ensure the residents needs and services would be met. 2. Resident characteristics Review of the facility resident census and condition form dated 11/15/16, revealed a total census of 42 residents, with the following identified needs: - 23 residents required assistance of one to two staff for bathing and 19 residents were totally dependent on staff for bathing. - 29 residents required one or two staff assist for transfers, and 11 residents were totally dependent. -35 residents that required assistance of one or two persons with eating, and four residents that required total assistance. - 30 residents required assistance of one or two persons for toilet use, and 10 residents were totally dependent on staff for toileting. - 32 residents required assistance of one or two staff for dressing, and eight residents were totally dependent on staff. -13 residents received antipsychotic medication. 3. Family Interviews Resident #76's daughter was interviewed on 11/16/16 at 5:25 p.m., and she said she visited the facility frequently, about two-to-three times each week. She was asked if the facility had enough staff available to ensure the residents received the care and assistance they needed without having to wait a long time and she stated, No they don't. (Resident #76) waits anywhere from 10 minutes to half-an-hour when she pushes her call light for assistance. And they always tell me it depends on what they are doing. She explained that recently she had propelled her mother from the dining room after dinner and she had to ask staff for help to get her mother into bed. She was told they couldn't put her to bed at that time, and that they had to take care of the people in the dining room first. She stated, Forty-five minutes later they finally came back. And she was falling asleep in her wheelchair. -The daughter explained that her mother used a mechanical lift and two staff were needed to move her. She said that her mother was once sitting in her wheelchair waiting to get back to bed and the staff told her they needed two people to help and would be right back in about 20 minutes. She stated, Forty-five minutes later they were here. She has to wait a long time most of the time. -The daughter said she had seen one staff member, Take her out of the wheelchair and just put her in bed without checking her brief. Last month when they took her out of the wheelchair and put her in bed, she dribbled all over the floor because the brief was saturated with urine. They don't check her brief often enough. Resident #2's family member was interviewed on 11/16/16 at 11:49 a.m. She said she did not think the facility had enough staff. She said the evening staffing was terrible, and there was not enough help with feeding assistance. The family member of resident #14 was interviewed on 11/15/16 at 1:09 p.m. She said the staffing was okay for her husband because she was always there to help him. She said the nights and weekends appeared to have less help. She said in the dining room in the evenings there was sometimes only one staff member serving the residents meals, and residents had to wait for an hour or more at times so they fell asleep waiting for the food to be served. 4. Resident Interviews Residents, who per facility and assessment were cognitively intact and interviewable and resided throughout the facility, made the following comments when asked about sufficient nursing staffing: Resident #56 was interviewed 11/16/16 at 11:12 a.m. He said he had to wait for so long that he had an accident in his pants waiting for help. He said then after that, he was in the bathroom, and had to wait again for another 20 minutes for the staff to come back to help him. He said that made him feel helpless and embarrassed. Resident #72 was interviewed on 11/15/16 at 3:32 p.m. The resident said that the facility only had one CNA working on each hall during the night shift. The resident said that staff are hard to reach by call light and that sometimes they did not answer his call light at all. He said that once during his stay, he was incontinent of urine due to his call light not being answered and he said that incident was embarrassing for him. He said that it only happened once, but once was enough. Resident #55 was interviewed 11/15/16 at 2:40 p.m He said he did not think there was enough staff working to provide care without having to wait a long time. He said one evening he had to wait for one and a half hours for his pain medication because someone called off from work and there was not enough help. Resident #36 was interviewed 11/15/16 at 3:28 p.m He said he did not think the facility had enough staff. He said the night shift at times only had one nurse for the whole facility. Resident #15 was interviewed 11/16/16 at 10:31 a.m He said he did not think the facility had enough staff. He said the evening shift especially could use more help for people after meals and getting people help for bedtime. Resident #63 was interviewed on 11/17/16 at 9:00 a.m. She said there was not enough staff. There were too many and not enough. Everybody plays. People can play too much. On nights there were only two CNAs on duty for 50 people. Most of the people were on that wing. When asked about the call lights, she said it could be an hour and a half to two hours before the call light was answered. There was only an LPN in the evening. 5. Staff Interviews On 11/16/16 at 6:29 p.m., restorative CNA #16 was asked if she was available for an interview. Before she was able to respond to the request, CNA #4 interrupted her and stated, She is actually helping me with two Hoyers if it could wait. CNA #16 clarified that she would be available after they were finished with the transfers. -At 6:47 p.m., restorative CNA #16 was interviewed. She said she felt the facility had enough staff available during the day shift and stated, But at night I feel they could use at least one more CNA. She explained that she routinely worked from 10:00 a.m. to 8:30 p.m. and during that time there were four CNAs on duty, but after 6:30 p.m., it dropped down to two CNAs. -The restorative CNA confirmed that she'd heard residents complain that the facility did not have enough staff and she gave the example that they would say their call light would go off, for a really long time. She said, If we get busy in a room toileting someone, then we can't leave them. And if lights are going off on the other end of the hall, you can't hear them. She said if multiple call lights are alarming at the same time she tries to prioritize by answering the bathroom call lights first. -The restorative CNA said she was pulled from her work in restorative therapy to work as a CNA on the floor, Quite a bit. At least twice a week, and she explained that she routinely worked four days per week. She stated, I usually will do the make-up restorative care the next day and try to cram everybody in there. On 11/16/16 at 6:41 p.m., LPN #8 was interviewed and asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. She stated, They have been kind of short staffed. Tonight they asked me to come in to pass pills because passing pills in the evening is really hard for one nurse. She explained that there were currently two nurses working that night until 10:00 p.m. because, They are waiting for one nurse to get her license and then after that there will be two nurses every night from 6:00 p.m. to 6:30 a.m. -The LPN confirmed that she'd heard residents complain that there weren't enough nurses and stated, At night it is usually pretty often because it was only one nurse on at one time. On 11/17/16 at 9:50 a.m., CNA #15 was interviewed and she confirmed that she had heard residents in the past complain that staff were rushing them. She said she heard that from residents, once or twice every two-to-three days I work. She explained that breakfast and dinner time were the busiest times of the day with the biggest need for help and stated, Because they all want to go to bed at once. The restorative nurse aide was interviewed on 11/17/16 at 9:45 a.m. She said the night shift could use more help with the residents that required two-person assistance. She said she works four ten hour shifts per week 10:00 a.m. until 8:30 p.m. She said she does restorative from 10:00 a.m. until 6:00 p.m. then she helps with work providing resident care from 6:00 p.m. until 8:30 p.m. She said the facility did have only one nurse working the night shift and now they have two nurses working on the night shift. The activity director was interviewed on 11/17/16 at 1:19 p.m. She said she was not a certified nursing assistant and had to have another employee that was certified to go with her when transporting residents on any type of outing. She said she does the meeting minutes for resident council. She said residents have made comments during the resident council meetings that they think the facility does not have enough help. She said she has had to cancel outings a few times due to not having an extra certified staff person to help assist her on the outing. CNA #6 was interviewed on 11/17/16 at 9:20 a.m. She said that, to her knowledge, she was the only staff member who was currently weighing the residents. She said that she tried to get weekly weights on the residents, but said as hard as she tried, she was not able to weigh everyone weekly. She said that she would be notified if a resident had not been weighed in a month. CNA #26 was interviewed on 11/16/16 at 6:30 p.m. She said there were usually two CNAs at night. When asked if there was enough staff, she said, I think maybe three would be better. It can get pretty hectic sometimes. Maybe between now and morning, it would be better to have the extra person in order to get to everything. The director of nursing was interviewed on the morning of 11/21/16. She said she came to work at the facility in July 2016 and had made some changes to how the staffing was documented. She thought there had been improvements in the number of staff scheduled. She said a total of ten residents in the facility required two-person assist. 6. Record Review The daily direct care staffing schedule for day shift, on average included: 12 hour shift with two nurses on the day shift, four CNAs, one bath CNA four days per week (40 hours per week for bath aide), and one restorative CNA four days per week, plus one restorative CNA for 12 hours each Sunday (52 hours per week restorative). Review of the daily direct care staffing schedule for night shift on average revealed the facility was staffed with two nurses and two CNAs per 12-hour shift. The schedule did not document call-ins or replacement staff, and multiple staff sign-in signatures were missing, sometimes for more than half the staff on a daily basis.

Based on observations, record review and staff interviews, the facility failed to provide each resident with sufficient fluid intake to maintain proper hydration and health for one (#2) resident reviewed for hydration of 30 sample residents. Specifically, the facility failed to provide adequate hydration for resident #2, contributing to hospitalization with [DIAGNOSES REDACTED]. The findings included: Facility Standards According to the resident hydration and prevention and dehydration policy provided by the registered dietitian (RD) at 12:47 p.m. on 11/21/16, revised 12/08, If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan . Physician will be informed. Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. A specific minimum amount should be included in the order. The dietitian, nursing staff and the physician will assess factors that may be contributing to inadequate fluid intake. Resident #2 Resident #2, age 74, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the 11/16 order summary report, the resident's [DIAGNOSES REDACTED]. According to the 10/20/16 quarterly minimum data sheet (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. She required total assistance of two persons with bed mobility, transfers, personal hygiene, dressing, and toilet use. According to the 7/20/16 initial MDS assessment, the resident had severe cognitive impairment with a BIMS score of six out of 15. The care area: dehydration/ fluid maintenance triggered and the care planning decision was marked. The care plan, initiated 10/15/16 and revised 10/15/16, identified the problem The resident has impaired cognitive function/ dementia or impaired thought processes related to dementia, as evidenced by impaired short and long term memory, difficulty making decisions, and decreased comprehension of verbal information. Interventions included: Communicate with the resident in her primary language: Spanish. Provide an interpreter as needed to facilitate comprehension. The care plan, initiated 10/10/16 and revised 10/21/16, identified the problem I am on antibiotic therapy for urinary tract infection [MEDICAL CONDITION]. Interventions included: Encourage adequate fluid intake. The care plan, initiated 8/12/16 and revised 8/12/16, identified the problem The resident has potential nutritional problem of noncompliance related to 2-gram sodium 1800 calorie American diabetic association diet. Interventions included: Monitor my meals and fluid intakes. Weigh me weekly and when needed. A. Record Review According to the dietary profile, dated 9/21/16: -Fluid intake: blank -Comments: blank According to the readmit dietary nutritional assessment, started on 9/27/16 and signed by the registered dietitian on 10/29/16 (one month for completion of the nutritional assessment) -Percentage intake: 25-50 percent -Altered GI function: None -Nutrition related lab values: blank -Summary of resident interview: Resident is sleeping and unable to be interviewed at this time. -Estimated fluid needs: 2520ml/ day -Percent intake required to meet estimated needs: 75 percent. -Additional notes: Recommend to offer Glucerna supplement twice daily (BID), fortified foods and preferred foods in order to increase protein-energy intake. -Nutritional monitoring: Will continue to monitor resident's weight and oral (PO) intake, per protocol. According to the fluid intake records provided by the assistant director of nurses (ADON) on 11/17/16 at 9:22 a.m. (half of the estimated fluid needs- 1260ml day): -9/19/16: 400ml (readmitted to the facility) -9/20/16: 760ml -9/21/16: 1075ml -9/22/16: 300ml -9/23/16: 300ml -9/24/16: 300ml -9/25/16: 940ml -9/26/16: 855ml -9/27/16: 540ml -9/28/16: 200ml -9/29/16: 550ml -9/30/16: 720ml -10/1/16: 840ml -10/2/16: 780ml -10/3/16: 1030ml -10/4/16: 950ml -10/5/16: 200ml -10/6/16: 400ml -10/7/16: 950ml -10/8/16: 200ml -10/9/16: 400ml -10/10/16: blank -10/11/16: 420 ml -10/12/16: 560ml -10/13/16: 600ml -10/14/16: blank -10/15/16: 100ml -10/16/16: 240ml -10/17/16: 60ml -10/18/16: 660ml -10/19/16: 960ml -10/20/16: 900ml -10/21/16: 390ml -10/22/16: 800ml -10/23/16: 675ml -10/24/16: 400ml -10/25/16: 420ml -10/26/16: 700ml -10/27/16: 600ml + 202ml (supplement)= 802ml -10/28/16: 70ml + 202ml (supplement)= 272ml -10/29/16: 450ml + 303ml (supplement)= 753ml -10/30/16: 350ml + 151ml (supplement)= 501ml -10/31/16: 60ml + 404ml (supplement)= 464ml -11/1/16: 635ml + 404ml (supplement) = 1039ml -11/2/16: 450ml + 404ml (supplement)= 854ml -11/3/16: 900ml + 404ml (supplement)= 1304ml -11/4/16: discharged (The ADON was interviewed on 11/17/16 at 9:22 a.m. and she said that this was the only documentation for fluid intakes for this resident) According to the 9/16 treatment administration record for catheter output: -9/19/16: readmitted to the facility -9/22/16: 1000ml -9/23/16: 500ml -9/24/16: blank -9/25/16: 500ml -9/26/16: blank -9/27/16: blank -9/28/16: 100ml -9/29/16: 500ml -9/30/16: 650ml (Missing documentation) According to the 10/16 treatment administration record for catheter output: -10/27/16: 300ml -10/28/16: 300ml -10/29/16: blank -10/30/16: blank -10/31/16: 550ml (Missing documentation) According to the 11/16 treatment administration record for catheter output: -11/1/16: 300ml -11/2/16: 500ml -11/3/16: 360ml -11/4/16- discharged According to a facility fax to the physician, dated 10/10/16, Resident has catheter, urine is amber in color and has a foul odor to it. May we have an order for [REDACTED].>According to the 10/16 Medication Administration Record [REDACTED] -10/27/16: Glucerna- one (100 percent) (approximated water content- 202ml) -10/28/16: Glucerna- one (100 percent) (approximated water content- 202ml) -10/29/16: Glucerna- one (100 percent) one (50 percent) (approximated water content- 303ml) -10/30/16: Glucerna- one (25 percent) one (50 percent) (approximated water content- 151ml) -10/31/16: Glucerna- two times a day (100 percent) (approximated water content- 404ml) According to the 11/16 Medication Administration Record: [REDACTED] -11/1/16: Glucerna- two times a day (100 percent) (approximated water content- 404ml) -11/2/16: Glucerna- two times a day (100 percent) (approximated water content- 404ml) -11/3/16: Glucerna- two times a day (100 percent) (approximated water content- 404ml) -11/4/16: discharged According to the progress notes: -11/4/16: When arrived with transport aid, her daughter requested she be taken to the emergency room (ER) instead of her appointment . She was being admitted with [DIAGNOSES REDACTED]. -11/4/16: Discontinue [MEDICATION NAME] powder for not being used in over 30 days. -10/26/16: New order for Glucerna dietary supplement BID. -10/21/16: Foley patent and draining yellow colored urine and small amount of sediment in tubing. Encouraging fluids. -10/20/16: Foley patent and draining yellow colored urine with small amount of sediment in tubing. Encourage fluids. -10/18/16: Resident on alert charting to antibiotic therapy for UTI. Gave last dose antibiotic tonight complained of being constipated. Gave as needed (prn) [MEDICATION NAME]. Continue to monitor. -9/19/16: Resident readmitted .Resident has 16 French catheter placed indwelling with 10ml balloon, urine clear yellow. (There were no dietary notes during this time) According to the emergency department report, dated 11/4/16: -Acuity- level 3- emergent -Diagnosis: [REDACTED]. -Notes: patient constipated, disimpacted According to the history and physical, dated 11/4/16, from the hospital post discharge from the facility; She has a chronic indwelling catheter although I'm not certain of the reason why . She was complaining of abdominal pain . She had received a laxative at the nursing home and was manually disimpacted and had a large amount of stool output . Assessment/ plan: probable pneumonia with small effusion, catheter associated urinary tract infection - (I am going to discontinue her catheter and check residual urine volumes to see if she needs it for obstruction of if she can be incontinent without it), [MEDICAL CONDITION] - (I think it is probably at least partially acute and prerenal in nature. I am going to give her some gentle IV fluids), [DIAGNOSES REDACTED], constipation, [MEDICAL CONDITIONS], depression and [MEDICAL CONDITION]. B. Staff interviews Certified nurse aide (CNA) #22 was interviewed on 11/21/16 at 10:20 a.m. She said they provided hydration at meals and throughout the day with snacks. The CNAs documented the fluids offered. Licensed practical nurse (LPN) #5 was interviewed on 11/21/16 at 10:50 a.m. She said this resident would drink sometimes. They tried to stay on top of the fluids and snacks. They contacted the doctor many times related to this resident not eating or drinking. Registered nurse (RN) #3 was interviewed on 11/21/16 at 12:20 p.m. She said they would fill the large water containers at bedside. They would offer hydration when they passed medications. What they received freely was not necessarily documented. She said this resident would take water anytime it was offered. The director of nurses (DON) was interviewed on 11/21/16 at 4:30 p.m. She said this resident would refuse to drink. They would continue to encourage. She said the doctor and the family was aware. The registered dietitian (RD) was interviewed on 11/21/16 at 1:00 p.m. She was unaware of this resident's hydration status.

Based on observations, family interview, record review and staff interviews, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as body weight, for two (#49 and #2) residents reviewed for nutritional status of 30 sample residents. Specifically, the facility failed to: -Prevent further weight loss after resident #49's amputation; -Prevent weight loss and promote wound healing for resident #2; and -Provide timely nutritional interventions/ assessments for residents #49 and #2 to prevent significant weight loss. The findings included: A. Facility Standards According to the resident nutrition services policy provided by the registered dietitian (RD) on 11/21/16, revised 12/08, The interdisciplinary team may choose to temporarily liberalize the diet if the resident is losing weight or not eating well. According to the nutrition/ unplanned weight loss- clinical protocol policy provided by the RD on 11/21/16, revised 12/08, The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month- 5% weight loss is significant; greater than 5% is severe. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. 6 months- 10% weight loss is significant; greater than 10% is severe .The physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. According to the 2016 [MEDICAL CONDITION] coalition for body mass index, The estimated percentage of total body mass for an above the knee amputation: 9.96%. <http://www.[MEDICAL CONDITION]-coalition.org/limb-loss-resource-center/resources-by-topic/healthy-living/about-bmi/>. Accessed on 11/28/16. B. Resident #49 Resident #49, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the 11/16 order summary report, the resident's [DIAGNOSES REDACTED]. According to the 11/3/16 30-day minimum data sheet (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. For weight loss: loss of 5% or more in the last month or loss of 10% or more in last 6 months: YES, not on physician-prescribed weight loss regimen. The care plan, initiated 8/16/16 and revised 8/16/16, identified the problem At risk for poor nutritional status and dehydration. Interventions included: Monitor my meals and fluid intakes .Weigh me weekly and as needed .I'm on a supplemental at this time. The care plan, initiated 8/12/16, identified the problem The resident has an activity of daily living (ADL) self-care performance deficit related to musculoskeletal impairment. Interventions included: Eating: The resident is able to: feed herself. She requires set up only. 1. Observations The resident was observed on 11/16/16 at 8:15am in the main dining room. She was eating a bowl of cereal independently. The resident was observed on 11/16/16 at 3:15 p.m. She was in bed sleeping. The resident was observed on 11/16/16 at 5:30 p.m. She was waiting at the DR table. By the end of her meal, she ate most of her hamburger with tomato and some potato chips. 2. Record Review According to the weights and vitals summary: -11/21/16: (Start of supplementation) -11/16/16: 97# (7.6% weight loss x 1 month) (17% weight loss x 3 months) -11/8/16: (RD assessment finished) -11/3/16: 90# (14.2% weight loss x 3 weeks) -10/13/16: 105# (status [REDACTED]. -10/8/16: readmission -9/19/16: 114# -8/9/16: 117# According to the meal intake records, provided by the assistant director of nurses (ADON) on 11/19/16: B (breakfast): 75%; L (lunch): 50% 11/18/16: B: 75%; L: 50%; D (dinner): 50% 11/17/16: B: 20%; L: blank; D: blank 11/16/16: blank 11/15/16: B: 75%; L: blank; D: 75% 11/14/16: B: 25%; L: 75%; D: blank 11/13/16: blank 11/12/16: blank 11/11/16: blank 11/10/16: blank 11/9/16: B: 25%; L: 25%; D: blank 11/8/16: B: blank; L: 25%; D: 75% 11/7/16: B: 50%; L: 50%; D: 50% 11/6/16: B: 75%; L: 50%; D: 25% 11/5/16: blank 11/4/16: blank 11/3/16: blank 11/2/16: B: 25%; L: blank; D: blank 11/1/16: B: 50%; L: 75%; D: blank 10/31/16: B: 75%; L: blank; D: blank 10/30/16: B: blank; L: 25%; D: 25% 10/29/16: blank 10/28/16: B: 25%; L: 25%; D: blank 10/27/16: blank 10/26/16: B: 75%; L: blank; D: blank 10/25/16: blank 10/24/16: B: 100%; L: 25%; D: 50% 10/23/16: B: 25%; L: blank; D: blank 10/22/16: B: blank; L: 75%; D: blank 10/21/16: B: 50%; L: 25%; D: 50% 10/20/16: B: 25%; L: blank; D: blank 10/19/16: blank 10/18/16: B: 75%; L: 50%; D: 25% 10/17/16: B: 75%; L: 25%; D: blank 10/16/16: B: 0%; L: 50%; D: blank 10/15/16: B: 5%; L: 5%; D: blank 10/14/16: B: 75%; L: blank; D: blank 10/13/16: B: 25%; L: 25%; D: 50% 10/12/16: blank 10/11/16: blank 10/10/16: B: 0%; L: blank; D: blank 10/9/16: B: 0%; L: 25%; D: blank (Missing documentation) According to the 11/16 Medication Administration Record: [REDACTED] -10/8/16: [MEDICATION NAME] tablet 12.5mg- give one tablet by mouth one time a day for hypertension. According to the dietary nutritional assessment, dated 10/16/16 and signed off on 11/8/16 by the registered dietitian (RD). (23 days for completion): -Percent intake: 50% -Admission weight: 105# -Usual weight: blank -Current weight: 90# -Weight change: significant weight change >5% x 1 month, >7.5% weight loss x 3months, > 10% weight loss x 180 days. -Summary: Resident reports good appetite and good oral intake. Resident stated that she enjoys the food offered to her and has no dietary requests at this time. -Estimated calories: 1431 calories/day -Estimated protein: 62gms protein/day (1.5gms/kg) -Estimated fluid: 1230ml/day -Percent intake required to meet estimated needs: 75%. -Recommend: providing resident with fortified foods and preferred foods. Recommend nutritional supplement of Mighty shake, BID for an additional 400 kcals and 12 grams protein/day. (Supplement not started until 11/21/16) According to the 11/16 order summary report, Regular diet, regular texture, regular consistency. According to the admission assessment, dated 10/8/16, weight: 114# (9/19/16). [MEDICAL CONDITION]- n/a- not applicable. Progress notes were reviewed from 7/22/16 through 11/21/16: -10/10/16: Resident had poor oral (PO) intake this a.m., encouraging fluids. -10/9/16: Resident refused to get up this a.m. Staff is assisting resident with meal at this time. -9/20/16: Resident is on a regular diet with regular texture and thin liquids. Resident is independent with meals in the dining room. Resident is not on a supplement at this time. Resident is eating 80% of meals at this time. Resident weight is 118#. BMI: 18. According to the physician note, dated 11/17/16: Review of symptoms: no recent weight change. 3. Staff Interviews Certified nurse aide (CNA) #22 was interviewed on 11/21/16 at 10:20 a.m. She said this resident was a bird-eater. She picked a lot. When asked if this resident was on a supplement, she said not that she was aware of. When asked if the weights were accurate, she said Yes and no. She loved the wheelchair scale but they needed to do better at documenting the wheelchair weight. The process needs to improve. When asked if there was a resident at risk meeting she said, No, but that would be good to have. It's lacking. Communication is lacking. Licensed practical nurse (LPN) #5 was interviewed on 11/21/16 at 10:50 a.m. She said she was not aware of any residents with weight loss except for one. The dietary manager (DM) tracked the weight loss and would recommend a supplement. They called the doctor for the order. Doesn ' t take any time at all. When asked about a nutrition at risk meeting she said she believed that management did that. She said, We aren ' t involved with that. She said this resident was a finicky eater. They would encourage smaller meals, snacks. Registered nurse (RN) #3 was interviewed on 11/21/16 at 12:20 p.m. She said the CNAs completed the weights. They were reviewed by the nurse and given to the DON. When asked if there were standard meetings for nutrition at risk she said, Not that I'm aware of. She said the nurses placed the weights into the computerized record. They would add a baseline and then the weight changes would trigger out. A note would then be placed into the progress notes. Interventions included supplements. The dietary manager would go over preferences. When asked if the RD had a role, she said, She does. I'm not sure her process for weight loss. She said this resident had been doing good lately. She does better with people sitting with her for socializing. The director of nurses (DON) was interviewed on 11/21/16 at 4:30 p.m. She said the CNAs would put the weights on the weight sheet. The DM would enter that into the computer. The DM would initiate weight monitoring and they would discuss the weights in the daily meetings. They would then decide if interventions needed to take place. The nutrition at risk meeting would take place in the morning meetings. She said the DM would track the weight changes. Interventions included: fortified foods, supplements and preferences. The staff should be aware of the residents with weight loss. She said she didn't know about this resident's nutritional status. The RD/DM and the nursing home administrator (NHA) were interviewed on 11/21/16 at 1:00 p.m. The RD said the CNAs gave her a list of the weights and she would enter into the computerized charting. They would review every morning and discussed interventions. She said she was the one who tracked the weight changes. She said this resident had her leg amputated and she thought she had written a progress note on that. She had been offered fortified foods since readmission. When asked how soon she sees a resident after a weight loss, she said, As soon as I can. She had recommended the mighty shakes. When asked if that had been started, she said, I believe so. She looked and said she did not see orders on the start of the supplement. It should have been written within a day or so. C. Resident #2 Resident #2, age 74, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the 11/16 order summary report, the resident's [DIAGNOSES REDACTED]. According to the 10/20/16 quarterly minimum data sheet (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. Under ADL performance: Eating: supervision with setup only. Transfer: total dependence with two-person physical assist. Personal hygiene: total dependence with two-person physical assist. Locomotion on unit: total dependence with one-person physical assist. Under pain: intensity: six out of ten- worst pain out of the last five days. Under the swallowing/ nutritional status: weight loss was marked for loss of 5% or more in the last month or loss of 10% of more in the last 6 months; YES, not on a physician prescribed weight loss regimen. Weight: 184#. According to the 7/20/16 initial MDS assessment, the resident had severe cognitive impairment with a BIMS score of six out of 15. The care area: nutritional status triggered and the care planning decision was marked. The care plan, initiated 10/15/16 and revised 10/15/16, identified the problem The resident has impaired cognitive function/ dementia or impaired thought processes related to dementia, as evidenced by impaired short and long term memory, difficulty making decisions, and decreased comprehension of verbal information. Interventions included: Communicate with the resident in her primary language: Spanish. Provide an interpreter as needed to facilitate comprehension. The care plan, initiated 8/12/16 and revised 8/12/16, identified the problem The resident has potential nutritional problem of noncompliance related to 2-gram sodium 1800 calorie American diabetic association diet. Interventions included: I am a slow eater some times. Allow me sufficient time to feed myself. Provide and serve diet as ordered consistent carbohydrates (CCHO) diet with regular texture and thin liquids. Monitor my meals and fluid intakes. Provide me with verbal encouragement. Weigh me weekly and when needed. 1. Record Review According to the weights and vitals summary: -11/3/16: 180# (8.1% loss since readmission) -10/30/16: (Area to buttocks appear worse) (Open area to left buttock) -10/27/16: (Started Glucerna supplement) -10/26/16: (Order for wound care nurse) -10/19/16: 184# (6.1% loss since readmission x one month) -10/13/16: 184.5# -9/26/16: 202# -9/24/16: (New opened area in the crease between buttocks) -9/22/16: per TAR: 214# -9/19/16: 196.2# (readmission) -9/19/16: per TAR: 242# (Missing documentation for weights) According to the meal intake records provided by the ADON on 11/17/16 at 9:22 a.m.: (Pain level per weights and vitals summary) -11/3/16: B: 0; L: 0; D: 0 -11/2/16: B: 25%; L: 0; D: 0 (Pain level: 7) -11/1/16: B: 0; L: 25%; D: 50% -10/31/16: B: 0; L: 0; D: 0 -10/30/16: B: 25%; L: 25%; D: 100% -10/29/16: B: 25%; L: 0; D: 0 -10/28/16: B: 75%; L: 0; D: 0 -10/27/16: B: 0; L: 0; D: 0 (Pain level: 6) -10/26/16: B: 50%; L: 50%; D: 0 (Pain level: 8) -10/25/16: B: 25%; L: 25%; D: 25% (Pain level: 5) -10/24/15: B: 0; L: 0: D: 0 (Pain level: 7 and 6) -10/23/16: B: 25%; L: 25%; D: 0 (Pain level: 7, 6 and 8) -10/22/16: B: 0; L: 0; D: 0 (Pain level: 6) -10/21/16: B: 25%; L: 50%; D: blank (Pain level: 5, 3 and 6) -10/20/16: blank (Pain level: 4, 3 and 4) -10/19/16: B: 5%; L: 25%; D: blank (Pain level: 6 and 7) -10/18/16: B: 25%; L: 25%; D: blank (Pain level: 8 and 5) -10/17/16: B: 25%; L: blank; D: blank (Pain level: 7, 8 and 9) -10/16/16: B: 50%; L: blank; D: blank (Pain level: 7 and 9) -10/15/16: blank (Pain level: 5 and 6) -10/14/16: blank (Pain level: 4) -10/13/16: blank (Pain level: 8) -10/12/16: B: 15%; L: 50%; D: blank (Pain level: 9 and 5) -10/11/16: B: 25%; L: 25%; D: 50% (Pain level: 6) -10/10/16: B: 0; blank (Pain level 6 and 5) -10/9/16: B: 0; L: 25%; D: blank (Pain level 5, 8 and 6) -10/8/16: blank (Pain level: 6) -10/7/16: B: 50%; L: 50%; D: blank (Pain level 8) -10/6/16: B: 25%; blank (Pain level 6, 5 and 6) -10/5/16: blank (Pain level 8 and 5) -10/4/16: B: 25%; L: 0; D: blank (Pain level 8) -10/3/16: B: 0; L: 25%; D: blank -10/2/16: B: 0; L: 0: D: 25% (Pain level: 6, 2, 8 and 6) -10/1/16: B: 75%; L: 25%; D: blank (Pain level: 8, 3, 8, 7, 6 and 5) -9/30/16: B: 25%; L: 75%; D: blank -9/29/16: B: 25%; L: 25%; D: blank (Pain level: 8) -9/28/16: B: 0; blank -9/27/16: B: 0; L: 25%; D: 25% -9/26/16: B: 75%; L: 0; D: blank (Pain level: 0) -9/25/16: B: 25%; L: 50%; D: blank -9/24/16: blank -9/23/16: blank -9/22/16: blank -9/21/16: B: 50%; L: 50%; D: 50% -9/20/16: B: 25%; blank -9/19/16: blank; D: 25% According to the 10/16 Medication Administration Record [REDACTED] -10/27/16: Glucerna- one (100 percent) -10/28/16: Glucerna- one (100 percent) -10/29/16: Glucerna- one (100 percent) one (50 percent) -10/30/16: Glucerna- one (25 percent) one (50 percent) -10/31/16: Glucerna- two times a day (100 percent) According to the 11/16 Medication Administration Record: [REDACTED] -11/1/16: Glucerna- two times a day (100 percent) -11/2/16: Glucerna- two times a day (100 percent) -11/3/16: Glucerna- two times a day (100 percent) -11/4/16: discharged (No diuretics ordered) According to the dietary profile, dated 9/21/16: -Appetite: Good. -Eating/Chewing section: blank -Comments: blank According to the readmit dietary nutritional assessment, started on 9/27/16 and signed by the registered dietitian on 10/29/16 (one month for completion of the nutritional assessment) -Diet order: controlled carbohydrate -Percentage intake: 25-50 percent -Nutrition related lab values: blank -Weight change: Marked for significant: weight change >5% x 1mo; >7.5% x 3mo; >10% x180days -Summary of resident interview: Resident is sleeping and unable to be interviewed at this time. -Estimated calorie needs: 1827 calories/day -Estimated protein needs: 100 grams/day (1.2 grams/kg) -Percent intake required to meet estimated needs: 75 percent. -Additional notes: Recommend to offer Glucerna supplement twice daily (BID), fortified foods and preferred foods in order to increase protein-energy intake. -Resident goals: Consume at least 75% meals and supplements. -Nutritional monitoring: Will continue to monitor resident's weight and PO intake, per protocol. According to the admission assessment, dated 9/19/16: -[MEDICAL CONDITION]: blank -Dentures: complete for upper and lower -Oral hygiene: limited assist -Skin: warm (no wounds documented) According to the progress notes: -10/26/16: Order: Glucerna dietary supplement, twice a day (BID). -9/30/16: Resident continues to complain of pain in right hip area even after receiving pain medication. Will continue to monitor. -9/26/16: Telephone order received from doctor: zinc, one capsule orally every day x 21 days; Vitamin C 500mg, one tablet orally every day x 21 days; and Juven, one package orally every day x 21 days. (Progress notes were reviewed and there was no mention of appetite, meal intakes or [MEDICAL CONDITION]) 2. Post Discharge According to the history and physical, dated 11/4/16, post discharge from the nursing facility to the hospital: She has had decreased appetite . According to the hospital physician progress notes [REDACTED]. -Malnutrition- The patient's [MEDICATION NAME] level is 1.5. She has multiple co-morbidities. -Mouth sores- The nurses have been very concerned by poor dentition and poor dental hygiene. It appears as though her dentures had not been removed for a long time. There was food stuck to the roof of her mouth. We are going to continue to provide good dental hygiene. 3. Interviews A family member interview was conducted on 11/16/16 at 11:49 a.m. The resident's food tray was found sitting at the bedside with plastic on top of it. The tray was not always set up for the resident. She had low blood sugars due to not eating. The resident had a lot of pain. LPN #5 was interviewed on 11/21/16 at 10:50 a.m. She said this resident's nutritional status was poor due to not eating. They would attempt snacks. They asked her what she liked. She refused to eat. They offered her anything she wanted. When asked if the RD was involved, she said, I believe she was involved. She could not remember if this resident was on a supplement. She said the doctor was notified. RN #3 was interviewed on 11/21/16 at 12:20 p.m. She said this resident did not eat when she had pain. The key was pain management. She would eat 75% when pain was under control. She ate for me. She said she would have aides sitting with this resident in her room. When she missed pain medications, we had to catch up which took some time. Hard to get it back under control. The DON was interviewed on 11/21/16 at 4:30 p.m. She said this resident's nutritional status was good in the beginning. Towards her second admission, she would refuse meals frequently. She said she was unaware if this resident had a weight loss. The RD/DM and the NHA were interviewed on 11/21/16 at 1:00 p.m. She said this resident had decreased intake. She was on a diabetic diet. She was not on a supplement. The RD said she had two weeks to get the assessments completed. She said she probably should ' ve finished the assessment earlier and helped to identify the weight loss.

Based on observations, record review and interviews, the facility failed to provide supervision and assistance to minimize falls and prevent injuries to three (#44, #2 and #76) of three residents reviewed for falls of 30 sample residents. Specifically, the facility failed to: -Ensure resident #44's air mattress and recliner were assessed and utilized safely; -Assess, evaluate and implement measures to address accident hazards and fall risks for residents #44 and #2; -Identify and implement safety measures and supervision before and after falls. These failures contributed to residents #44 and #2 experiencing falls with injuries. Resident #44 suffered a scalp laceration, emergency room visit and sutures; and resident #2 suffered a fractured hip. The findings included: I. Facility standards The facility Falls - Clinical Protocol policy, revised September 2012, read in pertinent part, evaluate and document falls . when and where they happen, any observations of the events, etc. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor . -For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall . If the cause of a fall is unclear .or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. After more than one fall, the physician should review the resident's gait, balance and current medications that may be associated with dizziness or falling . The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. -Monitoring and Follow-Up .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls . If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. The Falls and Fall Risk Management policy, revised December 2007, read in pertinent part, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g. hip padding or treatment of [REDACTED]. Monitoring Subsequent Falls and Fall Risk: The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. The Assessing Falls and Their Causes policy, revised October 2010, read in pertinent part, Review the resident's care plan to assess for any special needs of the resident . Residents must be assessed in a timely manner for potential causes of falls . Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame . Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record . After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred . Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. Staff will evaluate chains of events or circumstances preceding a recent fall, including: a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching or transferring from one position to another; e. Whether the resident was among other persons or alone; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture or objects in the way); and/or h. Whether there is a pattern of falls for this resident. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found . If the cause is unknown, but no additional evaluation is done, the physician or nursing staff should note why . Performing a Post-Fall Evaluation: After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, several paces, and return to sitting, and will document the results of this effort . When a resident falls, the following information should be recorded in the resident's medical records . Appropriate interventions taken to prevent future falls. II. Resident #44 A. Resident status Resident #44, age 89, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 10/30/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. He required limited assistance of one for eating, extensive assistance of one for personal hygiene and bathing, was totally dependent for wheelchair ambulation, and was totally dependent on two-plus for bed mobility, transfers, dressing and toileting. A Physician Therapy In-Patient Evaluation and Plan of Care note from the local hospital dated 10/16/16 read in pertinent part, admitted : 10/15/16 . History of Present Illness: Patient presented to ER with complaint of progressive weakness . Today's Treatment: Patient required raised bed and moderate assist X2 for sit to stand. The care plan dated 10/18/16 identified High risk for falls related to confusion, gait/balance problems and incontinence. The goals were, The resident will be free of falls through the review date. The resident will be free of minor injury through the review date. The resident will not sustain serious injury through the review date. The interventions included: Air mattress removed from bed to prevent further risk for falls. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . Ensure that the resident is wearing appropriate footwear, non-skid socks when ambulating or mobilizing in WC (wheelchair). Follow facility fall protocol. PT (physical therapy) to evaluate and treat as ordered or prn (as needed). The resident uses a tab and bed electronic alarm. Ensure the device is in place as needed. There was no evidence that this resident's care plan related to falls had been updated since 10/18/16, although he sustained five falls after the care plan was initiated. B. Resident Observations The resident was observed on 11/16/16 at 2:40 p.m. He was seated in his room and was in his wheelchair. There was an alarm on the resident's bed and a tab alarm on his wheelchair There was no air mattress; it was foam. There was no fall mat on the floor, but the resident was not in bed. The resident was observed on 11/17/16 at 2:57 p.m. He was seated in his room and was in his wheelchair. His call light was within reach. There was a tab alarm on the resident's wheelchair and a pressure alarm on the resident's bed. No alarm was seen on the resident's recliner. The bed was in the low position and there was no fall mat seen in this resident's room. The resident was not in bed at this time. There was a shiny red area seen high on this resident's forehead. The resident was observed on 11/21/16 at 9:46 a.m. He was seated in his room and was napping in his wheelchair. His call light was within reach. The tab alarm was placed on the resident's wheelchair. The resident was leaning towards the left in his chair. The resident did not have non-skid socks on his feet. He was wearing regular white athletic socks. The resident was observed in his room on 11/21/16 at 10:22 a.m. He had just finished some cares with the nurse. He was awake in his wheelchair at this time and still did not have any non-skid socks on. The resident was observed propelling his wheelchair towards the dining room on 11/21/16 at 12:00 p.m. He was still wearing his regular socks. The resident was observed in therapy on 11/21/16 at approximately 3:00 p.m. He was wearing regular socks in the therapy gym. The resident was observed sitting in his wheelchair in his room after having just completed therapy. He was wearing regular socks and his call light was within reach. C. Record Review The resident sustained [REDACTED]. 1. Fall Documentation a. Fall 10/21/16 - injuries from falling out of bed The fall investigation dated 10/21/16 at 7:37 p.m., read in pertinent part, Witnessed fall in resident's room: Resident was attempting to change positions in bed, noted the bed is an air bed and when rolling over onto right side, resident bed pressure changed, pushing him out of bed onto the floor. Resident noted to have hit front of head and landing on left side. The resident stated, The bed bucked me off. The resident sustained [REDACTED]. The predisposing factors related to this fall were noted as furniture, confusion, decline in function and new admission in last 30 days. The progress note related to this fall read, Resident fell out of bed to floor, noted scrape to front of head. Resident head bleeding profusely, applied pressure and towel, assessed neuros. Resident unable to follow simple commands. Uneven hand grasps noted. Resident sent to (local hospital) via emergent transport related to the head wound. There was no documentation as to who was notified of this resident's fall. There were no handwritten notes at the bottom of this incident report. There were no follow-up neurological checks found in the chart related to this fall. A Falls Management Program sheet dated 10/24/16 read, Root Cause Analysis: Fall from bed due to air mattress. Air mattress removed. Regular bed applied. The fall investigation did not mention that the resident had a urinary tract infection when the fall occurred. There was no evidence the facility had evaluated the mattress for safety before placing it on the resident's bed. The 10/21/16 hospital emergency room repoort read in pertinent part, Fall out of bed with head/scalp laceration . [AGE] year-old man who is a patient at a nursing home . fell out of bed and struck his head and has a laceration to the anterior scalp. He also has some skin tears to the upper extremities . dementia . Has some skin tears to the right forearm, left shoulder . He is disorientated to time and place and events . He does have a 2 cm superficial laceration to the anterior scalp with surrounding abrasion . He has a superficial skin tear to the right dorsal forearm. Also has a skin tear to the superior aspect of the left shoulder . Assessment: 1. A 2 cm anterior scalp laceration with simple repair. 2. Skin tear, right forearm and left shoulder. Plan: The patient was discharged back to the nursing home in stable condition. -Discharge instructions read: You were seen today for: scalp laceration, skin tear of forearm without complications and urinary tract infection (UTI) . Sutures to be removed from scalp laceration in 10 days. Routine wound care for skin tear. No antibiotics for UTI per comfort care instructions. b. Fall 11/3/16 - unwitnessed The fall investigation dated 11/3/16 at 3:07 a.m. read in pertinent part, Unwitnessed fall in resident's room: LPN (licensed practical nurse) found resident on floor at 2:50 a.m. Resident lying on right side, seems to have slid out of recliner. It was documented that no injuries were observed and the resident did not complain of pain. The resident stated he did not hit his head. The resident was moved from the floor to bed by two nurses and three CNAs (certified nurse aides). Predisposing factors related to this fall were: fall alarm, gait imbalance, impaired memory, weakness/fainted, diabetes and resident was in arm chair and not in reclining position. Resident has no fall mat and tab alarm did not sound. Resident does not fit well in bed and requested to sleep in arm chair. Resident needs a bed that sits closer to the ground. A handwritten note on the bottom of this incident report read, Family to bring in larger, personal recliner from home. No post fall investigation was documented. There was no documentation of who was notified of the fall. The Neurological Assessment Flow Sheet was void of the last three neurological checks related to this fall. c. Fall 11/5/16 - unwitnessed with injury The fall investigation dated 11/5/16 at 11:00 p.m., read in pertinent part, Unwitnessed fall in resident's room: Resident found on floor next to his bed, lying on his left side. The resident said that he did not hit his head and landed on his bottom. The skin assessment showed there was a new 1 cmX1cm abrasion on his left 2nd toe. Denies pain at this time. Range of motion, good neuro checks wnl's (within normal limits). PCP (primary care physician) and DON (director of nursing) notified, passing on for day shift to notify family. This form showed that there were no predisposing factors related to this fall. There was a handwritten note on the bottom of this incident report that read, Alarms in bed and recliner. There was no post fall investigation related to this fall. d. Fall 11/10/16 - unwitnessed with injury The fall investigation dated 11/10/16 at 1:04 p.m., read in pertinent part, Unwitnessed fall in resident's room: Resident found on floor by CNAs. Resident was transferring self, lost balance and fell , has a skin tear 3X3 to right side of neck and a 6 cm cut to left big toe. The resident said that he was getting up from his recliner and fell . The immediate action taken was to place an alarm for recliner and to unplug the electric chair so he doesn't have it lift him up. The precipitating factors related to this fall were fall alarm, gait imbalance, impaired memory, decline in function and ambulating with assist. There was a handwritten note at the bottom of this incident report which read, Unplug recliner to prevent resident from lifting chair up, place pressure alarm. There was no documentation who was notified of this resident's fall. There were no follow-up neurological checks found related to this fall. There was no post fall investigation related to this fall. e. Fall 11/11/16 - unwitnessed The fall investigation dated 11/11/16 at 2:28 a.m., read in pertinent part, Unwitnessed fall in resident's room: Resident found on foot of his recliner, sitting down. Resident denies pain. Neuros WNLs. Range of motion good. Skin assessment WNLs. PCP was notified and DON, via communication board, requested that day shift notify this resident's family. Predisposing factors related to this fall included: furniture, confusion. There were follow-up neurological checks related to this fall; however, neither day nor night shift documented on this flowsheet on 11/12/16. There was no post fall investigation related to this fall. There was a handwritten note at the bottom of this incident report which read, Recliner evaluation to determine appropriate sizing for resident. Family requests resident continue use. Therapy education for safety. 2. physician's orders [REDACTED].>- The order dated 11/17/16 read, Staff may use Hoyer lift for transfers prn (as needed) for patient/staff safety. Recommend use of Serra lift with patient's feet protected with treaded socks or post-op shoes prn related to difficulty walking, muscle weakness and repeated falls. - The order dated 10/20/16 read, Sabina lift for all transfers per nursing judgement. - The order dated 10/18/16 read, PT 5Xweek X8 weeks. 3. Fall Risk Assessments - The fall risk assessment dated [DATE] rated this resident at a 15, which meant the resident was at high risk for falling. - The fall risk assessment dated [DATE] rated this resident at a 12, which meant the resident was at high risk for falling. - The fall risk assessment dated [DATE] rated this resident at a 10, which meant the resident was at high risk for falling. - The fall risk assessment dated [DATE] rated this resident at a 7, which meant the resident was at low risk for falling, although the resident fell on this same date at 11:00 p.m. - The fall risk assessment dated [DATE] rated this resident at a 9, which meant the resident was at low risk for falling, although the resident fell on this same date at 2:28 a.m. 4. Therapy Records Physical therapy (PT) and occupational therapy (OT) notes were reviewed from 10/18/16 through present and there was no documentation that either therapy department had completed an evaluation of this resident's recliner currently in his room (see observations below). The facility's Physical Therapy: Therapy Progress Report from 10/18/16 through 10/28/16 read in pertinent part, Diagnoses: [REDACTED]. Short-term goal #4: Patient will decrease risk for falls as evidenced by an increase in score to 15/28 on the Tinetti Assessment indicating high risk for falls. Baseline (10/18/2016): 3/28 (high risk for falls) . Current (10/28/2016): 11/28 (high risk for falls) . Instructed patient and primary caregivers in compensatory strategies, energy conservation techniques, falls recovery techniques, safe transfer techniques and use of assistive devices(s) in order to increase functional mobility skills. This report was dated by the physical therapist on 10/29/16. The facility's Physical Therapy: PT Evaluation and Plan of Treatment from 10/18/16 through 12/20/16 read in pertinent part, Patient will decrease risk for falls as evidenced by an increase in score to 15/28 on the Tinetti Assessment, indicating high risk for falls. (Target: 10/31/16) .Frequency: 5 time(s)/week. Duration: 8 week(s). Intensity: Daily. The facility's Occupational Therapy: Therapy Progress Report from 10/18/16 through 10/31/16 read in pertinent part, Diagnoses: [REDACTED].muscle weakness (generalized), and need for assistance with personal care .Instructed patient and primary caregivers in compensatory strategies, positioning/pressure relieving techniques, safe transfer techniques, self care/skin checks and safety precautions in order to increase safety and decrease need for assistance with variable carryover demonstrated by caregivers, facilitating the need for further instruction and analysis of caregiver implementation of and patient response to instructions/techniques. The facility's Occupational Therapy: OT Evaluation and Plan of Treatment from 10/18/16 through 11/16/16 read in pertinent part, Reason for Referral: Patient referred to OT due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced functional activity tolerance, reduced static and dynamic balance, decreased judgment, cognitive deficits, increased need for assistance from others and reduced ADL participation indicating the need for OT to assess safety and independence with ADLs, maximize independence with ADLs, develop and instruct on compensatory strategies and improve rehab potential . Patient is [AGE] year-old male that was hosptalized on [DATE] following two falls in two consecutive nights. Patient lives with elderly spouse and was unable to safely maintain current functioning; therefore admitted to this SNF following brief hospitalization for ongoing rehab and discharge planning. D. Staff Interviews Licensed practical nurse (LPN) #5 was interviewed on 11/15/16 at 1:50 p.m. This LPN said that resident #44 had sustained two or more falls in the last 30 days. She said that on 10/21/16, this resident fell out of bed in his room and sustained a head injury; she said that the resident went to the hospital and got stiches. She said that he was found on the floor next to his bed on 11/5/16 and sustained a scrape on the top of his left toe. She said that on 11/10/16, this resident was trying to transfer himself and received a skin tear on the right side of his neck and left great toe. She said that on 11/11/16, this resident was found at the foot of his recliner, but had no apparent injuries after this unwitnessed fall. She was asked what type of interventions the facility had put into place to prevent this resident from falling. She said they had put a tab alarm on his wheelchair, provided education to the resident, that the staff tried to check on this resident frequently, and that they had received an order to place the resident's mattress on the floor just in case. The DON was interviewed the afternoon of 11/17/16. She was asked about follow-up neurological checks following the resident's falls sustained on 10/21/16 and 11/10/16. The DON returned with additional documentation on 11/17/16 at 3:50 p.m., but stated no documentation could be located regarding these two required neurological assessment flowsheets. She also said that the facility was still trying to find the hospital report for the head wound that this resident sustained [REDACTED]. The DON and NHA were interviewed together on 11/21/16 at 10:20 a.m. They said that the staff, including every department manager, reviewed every fall sustained during the previous 24 hours during their stand up meetings each morning. They stated that they kept a log of these falls, but that log just included the resident's name and date. They said that they would write any new interventions the team came up with on the bottom of the incident report related to any particular resident's fall. They said that if the incident report was void of any handwritten signatures and interventions, there was no new intervention that the team discussed implementing. The DON said that for every fall, the designated family member should receive a phone call. The facility's procedure used to be that family members could be contacted the next morning if the fall occurred at night, but she acknowledged that was not being done, so the procedure was being changed to requiring a phone call to the family member immediately following the fall. She said that if a resident fell , the care plan should be updated within 24 hours of the fall. The MDS coordinator was interviewed on 11/21/16 at 10:51 a.m. She said that the assistant director of nursing (ADON) was the staff member who usually updated resident care plans in relation to falls. She said that fall interventions that were put into place were changing this resident's recliner, pressure alarms, a tab alarm for the wheelchair, and she believed the therapy department got this resident a new wheelchair, but she could not be certain about the wheelchair. She also mentioned ongoing education for the resident about not transferring himself. She acknowledged the resident probably would not be able to understand and remember education and reminders about fall prevention. The ADON was interviewed on 11/21/16 at 2:10 p.m. She said that she had not updated this resident's care plan in relation to falls because she had been on vacation. Physical therapist (PT) #20 was interviewed on 11/21/16 at 2:55 p.m. He said that he did an evaluation of this resident's wheelchair approximately two weeks ago, but did not document anything about it. He said he just told a nurse (he could not remember which nurse) that the only interventions recommended to minimize this resident's falls were either taking away his recliner (the resident told this PT he wanted to continue using the recliner that his family brought him) or putting down dysom strips on his wheelchair cushion so that he would not slide off. The PT said that certain clothing material on this roho cushion acted just like glass and the resident would continue to slid off his cushion if wearing certain types of clothing. The PT was asked about non-skid socks and he stated because this resident had so much edema in his feet, even the largest non-skid socks would not fit him unless they were cut away on the back. He said that the family has been asked to bring special fitting slippers or shoes that he had at home into the facility, but the family, who visited occasionally, had failed to do so yet. He said that he did place a new roho cushion on the resident's wheelchair, but that was all that had been done for this resident besides therapy, through their department. This PT was asked if he had ever evaluated this resident's air mattress and he said that he had not and that he had heard that the resident no longer had an air mattress on his bed. The DON was interviewed on 11/21/16 at 5:00 p.m. She said that the IDT team did look into a fall mat as an intervention, but that the therapy department felt a fall mat would have been more of a tripping hazard than a preventative measure. She did say that the team discussed using dysom tape on the resident's wheelchair cushion and that the facility did order some dysom. She did not know when it was ordered or if it had arrived. She stated that if it arrived, it would have been delivered directly to the therapy department. (It was not observed having been placed on this resident's wheelchair.) She did not know if the resident's physician had reviewed the resident's medication regime regarding medications that could contribute to falls. She said that the missing documentation on follow-up neurological sheets was an issue. She said that the IDT team did look at potential root causes of falls when reviewing the falls, but that they did not document these root causes. She said that the facility did discuss the fact that this resident did have a UTI during the fall on 10/21/16 in which the resident sustained [REDACTED]. She acknowledged that a current UTI was a potential contributing factor to a resident's fall. None of the staff interviewed mentioned anticipating the resident's needs and conducting frequent checks to provide supervision to minimize falls. The staff interviewed could not recall specifics about this resident's fall with injury due to lack of documentation in relation to fall investigations in general. III. Resident #2 A. Resident Status Closed record review revealed resident #2, age 74, was admitted on [DATE], readmitted [DATE] and discharged on [DATE]. According to the face sheet, admitting [DIAGNOSES REDACTED]. According to the 7/20/16 minimum data set (MDS) assessment, the resident was admitted with a fracture related to a fall within the six months perior to her admission, and a fall within the last month prior to her admission. She was receiving occupational and physical therapy. She required extensive assistance with activities of daily living. According to the 10/20/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of seven out of 15. She required total assistance of two persons with bed mobility, transfers, personal hygiene, dressing, and toilet use. She required total assistance of one person with bathing. Her day to day activities had been limited due to pain. The resident had frequently experienced pain or hurting in the past five days prior to assessment. According to the 9/15/16 MDS discharge assessment, the resident had a fall with major injury. According to the care plan, dated 8/12/16 and revised on 8/23/16 and 9/12/16, the resident had an actual fall resulting in a right side bimalleolar fracture (ankle fracture). The goal was that her fracture would resolve without complication and that she would not have any additional falls. The interventions included: -Ensure the call light is functioning properly prior to leaving the resident's room, dated 8/23/16 -Determine and address causative factors of a fall, dated 8/23/16 -Monitor, document, report to the physician any signs and symptoms of pain, bruises, change in mental status, confusion, sleepiness, inability to maintain posture, and agitation, dated 8/23/16 -Provide activities to promote exercise and strength building when possible, dated 8/23/16 -Physical therapy consult for strength and mobility, dated 8/23/16 -The resident would not be left unattended when on the toilet, dated 8/23/16 The care plan was void of documentation of an update after she had a fall on 9/15/16 that resulted in a fracture of the right hip, pain, and a hospital emergency department visit (see below). B. Record review Fall risk assessments According to the 8/23/16 fall risk assessment the fall risk score was eight indicating a category of low risk. -According to the 9/10/16 fall risk assessment the fall risk score was six indicating the category of low risk. -According to the 9/15/16 fall risk assessment the score was nine indicating a category of low risk. -According to the 9/19/16 fall risk assessment the score was 15 indicating a category of high risk. The fall risk assessment included that if the total score was ten or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Nurses' notes According to the nurse's note dated 8/22/16 at 1:52 p.m., the resident was yelling out for staff to help her. She was found on the floor with her head against the bed and her legs out bending. She stated that she was going to the bathroom and slid. She was alert and oriented times three. She was a total assist back to bed. She was encouraged to use the call light for help. She said that the call light was unplugged. Neurological checks were started. She was transferred to the hospital for evaluation at 4:00 a.m. The nurse's notes were void of documentation related to signs and symptoms that resulted in the resident being transferred to the hospital on [DATE] at 4:00 a.m. The interdisciplinary notes/fall committee note dated 8/23/16 at 8:05 a.m. included information the resident was transferred to the hospital for evaluation and treatment secondary to fall and confusion. The staff was educated to stay with the resident at all times while she was on the toilet and to ensure that the call light was functioning prior to leaving her room. According

Based on resident and staff interviews and record review, the facility failed to prevent medication errors for two (#2 and #3) of three sample residents. Specifically, the facility administered medications intended for resident #2 to resident #3, resulting in resident #3 being hospitalized overnight for treatment of [REDACTED].#2 missing her medications. Findings included: A. Facility Policies/Procedures The facility policy on Medication Administration, dated 3/16/15, included in pertinent part, Never administer medications supplied for one resident to another resident. The policy on Identifying and Managing Medication Errors and Adverse Consequences, revised 4/07, included in pertinent part: -The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. -The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's attending physician immediately. -In the event of a clinically significant adverse medication consequence, nursing staff shall implement and follow any related physician orders, and shall monitor closely and document the resident's condition and response to any corrective interventions for at least the next 24 hours or as otherwise directed. -Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form. -The Medical Director, Director of Nursing Services, and Consultant Pharmacist shall review medication errors and adverse medication consequences as part of the facility's Quality Assurance process. B. Resident Failures Cross-reference F309 regarding failure to ensure highest practicable quality of care regarding medication administration. According to resident and staff interview and record review, resident #3 was erroneously given medications that were ordered for resident #2 at approximately 4 p.m. to 5 p.m. on 9/8/15. 1. Failure to properly identify residents before administering medications Licensed practical nurse (LPN) #1 mistook resident #3 for resident #2 and gave resident #3 medications that were ordered for resident #2. LPN #1 was interviewed the morning of 9/30/15. She said she was a traveling nurse and 9/8/15 was her first day to work at the facility. When asked how she properly identified residents prior to administering medications, she said, Make sure you have the right resident, check against the MAR (medication administration record), look at the picture (in the MAR book). (Resident #2) is on the same hall (as resident #3) with one room in between. (Resident #3 and LPN #1) smiled at each other, I said hello, neither one of us could understand what the other was saying (due to a language barrier), she was very pleasant and friendly and she took the medication. She refused the blood sugar check. LPN #1 acknowledged that resident #3 was in her room, she had no roommate, her name was on the door, her picture was in the MAR, she did not request a translator when she and resident #3 could not understand each other, and she did not double check and ask another nurse when resident #3 refused the blood sugar check. 2. Failure to timely notify the hospital staff and physician LPN #1 said she was notified in report on the morning of 9/9/15 that resident #3 had gone to the hospital, complained of nausea/vomiting and said she got someone else's medications. However, a medication error report was not completed until 1 p.m. and there was no documentation on the medication error report or in resident #3's chart that the hospital staff or the resident's physician were notified timely. The resident was still in the hospital and the hospital staff did not know what medications she had erroneously received, per review of the hospital report and the resident's medical record, which on 9/9/15 read in part, given incorrect medication of unknown type . and then approximately 1 hour later developed severe nausea and vomiting. 3. Failure to ensure medication error reports were timely and accurately completed Review of the medication error reports, completed for both residents, both completed on 9/9/15 at 1 p.m. for the errors dated 9/8/15 at 5 p.m., revealed the following: a. For resident #3, the description of the error read, Resident given wrong medication [MEDICATION NAME] [MEDICATION]) 25-100 mg tab 3 tab po and [MEDICATION NAME] (a supplement) 2 tab po @ 5 pm (orally at 5:00 p.m.). Outcome to resident: Resident reported nausea/vomiting requested to go to ER (emergency room ) admitted (with [DIAGNOSES REDACTED]. The physician and director of nursing/supervisor were notified at 1 p.m. -The corrective action taken section was blank. The measures taken to prevent recurrence read, Pictures in MAR for identification of residents. The type of error was wrong medication, wrong resident. The reason for error was failure to identify resident. The person making the error was LPN #1. The signatures of the persons finding/reporting the error included the director or nursing (DON), attending physician, medical director, pharmacist and administrator were left blank. b. For resident #2, the description of the error read, [MEDICATION NAME] 25-100 mg tab 3 tabs po TID (by mouth three times daily) and [MEDICATION NAME] 2 tabs TID po were not given at 5 pm resulting in no adverse reaction. Corrective action taken read, VS (vital signs) taken 128/70, 97.6, 72, 16, 94%, monitor for adverse reactions. Measures taken to prevent recurrence read, Pictures in MAR for identification of residents. The type of error and reason were noted as wrong medication, missed dose, and failure to identify resident. The person making the error was the only signature, dated 9/9/15. The signatures and dates for the person finding/reporting the error, DON, attending physician, medical director, pharmacist and administrator were blank. 4. Failure to timely and accurately identify the medication errors for both residents There was no evidence in either resident #2 or #3's medical record to show that LPN #1 reported the medication error to the residents' physician(s). There was no evidence the facility reviewed the MARs to ensure the medication error reports and resident monitoring for side effects were accurate and complete, and to prevent further outcome to the residents. According to the 9/15 MAR, resident #2 had [DIAGNOSES REDACTED]. The resident was ordered the following medications at 5 p.m.: [MEDICATION NAME] 25-100 mg (antiparkinson medication), 3 tablets three times daily with meals - **Do not give before meals to prevent nausea; [MEDICATION NAME] (supplement for abdominal pain) two tablets with meals, [MEDICATION NAME] HCL 500 mg, 2 tablets **give with food**; fingersticks twice daily fasting and pre-supper at 4:30 p.m.; and [MEDICATION NAME] 70/30 ten units subcutaneously every hour of sleep immediately before supper with 5 p.m. marked on the MAR. -All the above medications were initialed as given by LPN #1 except the fingerstick for which there was no value. -Review of the MAR indicated [REDACTED]. She did not say why she believed the resident received [MEDICATION NAME] and [MEDICATION NAME] and not [MEDICATION NAME]. She also did not explain the timing of the medications, for example giving [MEDICATION NAME] and [MEDICATION NAME] before dinner contrary to physician orders. She further did not voice concern about resident #2 missing her [MEDICATION NAME] and [MEDICATION NAME]. 5. Failure to document medication errors in resident medical records Resident #2 had no nursing or interdisciplinary notes in her medical record between 9/4 and 9/14/15. There was no care plan update to alert nursing staff to the medication error and the need for follow-up monitoring or resident identification. A separate VS sheet provided by the facility showed her vitals were taken once daily 9/9/15 through 9/12/15. The resident's [MEDICATION NAME] administration and BG results were blank on 9/9/15. (It was also blank on 9/3 and 9/26, and BG results were often blank when [MEDICATION NAME] was given. Overall the resident's [MEDICATION NAME] documentation was sporadic and without physician parameters. An MD order dated 8/31/15 read, BGs PRN per physician - please check prior to insulin administration per nursing judgement.) -The resident was also to receive [MEDICATION NAME] (an antipsychotic which can be pink, yellow or white) 50 mg at 8 p.m. or bedtime. There was no evidence LPN #1 was asked, or whether it was investigated, to ensure this medication was not also given to resident #3 in error. 6. Failure to timely and consistently document medication error in resident medical records Resident #3 had no nursing or interdisciplinary notes in her chart between 9/4 and 9/22/15. Her care plan was not updated regarding the medication error. -The 9/22/15 IDT (interdisciplinary team) meeting note documented in part, On 9/9/15 res c/o nausea, emesis noted x 2, and headache. Res transferred to (hospital emergency room ) for eval and tx (treatment) per her request. Res noted to have UTI, returned on IV ABT (antibiotics) . -A note on 9/29/15 at 11:32 a.m. (the date and time the complaint investigation began) read, Late entry for 9/15/15. Follow up from medication error on 9/8/15. Res was given another residents medication causing nausea and vomiting. Res was transferred to (hospital ER) for eval and treatment. Returned with new orders for ABT for UTI. Res had c/o headaches over the next 2 days. PRN medications offered as per physician orders. SSD (social services director) followed up with res regarding concerns with medication error. NHA spoke with resident and family regarding situation. Copies of current medications with explanation and pictures provided to res for her well-being, to identify medications she is given routinely, which resident stated was very helpful. Assisting res in goals to discharge home with daughter and son-in-law. Will continue to follow up with resident PRN (as needed). Review of resident #3's MAR indicated [REDACTED]. Her regularly scheduled medications were iron 325 mg daily, multivitamin capsule daily, vitamin D3 50,000 unit cap once weekly, [MEDICATION NAME] (muscle spasms)10 mg daily. All other medications were supplements and all were to be given at 8 a.m. Staff Interview: During the exit interview, late afternoon on 9/30/15, the nursing home administrator and nurse consultant #2 said they would investigate the medication errors.

Based on resident and staff interviews and record review, the facility failed to provide the highest practicable quality of care for one (#3) of three sample residents regarding medication administration. Specifically, resident #3 was administered medications that were prescribed for resident #2. This failure resulted in resident distress as evidenced by her nausea, request to go to the emergency room (ER), and her fear of subsequent medication errors stating she felt, scared and unsafe. The findings included: A. Professional Reference regarding Medication Administration According to Clinical Nursing Skills & Techniques, by Perry, Potter & Ostendorf, 8th Edition (copyright 2014), page 480-489: Safe Medication Administration: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation -Read the label on the medication container and compare it with the MAR (medication administration record) at least 3 times: before removing the container from the supply drawer, when placing the medication in an administration cup/syringe, and just before administering the medication to the patient . -Review any pre-administration assessments (e.g., vital signs, review of laboratory results) . -Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication . -When an error occurs, the patient's safety and well-being become the top priority . B. Professional Reference regarding Medications and Potential Side Effects According to the Mayo Clinic website regarding medications and side effects, mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/side-effects/drg- 074?p=1, updated 10/1/15 and accessed 10/9/15: -[MEDICATION NAME] is used to treat high blood sugar levels that are caused by type 2 diabetes. Side effects may include abdominal or stomach discomfort, cough or hoarseness, decreased appetite, diarrhea, fast or shallow breathing, fever or chills, general feeling of discomfort, lower back or side pain, muscle pain or cramping. Less common side effects include anxiety, blurred vision, chest discomfort, cold sweats, coma, confusion, difficult or labored breathing, dizziness, headache, nausea, nervousness, redness of face/neck/ arms, [MEDICAL CONDITION]. -[MEDICATION NAME] tablets are white. According to the RxList.com website regarding [MEDICATION NAME] side effects, revised 3/28/11 and accessed 10/13/15: [MEDICATION NAME] serious side effects may include restless muscle movements in your eyes, tongue, jaw, or neck; tremors; high fever, stiff muscles, sweating, fast or uneven heartbeats, rapid breathing, feeling like you might pass out; [MEDICAL CONDITION]; severe nausea, vomiting, or diarrhea; uneven heart rate or fluttering in your chest; confusion, hallucinations, anxiety, agitation, depressed mood, thoughts of suicide or hurting yourself; chest pain or heavy feeling, pain spreading to the arm or shoulder; muscle pain, numbness or tingly feeling. -[MEDICATION NAME] tablets are yellow or [MEDICATION NAME]. C. Resident #3 Resident #3, age under 55, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Resident Status According to the 7/14/15 Minimum Data Set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident had no mood or behavioral symptoms. The resident spoke Spanish and requested an interpreter for communication, used a wheelchair for ambulation, and required extensive assistance with activities of daily living (ADLs). Listed [DIAGNOSES REDACTED]. According to the September 2015 Medication Administration Record [REDACTED] -Iron 325 mg, one tablet daily -Multivitamin, one capsule daily -Vitamin D3(supplement) , one 50,000 unit capsule every week -[MEDICATION NAME] (muscle relaxant) 10 mg, one tablet daily for muscle spasms -Elemental, (a supplement) one package with 8 oz water daily for wound healing -Ertapenem (an antibiotic) 1 gm daily IV (intravenously) x 3 (for three) days, start 9/10 for urinary tract infection -All the resident's medications were to be given at 8 a.m. except the Ertapenem IV which was given at 3 p.m. The resident was not prescribed any evening oral medications. -The MAR indicated [REDACTED]. (resident) after meals to assess if she has trouble eating or any nausea vomiting at 9 a.m., 1 p.m. and 7 p.m. starting on 9/15/15. -The care plan identified on 11/27/14 that the resident spoke Spanish only. Approaches included to provide an interpreter as needed, allow the resident plenty of time to respond, provide a quiet environment when discussing important issues along with an interpreter, and that the resident was able to understand most hand gestures. 2. Resident Interview The resident was interviewed via interpreter at 1 p.m. and 3:30 p.m. on 9/29/15: -She said she had been sent to the hospital two weeks ago because she had been given another resident's medications before dinner. After she took them, she began throwing up, went blind for a little bit, her right arm began contracting, and her lips were getting swollen. The resident said she was in the hospital from about 8 p.m. on 9/8/15 until midday on 9/9/15. -In the hospital, they started an IV, gave her medications to stop her vomiting, and she did not know what else. They gave her a copy of the hospital report but she did not know what it said. The nursing home told the hospital nurse they did not know what she was given. -She recalled taking three white pills and two pink or yellow pills, five pills total. She said she asked the nurse what they were for, and the nurse said they were for her stomach, but the resident responded that she did not have issues like that. -The resident said a similar situation had occurred before at the facility. She was given two pills that were not hers, and she held them under her tongue and spit them out after the nurse left her room. -She said she was afraid of taking any medications from the facility. -She said she wanted to know the truth of what happened on 9/8/15. -She said she felt she was treated differently after the incident, and that the aides and workers passed by her room and did not say anything to her. -The resident said she did not believe she would have had such a severe reaction to the [MEDICATION NAME] and [MEDICATION NAME] supplements she was told she was given in error (see below review of medication error). She said she was violently ill and had to go to the hospital. She said she did not want to take the medications and the nurse made her take them. She said the nurse tried to draw blood from her hand and she would not let her. 3. Hospital History and Physical Report Review of the hospital report dated 9/9/15 revealed the following: -The resident was admitted on [DATE] -By report the resident was given incorrect medication of an unknown type at the facility and then approximately an hour later developed severe nausea and vomiting. -By report the patient received approximately five tablets at 4 p.m. and the nausea and vomiting started at 5 p.m. Apparently the family called the police to file a report. -The resident had quite severe nausea and vomiting and was given [MEDICATION NAME] incrementally to total 12 mg IV. Abdominal 3-way x-ray is unremarkable. Labs are unremarkable except urinalysis shows positive [MEDICATION NAME]. She has a history of extended spectrum beta lactamase Escherichia coli urinary tract infections (E-coli caused urinary tract infections) and therefore has been started on [MEDICATION NAME] . had continued nausea and vomiting . given IV fluids . hemodynamically stable, afebrile. EKGs unremarkable . suspect that this patient will require only one midnight and therefore have admitted her observation status to acute care for antiemetics and IV fluids and empiric antibiotics awaiting urine culture. -The [DIAGNOSES REDACTED]. It is possible they were another patient's medications. An investigation into this event is occurring at (the facility). D. Facility Investigation/Response to Medication Error The nursing home administrator (NHA) was interviewed at 2 p.m. on 9/29/15 and a copy of the facility investigation was requested. The NHA interview revealed: -The resident was given two [MEDICATION NAME] (antiparkinson agent) and three [MEDICATION NAME] (anti-gas) supplements intended for another resident (#2) by a PRN agency nurse who still worked in the facility. The nurse also tried to draw blood for a blood glucose reading. -The facility did not report the nurse's medication error to the department of health or to the board of nursing. -The resident's family called the police. There was no police report per the police officer because no crime was committed. The facility's investigative summary, initiated 9/8/15, written by the NHA, and provided by the NHA on 9/30/15, revealed: -On 9/8/15, a certified nurse aide (CNA) reported at approximately 7 p.m. that resident #3 had thrown up, and had told staff that she took five pills at 4 p.m. that she did not believe were hers. The nurse evaluated the resident and noted vital signs were within normal range. The resident was sent to the ER by staff. -On 9/9/15, the resident returned to the facility. Per the hospital report, the resident was diagnosed with [REDACTED]. The resident's family called police who arrived at approximately 6:30 p.m. No case number was available. The employee was counseled regarding the five rights and expectations while working at the facility. -On 9/10/15, the NHA met with the resident and family and the resident gave her statement through her family member as translator. The NHA told the resident it was believed she was given another resident's medications accidentally. The ADON (assistant director of nursing) printed pictures of all resident medications, time schedule and name on the sheet for the resident's reference. Staff attempted to get discharge orders per resident request but were unsuccessful in finding alternate safe discharge. -On 9/12/15 and 9/13/15 Spanish speaking and other staff provided emotional support daily and no further concerns were indicated. -On 9/14/15 the resident reported to the SSD that she felt unsafe and requested to know what medications the team believed she had taken. With a staff translator, the nurse consultant and NHA met with the resident, the consultant explained the medication the team believed she was given and offered emotional support. The resident said she felt safe and had no further questions or concerns. -On 9/13/15 and 9/14/15 the nurse consultant checked in with the resident who did not indicate any further concerns. All nursing staff would be educated on the five rights on 10/2/15. No abuse or neglect were substantiated by the investigatory team. A written undated statement was attached from the licensed practical nurse (LPN) #1 who gave the medications, as follows: On 9/8/15 I gave the 5 pm med (medication) pass as ordered per MAR. Everyone took their meds. -On 9/9/15 was given report by off going nurse that (resident #3 listed by room number) became ill (with nausea/vomiting) and requested to go to hospital ER (emergency room ) (due to) being given medication. The resident said she had been given 3 white pills and 2 pink pills. Resident was (diagnosed with [REDACTED]. -I questioned myself if I had made a med error. I knew that I did not give pink pills. I went to the administrator and told her I thought it was possible I made a mistake. I gave 3 yellow tabs and 2 white. I realized when I pulled 12 p.m. meds for (resident #2 listed by room number) that it was exactly what I had given to (resident #3) on 9/8/15. I told the administrator and filled out med error sheets and informed MD (primary care physician). -I had confused the two residents by name. Both are of Hispanic origin. Neither of them had on name bands. When the resident (#3) returned from the hospital, there was no doubt that I had made the mistake. I knew that she was the one who received the meds. A written statement from the CNA dated 9/8/15 read in pertinent part as follows: Resident had call light on (and) (two CNAs) went to see what she needed . (Resident) in bed throwing up into a trash bag. She was crying and very scared. We couldn't communicate well with her so we called (resident #3's friend) to translate . Resident told (translator) she was given 3 (three) white pills and two pink pills. Resident didn't want to go to hospital . Resident called within 15 min (minutes) complaining of stomach ache, headache, and vomiting. (Through family interpreter on the phone, who had called) resident asked to be sent out . (Family) stated she was on her way down here and that she was calling the police and hung up. They showed up . right as she was being transported by EMS (emergency medical services). They stayed and talked with the nurse before leaving. The NHA noted on 9/10/15 that at 2 p.m. that day she met with the resident, a facility CNA #4 and three family members. The resident's family member translated. The resident said she received three white pills and two pink pills at 4 p.m. on 9/8/15 and the nurse tried to take her blood sugar but she refused. The NHA told the resident and family she would investigate and reviewed the hospital notes. On 9/11/15 at 12:32 p.m. the NHA interviewed LPN #1 and requested a written statement (see above). E. Continued resident concerns On 9/14/15 (five days after the resident's return from the hospital) a concern/comment form completed for resident #3 by the former social services director (SSD) read that the resident (1) Wants to know all details of med error case ASAP (as soon as possible) - doesn't want to wait for a meeting; (2) Feels scared and unsafe, wants to be transferred to SNF (skilled nursing facility) in (another city) and wants to call state for support. Feels nursing staff doesn't care or communicate. The investigative findings documented by the NHA, read, Interview (with) SSD unclear. Admin and nurse consultant followed up. Res was told what meds staff believed were given. Res was given pics (pictures) of meds. Action taken: Admin and nurse consultant met (with) res 9-14-15. Resolution: Res stated she felt safe and would let staff know if she has any further concerns. Nurse consultant checked on res x 3 days to ensure res felt safe and medication was correct. Will continue to monitor. This was signed by the NHA on 9/15/15. A corresponding social services note read that the SSD met with the resident to follow up on grievance, utilizing a dietary staff person as interpreter. The resident expressed feeling anxious, scared and unsafe due to the recent incident and was eating minimally because she was concerned facility staff might poison her. The resident displayed anxiety and distress, had contacted family, local police and an attorney and wanted to discharge from the facility. Community options were discussed. The resident also asked for the Spanish line for the state health department. The SSD was given the wrong number posted in the facility and was working on getting the correct Spanish line for resident, provided emotional support and told the resident the NHA would speak with her that day about all the details of the grievance. The resident was pleased to hear this would occur. The SSD left a message with the resident's daughter to set up a care conference. The resident had grievances filed and was seeking to discharge out of the facility. The SSD wrote that she would meet w/res once an interpreter is available. F. Staff Interviews and MAR indicated [REDACTED]>LPN #1 was interviewed on the morning of 9/30/15 with the assistant director of nursing (ADON). -When asked what steps were taken to prevent recurrence, LPN #1 said she was not communicating with resident #3 anymore. Everybody thought it was best not to go on the hall, to keep from upsetting her, not working with her or (resident #2) anymore . I now check everything - I've learned the residents here now, ensure I familiarize myself with those people, check those pictures (in the MAR), double check the room numbers, and if I have any questions at all go to (the ADON) or another nurse. -LPN #1 said that on the evening of 9/8/15, she gave medications, did report, did medication count, and left after that. One of the aides came in and wanted to know what meds (resident #3) had and I told her, and she went back and told the resident and then we did report and counted and everything and I left. -When I came in and got report (the next day, the charge nurse) said (resident #2) had gone to the hospital, complained of of nausea/vomiting and said she got somebody else's medication. I sat there and said I just knew it was (resident #2) that I'd given meds to, then I realized and went and talked to the NHA and told her I thought I'd given her (resident #2's) meds. I was still on that same hall the next day. I don't recall what time (resident #3) came back. It was about 4 pm when she got back. I called the doctor, they both had the same doctor, so I reported it to the doctors, what had happened, so we monitored them. Took their vitals, (resident #2's) once, then I got (resident #3's vitals) when she got back from the hospital. They were fine. There was no distress or adverse reaction. (Resident #3) seemed nervous - whenever I walked by the room she'd get a look on her face and I didn't actually go in. The CNA checked her vitals - they were normal for her. The hospital did a lot of blood work. When I called the doctor office (about 1 pm) they said they'd call the hospital. G. Facility follow up During the exit interview late afternoon of 9/30/15, with the NHA and nurse consultant #2, they said they would re-investigate the medication error issue and the resident's continued fearfulness, and LPN #1's behaviors that concerned the resident, of which they were previously unaware.

Based on resident and staff interviews and record review, the facility failed to protect residents, including four out of seven residents sampled for abuse and/or mistreatment (#74, #57, #21 and #23), from abuse that involved verbal abuse, mental abuse, rough handling, and withholding of personal care. Interviews revealed that residents had reported to staff and staff had reported to management that residents had been abused and mistreated. -Resident #74, who was dependent, reported she had been told, among other things, by certified nurse aides (CNAs), primarily CNA #1, to provide her own care, told she smelled, and told no one wanted to care for her. Staff interviews indicated management was notified of the resident's allegations prior to 2/10/15. -Other residents, who wished to remain anonymous out of fear of "repercussions" or because "it doesn't do any good," stated that in the past, they had reported residents being yelled at, denied care, and spoken to in harsh tones. No steps were taken by the facility to ensure residents were protected from abuse and/or mistreatment. CNA #1 continued to provide direct care to resident #74 without restriction or oversight. On 2/10/15, resident council minutes at 3:30 p.m. documented a resident stated "there is a CNA that is unkind, rude and rough." The SSD did not report the above allegation from the resident council to the nursing home administrator and the Director of Nurses (DON) so that an immediate investigation could begin. Rather, the social services director (SSD) filed a grievance. On 2/10/15 in the afternoon, interviews and record review revealed resident #57's spouse reported resident #57 had been "thrown around" the previous night by CNA #1 during a transfer and had hurt him. The facility investigation of these allegations revealed two other residents, #23 and #21, reported CNA #1 previously had been rough and "nasty" with them. Per resident #21, this had happened more than once. The facility's failure to recognize resident abuse and/or mistreatment and timely respond to residents' allegations of abuse contributed to further abuse, and residents' fear of abuse, retaliation and of their safety. This created a situation of immediate jeopardy for serious harm. Cross-reference F165 - Voice grievances without fear of reprisal; F225 - Thoroughly investigate abuse; and F226 - Operationalize facility abuse policy and procedures. The findings included: I. Imposition of Immediate Jeopardy On 2/11/15 at approximately 12:30 p.m., the nursing home administrator (NHA), corporate regional director of operations, and corporate regional director of clinical services were informed by the Colorado Department of Public Health and Envrionment (CDPHE) that the facility's failure to protect residents from abuse created a situation of immediate jeopardy for serious resident harm. II. Facility Response and Removal of the Immediate Jeopardy On 2/12/15 at 10:58 a.m., the following plan (draft #4) was submitted by the facility to CDPHE to remove the immediate jeopardy. The plan read: What has been done to ensure our residents reporting abuse feel safe? ? CNA #1 suspended pending results of investigation. This action will ensure no resident is cared for in our facility by the CNA who allegedly administered the abuse. Certified Nursing Assistant alleged to have abused resident Resident #74, Resident #57, Resident #21, and Resident #23 has not worked since the allegations were reported to the facility. Director of Nursing notified said certified nursing assistant on 2/11/15 at 2:00pm of immediate suspension pending results of investigation. ? CNA #1 was reported to the board of nursing. Human Resources Director will report CNA #1 to the Colorado Board of Nursing on 2/12/15. ? Police notified of abuse. This action will ensure that if the CNA is found guilty of criminal charges, said CNA will no longer hold a license to provide care to any of our residents either in our facility or in the community. Director of Nursing and Regional Director of Operations completed a police report related to the allegations of abuse with Officer (name) via case number (number) on 2/10/15 at 4:45pm. During the report, Officer (name) indicated the police department would be notifying Adult Protective Services of the alleged abuse. ? Residents alleging abuse were interviewed immediately and asked if they felt safe. This action will ensure the residents reporting abuse feel safe. Regional Director of Clinical Services and Assistant Director of Nursing conducted interviews with residents Resident #23 and Resident #21 on 2/10/15 at 6:05pm and 5:46pm respectively. Assistant Director of Nursing and Social Services Director conducted an interview with resident number Resident #57 on 2/10/15 at 4:05pm. Assistant Director of Nursing and Social Services Director conducted an interview with resident Resident #74 on 2/11/15 at 2:30pm. During the interview, residents were asked if they felt safe. All residents responded they felt safe in our facility with the exception of Resident #21. Resident #21 indicated that he would feel safe if CNA #1 no longer worked at the facility. ? Residents alleging abuse were offered psychological services as a result of the alleged events. This action will ensure residents reporting abuse are treated for [REDACTED]. Social Services Director asked residents Resident #74, Resident #21, Resident #23, and Resident #57 if they would like to have psychological services scheduled for them on 2/11/15 at approximately 5:30pm. Resident #57 and Resident #23 refused psychological services. Resident #74 has an appointment pending. Resident #21 receives psychological services on a regular basis. His next appointment is scheduled for 2/12/15 at 11:00am. Resident #74 and Resident #21's psychiatrists will be notified of the alleged abuse prior to the appointments. ? Social Service follow up visits. This action will ensure the resident continue to feel safe, no futher issues arise, and there is no retribution. Social Service Director or Designee will visit with Resident #74, Resident #21, Resident #23, and Resident #57 for the next 72 hours to ensure no further issues arise then every other day visits then weekly visits for 4 weeks to ensure no retribution. What have we done to ensure all residents are safe and free from abuse at this time? ? Resident interviews were conducted for all cognitive residents. This action helps us to identify any additional abuse that has not been reported. The Social Services Director and Administrator in Training conducted resident interviews starting on 2/10/15 and completed on 2/11/15 at 3:50pm. No residents interviewed alleged any new, unreported abuse. ? Family Interviews will be conducted. This will help to ensure any unreported abuse is discovered. The Administrator or Designee will contact all family members of noncognitive residents on 2/12/15 to ask them if they have witnessed or if any abuse has been reported to them and to ask if they feel comfortable reporting abuse/neglect and concerns to staff. ? Resident skin assessments were completed for all noncognitive residents. This action helps us to identify any additional abuse that has not been reported. The Assistant Director of Nursing and the MDS Coordinator conducted skin assessments on all noncognitive residents on 2/11/2015. Bath Sheets were used to document results of the skin assessments. Any areas of unknown origin related to bruising or other skin conditions will be fully investigated per our Incident Report Policy. No resident assessment resulted in signs of obvious physical abuse. ? Management staff on duty. Around the clock management staff will be on duty during the investigation of CNA #1. This will help to ensure there is no retaliation and will help to identify any unreported problems. The MDS Coordinator will be on duty until 3:00am 2/12/15 and (in lieu of) CNA #1, the ADON will be on duty starting at 3:00am on 2/12/15. What have we done or what will we do to ensure all residents feel safe and feel comfortable reporting abuse and neglect? ? Responsible parties of residents will be notified of the definition of abuse and neglect, will be notified how to report abuse/neglect/concern, and will be provided with phone numbers to (the facility's) Compliance Hotline phone number, Ombudsman phone number, and State Complaint Hotline phone number via letter. This will ensure responsible parties understand how to report abuse, neglect and concerns. Social Services Director or Designee will complete mailing of letters to notify responsible parties of the process for filing and reporting grievances and abuse completed by 2/11/15 at 7:00pm. ? Employee interviews will be conducted by corporate staff. This will ensure staff feel comfortable reporting any concerns of reporting to current management staff. Regional Director of Operations and Regional Director of Clinical Services will complete an interview with staff members to ask if they have witnessed abuse or neglect at anytime or if they have reported abuse, neglect or a concern at any time that was not investigated and addressed. Interviews will be completed on 2/11/15 by 11:00pm. Results of interviews will be compiled and addressed based on findings. ? Resident abuse, neglect, and concern education during Resident Council. This education will help ensure resident safety by ensuring residents understand the process of how to report abuse, neglect and concerns along with giving them options of who to report these concerns to. Social Services Director or Designee completed education with residents what is abuse and neglect, how to report abuse and neglect, and how to file a concern via a Resident Council Meeting held at 4:00pm on 2/11/15. What will we do to ensure all reports of abuse and neglect are investigated and appropriate action is taken? ? Educate management staff on policies and procedures related to Abuse/Neglect Reporting and Comment/Concern Policy and Procedure. This process will provide reeducation to the management of the expectations of outlined in the policies and procedures. Director of Operations and Regional Director of Clinical Services will inservice all administrative staff on Abuse/Neglect Reporting and Comment/Concern Policy by 11:00pm on 2/11/15. o Abuse Prevention Policy & Procedure o Concern/Comment Policy/Procedure o Concern/Comment Report o Notification List o Investigation Procedure ? Director of Nursing or Designee will inservice all staff working on Abuse/Neglect Reporting and Comment/Concern Policy started on 2/11/15. No staff member will be allowed to work until in-service education is provided on Abuse, Neglect policy and our grievance policy and procedure. o Forms of abuse o Immediate action o How to report abuse o Who to report abuse to o Instruction to report abuse as soon as its reported or witnessed On 2/12/15 at 11 a.m., the NHA and corporate regional directors were notified that the immediate jeopardy had been removed. However, based on interviews and record review deficient practice remained at H level, actual harm at a pattern. III. Resident Protection System - Preventing Abuse and Neglect The facility Abuse Prevention Policy & Procedure (revised 3/1/13), provided by the facility on 2/11/15, read in part as follows: The purpose of this written Resident Abuse, Neglect and Misappropriation Prevention Program (RANMP) is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked, could lead to abuse. Policy Statement This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. -Report all allegations of abuse immediately to the Director of Nursing and the Administrator. -Any allegation of abuse is reported immediately to the state agency and to all other agencies as required, per state and federal guidelines. -"Immediately" means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. Refer to State, Federal and Elder Justice Act guidelines. Definitions Abuse - A basic definition describes abuse as "the harmful treatment of [REDACTED]." A more substantive definition of abuse is as follows: "the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or mental anguish, or deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain and mental anguish." The most common forms of abuse include: Mental Abuse - The infliction of mental anguish, includes but is not limited to: humiliation, intimidation, harassment, and threats of punishment or deprivation. Physical Abuse - The infliction of physical pain or injury, includes but is not limited to: slapping, pinching, hitting, kicking, or shoving. It also includes controlling behavior through corporal punishment. Verbal Abuse - Any use of oral, written or gestured language that willfully includes the disparaging and derogatory terms to residents, their families or within hearing distance, regardless of their age, ability to comprehend or infirmities. Examples of verbal abuse include but are not limited to: saying or doing something with intent to frighten a resident or otherwise make him/her feel unsafe or insecure; gesturing a slit throat, passing a note that reads, "You talk too much! Be careful what you say about me." Neglect - The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness; e.g., denial of food or health-related services, abandonment. Reporting/Investigation/Response Policy Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner as detailed below. Procedures: Reporting - All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, so that the resident's needs can be attended to immediately and investigation can be undertaken promptly. Nursing staff duties: 1. An incident of abuse must be reported to the charge nurse who will examine that resident, document findings in the clinical records and immediately initiate the investigation protocol. 2. The administrative or nursing supervisor assumes responsibility for immediate notification of the Administrator and the Director of Nursing, by phone if necessary, and also notification of the appropriate department head. 3. Nursing is to document on the resident's physical and emotional status every shift for 72 hours following the incident. Facility Social Worker is to provide counseling and support to the resident and possibly the family involved. The counseling is to be provided as long as necessary. The psychosocial intervention is to be documented in the resident's clinical record. Administrator shall take the following actions to address issues of resident care raised by suspected abuse: -Call police when assault or wanton neglect is suspected and/or confirmed by investigation. Investigation - All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. Additionally, the facility will thoroughly investigate, under the direction of the Administrator, all injuries or unknown origin to determine if abuse or neglect was involved. Cross-refer to F225, failure to investigate allegations of abuse, for the facility investigation policy. IV. Failure to Recognize and Respond to Allegations of Abuse and Protect Residents from Abuse A. Failure to Recognize and Respond to Allegations of Abuse 1. Resident interviews - anonymity requested Two residents interviewed during survey 2/9/15 - 2/13/15, requested anonymity in their interviews. Both residents per the facility and resident assessment were cognitively intact without behavioral symptoms. a. A resident who requested anonymity was interviewed on 2/9, 2/10, 2/11 and 2/12/15, and made the following comments: -The resident said s/he had been verbally abused, had seen other residents being abused and mistreated, and had reported abuse, but "it doesn't do any good" and "of course I was the trouble-maker." The resident said s/he had seen and heard staff yell at residents with dementia who were unable to speak for themselves, "What do you want? What's wrong with you? (Staff are) overworked and they take it out on the residents with Alzheimer's ... They don't pay any attention. (A resident with dementia) will just sit, and you can see her going down and down and down ..." The resident said s/he did not report abuse any more due to being "afraid of repercussions." Asked what would happen, the resident said, "(Repercussions) will happen. It goes all the way to the top." In an interview on 2/11/15 the resident reiterated that s/he did not want follow-up on his/her stated concerns because s/he did not "want retaliation..." b. A second resident who requested anonymity was interviewed on 2/11/15 and made the following comments: "I have a problem with one of the employees. I do not know her name or her title. I did not see her yesterday or today. I saw her last week ... The staff person stated she could not help me ... The staff person said it in a harsh tone and she did not tell me who to go see to get (what was needed)." The resident stated s/he reported the problem to a management staff person and added, "I do not want you to do anything. Just forget it. I do not want to get in trouble. Do not tell anyone about what I have said to you." 2. Resident #74 Resident #74 was admitted to the facility on [DATE], discharged to an acute care hospital for change in condition (sepsis) on 2/2/15, and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident Status: According to the 1/15/15 Minimum Data Set (MDS), the resident had a BIMS (cognition) score of 15 indicating she was cognitively independent, with no mood or behavior symptoms. She required extensive two-plus-person assist with bed mobility, transfers, dressing, toilet use and personal hygiene. She was dependent for bathing, had lower extremity range of motion impairment on both sides, used a wheelchair for ambulation, and was frequently incontinent of bowel and bladder. She received diuretic medication seven out of seven days. The resident's care plan, dated 1/16/15, identified the resident needed assistance with activities of daily living (ADLs). Approaches included: "Occupational therapist to work with me on transfers and ambulation ... ADL retraining. Break my tasks up into smaller steps. Allow me rest breaks between tasks. Assist with toileting/incontinence care as needed." a. Resident Interview Resident #74 stated during an interview on 2/11/15 at 9 a.m. that CNA #1 had been abusive to her. The resident said she had written a letter and given it to the director of nursing (DON) before she was admitted to the hospital on [DATE]. When she was readmitted to the facility on [DATE], CNA #1 was still assigned to work with her, and the abuse continued. At 9:21 a.m. on 2/11/15, the resident provided a copy of the undated, unsigned letter, which read as follows: "To whom it may concern -Why did it take 2-1/2 (hours) for me to get lunch, was served ice cold -My bed was changed and I was given one sheet. -Needed my diaper changed and it took 20 minutes for the aide to change it, then I got a lecture for sitting in it. -I do not appreciate being used as a rag doll, being told what time I need to wake up. -I do not need someone going through my items without my permission or when I'm not here. -Did not like being woke up at 4am for a 630 bath which I did not ask for. -Was told if I did not get up was told my bed would not be made. -I was left in my chair for 3-1/2 hrs on 3 different occasions, once for 1/2 hr and twice for 1-1/2. -Takes up to 30 minutes to answer the light. -I was told to either hold it in or stay up. -For some reason she thinks this will keep her from having to change the sheets again. -Was told again not to sit in it, if she didn't wait 10 minutes I wouldn't have to. I am tired of being degraded for having an accident. -Not allowed to change a wet diaper so I get to sit in that also. -Was told she had 45 people and worked alone, then she started talking to someone behind the door. -I have a really bad diaper rash and the aide ripped off my diaper, not only did I bleed I also cried. -Threw away my own personal food. -Took my bed pan away. -Was told I could not bathe alone." The resident said that 95 percent of the letter was about CNA #1 and the other part was about CNA #2. The resident said both CNAs are "telling me I can't use the restroom at a certain time, telling me I needed to clean my own bed," and made her use the bedpan because it was easier for them than helping her to the bathroom. "They make you feel this big (the resident gestured with a one-inch space between her thumb and index finger). So then I would stop telling (CNA #1) and clean up myself, then she would walk in right in the middle of me cleaning myself and say, 'What are you doing (resident #74)?'" The resident said she did not like the way CNA #1 treated her and other residents, that the CNA was "rude" to residents, and that CNA #1 "runs the operation when she gets into the room (and when residents ask her to help them with specific care in specific ways) says, 'We're going to do it my way.'" The resident said this was on the list of concerns that she gave to the DON on or about 2/2/15. The resident said that when she returned from the hospital (2/9/15), CNA #1 worked with her "my first day back and it just went back to the same stuff." The resident said she told CNA #40, both before and after her hospitalization , that CNA #1 was mistreating her. The resident said she had also reported to another CNA whose name she could not recall, about CNA #1's abusive treatment. However, nothing changed; CNA #1 continued to care for her and treated her the same. She said her first night back after hospitalization (2/9/15), CNA #1 "told me to take everything off, all the sheets and everything." The resident said she stripped her bed and removed her nightgown, and the CNA asked her why she removed her gown, then said, "'This is how it's going to be. If you're going to keep doing this yourself you don't need me. You're going to do it yourself.' It was like she was going to make me cry again. Then she said, 'Why are you crying?' She told me I couldn't go in the bathroom, it was too late, that I had to use the bedpan. She said the CNA made her feel abused, and stated, "I don't like to be treated like that." She said that the day before, in the morning, CNA #1 had run over her toes with the Sara lift, told her to lie about what time the CNA had awakened her, told her she couldn't bathe alone and then sat there and watched her bathe. She said, "Nobody else has done that. And if she doesn't think you hurry enough, she'll just grab you and start washing you." She said all the nurses had a meeting about her letter after she gave it to the DON. She thought the meeting was at the end of January and before her discharge to the hospital. She said the DON did not say what she was going to do about it. 3. Resident Council 2/10/15 Resident council minutes, dated 2/10/15, revealed the following resident comment: "Resident states that there is a CNA that is unkind, rude and rough. SSD (social services director) reminded residents of their right to be free of abuse and that they can report abuse to any staff member." A handwritten note on the minutes under this resident comment read, "SSD filed grievance (with) SSD. (SSD initials)." The SSD did not report the above allegation from the resident council to the nursing home administrator and the DON as expected per facility policy (see above) so that an immediate investigation could begin. Rather, the social services director (SSD) filed a grievance. 4. Staff interviews Staff interviews revealed staff was aware of resident abuse and/or mistreatment, including CNA #1's treatment of [REDACTED]. Some staff stated the abuse and/or mistreatment was discussed among themselves. Some staff stated it was reported to management staff. a. CNA #25 CNA #25, interviewed on 2/10/15 at 6 p.m., said she had received complaints from residents about abusive treatment and had reported it. Specifically, the CNA said: -"Abuse has been reported to me and I've taken it to management; (by resident #74), almost two weeks ago. I took it to my charge nurse and my charge nurse passed it along ... (Resident #74) reported that a certain aide had been rough with her. She was so afraid. That aide had flat out told her that none of us aides wanted to help her because of the multiple times she was on the call light. She went all night without using her call light. She went from being able to tell us that stuff to us having to dig it out of her. She said she was afraid to ask for help because that aide had told her she stunk and nobody wanted to help her because she stunk. -When I report it, I get the backlash. The aide was (CNA #1). She worked last night ... I know she's not working tonight. I'd sit down and talk to (resident #74) and see what she has to say. She had it all written out on a sheet of paper and she still has it ... (Resident #74) was that scared: she went a 12-hour shift without asking for help ... -It was reported to my charge nurse that night ... and the next day it was reported to (the DON)." b. CNA #22 CNA #22, interviewed on 2/11/15 at 11 a.m., said a resident who speaks another language (which the CNA understood) had reported to her that some staff refused to provide care for her and "she doesn't know why ... She hasn't said anything for the last two weeks. She's scared to say something ... maybe they're going to get mad ... or something..." CNA #22 said she had reported the resident's concerns to other CNAs but the resident "doesn't want me to say anything to the head nurses ... She says, 'I'm just telling you'; I said you're telling me, so I have to say something. However, CNA #22 said "I just talked to (the other CNAs)" who denied refusing to care for the resident. c. CNA #30 On 2/11/15 at 12 noon, CNA #30 was interviewed. She said a resident had reported to her that "one of the nurses wasn't giving her enough time. She asked her to be more gentle when she was putting on her dressings because her backside was sensitive. I reported it to (the DON and Assistant DON)." CNA #30 said she did not recall who the nurse was; it was about a month ago. d. CNA #40 CNA #40 was interviewed on 2/11/15 at 3:50 p.m. She said resident #74 "is really terrified of (CNA #1). She's told me. She asks if (CNA #1) is working because she doesn't really want to put her call light on if she is. She asks to go to the bathroom and (CNA #1) will say 'Here's a bedpan, call me when you're finished.' She needs a Sara lift and two people and (CNA #1) will tell her there isn't enough help for her to pick her up from the bed for the toilet and she has to use the bedpan." CNA #40 stated, "(Resident #74) and I had talked about this before she went to the hospital ... She asked me (upon her readmission) who was working nights and (CNA #1) was going to be working and I felt so bad to tell her that tonight is going to be (CNA #1 and another CNA). So she said, 'I can't use my call light.' -(Before) I was doing patient care and she was not using her call light for help. We'd go in to check on her. She was trying to take off her (briefs) and clean herself up. (CNA #25, CNA #14) and I would say we can help you, you can call us. She said no, because she'd already been told by (CNA #1) she had to do it herself because there wasn't enough help. CNA #40 said, "Several people reported. (Resident #74) herself filled out (a grievance) before she went to the hospital. (CNA #14) saw her fill out the report. I reported (CNA #1) was being rough and refusing to help her. It had to have been (a report to) (the DON) or possibly (the MDS coordinator). I know it was one or both of them. I know (CNA #14) and possibly (CNA #24) reported." e. CNA #14 CNA #14 was interviewed at 12:35 p.m. on 2/12/15. She said she had heard of "people being rough," and reports were "turned in to department heads." She recalled resident #74 "complaining about (CNA #1) before she went to the hospital. (CNA #25) took the complaint; I don't know who she gave it to. (Resident #74) just said she didn't care for (CNA #1) being in her room. Most of it's about toileting, being able to go to the bathroom ... (Resident #74) said she felt she wasn't given the opportunity to go to the bathroom. She has said that several times and I have reported it. I've reported it to my nurse (RN #16) per chain of command. Whenever (CNA #40) and I work together we tell (resident #74) we'll help her any way we can ... (she) said she was afraid to use her call light." f. Licensed Practical Nurse (LPN) #35 LPN #35 was interviewed on 2/12/15 at 10:15 a.m. She said that two or three weeks ago, she heard CNA #25 telling RN #16, the nurse she was working with that night, about resident #74 writing up a list of things that were happening to her. The LPN said the resident "did show me the list. She had the list on her table and was kind of reading it to me. She was very shaken and shaky. She said she was going to rewrite the list, the handwriting was really bad. CNAs told her she couldn't take herself to the bathroom anymore, couldn't access wipes and briefs anymore. She felt very violated, that they were taking her food before she was finished with it and that the CNA was sort of bossy with her and told her when to do things. I just explained to her to report that ... and if she doesn't feel comfortable with them she could ask them to leave at any time. She said she wanted to talk to management. I didn't ask her who the CNA was. I didn't want to put her on the spot. I was there, (RN #16) was there. (CNA #25) was the one who told (RN #16). I can't remember specifically who was there that night and it was at shift change. (RN #16) was working on (resident #74's) hall that night. ...(Resident #74) thanked me ... She cried a little bit. She hugged me. I told her that if she needed anymore help from me to let me know." LPN #35 said she was off for a few days after that, when she returned resident #74 had been admitted to the hospital. LPN #35 said she assumed the problem had been taken care of. LPN #35 said she did not report the resident's concerns because the resident had her list, she was going to write it up and RN #16 was going to turn it in to the DON. The LPN said, "I did work the next day and when (the DON) came in she went into (resident #74's) room to talk to her. I felt I didn't really need to talk to (the DON) about it. I just assumed (resident #74's letter) was turned in because (the DON) went into (resident #74's) room. The LPN said she talked to resident #74 after the DON visited and resident #74 told she was okay, but also said 'they' (CNAs) took her wipes away from her, put things up high." The LPN said CNA #25 told her resident #74 had sai

Based on resident and staff interviews and record review, the facility failed to: -Adequately screen six of six employees reviewed (#1, #3, #21, #46, #47 and #48) prior to hire; -Report allegations of abuse; -Investigate abuse allegations timely and thoroughly; -Document and investigate an injury of unknown origin; and -Protect residents during the investigations. The facility's failure to investigate abuse allegations by resident #74 caused resident #74 to experience continued abuse, and caused residents #21, #23 and #57 to suffer abuse. The failures affected four of seven residents sampled for abuse investigations (#74, #21, #23 and #57), and put all facility residents at risk. Cross-reference F223, failure to protect residents from abuse. The findings included: I. Failure to adequately screen staff prior to hire A. Expectations The facility Abuse Prevention Policy & Procedure, revised 3/1/13, required in pertinent part under "Employment Practices": -"The purpose of the screening process is to identify and confirm the acceptability of potential candidates for employment based on information obtained through the application and interview process." The "Pre-Employment Screening" procedure included the following: - "Prior Employment Reference(s) - Reference check(s) of the candidate's prior employment must be conducted by the department director, or designee, hiring the candidate." B. Record Review Review of six employee files (#3, #46, #47, #48, #21, and #1) with the human resources director (HRD) on 2/11/15 at approximately 2:30 p.m. revealed the following pertinent findings. Employee #1 was hired on 7/3/14; there was evidence that only one reference was obtained, which was from the employee's sister. Although the employee's file revealed messages were left for additional references, the employee's file failed to reveal that any attempts to follow up on the references were made prior to or after the employee's hire date. Employee #3 was hired on 1/9/15; there was no evidence in the employee's file that reference checks had been attempted or obtained prior to or after the employee's hire date. Employee #21 was hired on 10/27/14; there was evidence that only one reference was obtained in the employee's file. Additionally, there was no evidence in the employee's file that any other references were attempted prior to or after the employee's hire date. Employee #46 was hired on 11/20/14; there was no evidence in the employee's file that reference checks were attempted or obtained prior to or after the employee's hire date. Employee #47 was hired on 10/27/14; there was evidence that only one reference was obtained in the employee's file. Although the employee's file revealed messages were left for two additional references, the employee's file failed to reveal that any attempts to follow up on the references were made. Employee #48 was hired on 1/23/15; there was evidence that only one reference was obtained in the employee's file. Additionally, there was no evidence in the employee's file that any other references were attempted or obtained prior to or after the hire date. C. Staff Interviews The HRD was interviewed on 2/12/15 at 4:05 p.m. and stated that according to their corporate person she believed the facility followed state laws regarding checking employee references and believed that there should be two references completed prior to hiring an employee. The Director of Nursing (DON) was interviewed on 2/13/15 at 10:45 a.m., in the presence of the Regional Director of Operations (RDO #41). The DON stated that potential employees fill out an application on line. The applications are then e-mailed to her and human resources. The applications are then reviewed for potential hires and interviews are then scheduled. If a decision was made to hire the employee, a drug screen and background check was completed. Once the drug screen and background checks were back, the DON stated she would complete the reference checks. The DON stated that she attempted to call all four references, and typically would write on the employee's application who was contacted. The RDO and Corporate Human Resources (CHR #43) were interviewed on 2/13/15 at approximately 11:00 a.m. The RDO was present in person and the CHR was available via the telephone. The CHR stated that the hiring manager completed the interview and made the decision to hire the employee and continue the hiring process. If the hiring manager decided to continue the hiring process, the policy guided the manager to offer them a job, which was contingent on pre-employment checks; such as drug screen, abuse registry, sex offender registry, Department of Regulatory Agencies, and the Office of Inspector General's Office. Once those checks have been completed, further review may be required. The CHR stated that she would expect the hiring manager to have attempted a minimum of two references. The references should include documentation on whom they called and when the call was made. II. Failure to investigate allegations of abuse and protect residents during and after investigations A. Expectations The Abuse Prevention Policy and Procedure, revised 3/1/13, read in pertinent part under "Investigation": "All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator. An immediate investigation into the alleged incidence, during the shift it occurred on, is initiated as follows: 1. Complete Resident Incident Report form a. Personnel shall complete resident incident report at time of incident/event b. Follow up & investigation results are completed per policy time zone and by appropriate personnel. 2. Interview the resident or other resident witnesses (e.g., roommate, if appropriate). The interview is to be dated, documented and signed by the nursing supervisor. A sample 'Resident Interview Form' is attached. 3. Interview the staff member implicated. Have the employee document his/her knowledge and/or version of the incident in a written narrative that is dated and signed. An 'Employee/Witness Investigation Statement' is attached. 4. Interview all staff on that unit, as well as other staff or other available witnesses. Witnesses are to document their knowledge of the incident in a written narrative, signed and dated, on the 'Employee/Witness Investigation Statement' form. Continued Facility Investigation: 1. The Administrator, or his/her designee, will ensure that the investigation is completed within 48 to 72 hours. 2. The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in progress. Response - The Administrator, Director of Nursing or their designee assumes responsibility for notification of the incident and investigation findings as well as follow-up. Immediate Response: 1. Notification of the attending physician and resident's responsible party with corresponding documentation of this notification in the resident's clinical record. 2. Any employee suspected (alleged) of abuse will be suspended as the incident is reported; pending outcome of the investigation. 3. Immediate notification to (corporate) for risk management support, if applicable. 4. Documentation in the medical record to reflect direct observable facts, i.e. resident's statement about what occurred, physical findings. 5. An incident report is to be completed, to include the written summary of the investigation and facility actions taken, for QA review and litigation analysis. Response at Completion of Investigation: -Written notification to the State Health Department and other required regulatory agencies summarizing the incident, investigation results and facility actions taken to protect the resident(s) and prevent a similar occurrence. -Follow-up with appropriate disciplinary action, which may include reinstatement with or without re-training or termination as indicated by investigation results. -When the investigation is inconclusive, written documentation of a monitoring program is completed, reviewed with the employee and implemented. -Once the investigation is completed, the Administrator or designee will inform the resident or the resident's representative of the results of the investigation and corrective action taken, if any. -The completed investigation and all reports/statements generated will be forwarded to the facility's Quality Assurance/Performance Improvement Committee for review. Investigation Guidelines: -The social worker is to interview other potential victims within 24 to 48 hours of the alleged incident. Administrative Tips on Conducting the Investigation: -Nurses' notes must include notification of the physician, family and description of incident. The notes should not include State, Police, Ombudsman notification - that would be documented on the incident report. Investigation File Checklist: -Take statements immediately from everyone that was working on the appropriate unit even if they say they do not have any information. -In addition, Social Services is to interview other potential at risk residents. -Revise care plan (including CNA information) based on IDT recommendations and place a copy of the updated resident care plan in the investigative file. The following forms and checklists were included as attachments to the abuse prevention policy and procedure: -Notification Checklist, Resident Incident Report, Resident Incident Follow-Up Report, Investigation Report: Injury of Unknown Origin, Resident Interview Sample Questions, Employee Investigation Interview Form, and Summary of Investigation." B. Record Review Revealed Inadequate Investigations 1. On 2/11/15 the nursing home administrator (NHA) was asked to provide copies of the investigative reports from abuse investigations conducted within the past six months. One investigative report, dated 1/14/15, regarding a staff-to-resident sexual abuse allegation was provided. The allegation was not substantiated and the staff person involved no longer worked at the facility. Review of the report revealed that during the investigation, two residents stated they had been verbally abused by staff, see below: a. Resident (res) #20, interviewed on 1/15/15 by an unidentified facility staff member, said she had been verbally abused by "a nighttime aide/nurse ... who returned to res (resident's) room & was loud & rude. Made the res cry. Per res, res aware from another team that this aide is returning after a leave & res is worried ... Said overnight nurse (first name) is verbally rude & ignores res @ times." When asked for the investigative report regarding this allegation, the facility provided a Concern/Comment Report, dated 1/15/15, completed by the social services director (SSD), which read, "Res c/o (complained) overnight CNA (first name) is 'verbally rude & ignores' res @ times." The investigation/response section was blank. The concerned party response read, "Per res request, res did NOT want to file a grievance. 2/11/15 F/U (follow up) - Res states (staff first name) has been 'nice,' no further concerns." The nursing home administrator (NHA) signed the form on 2/11/15. An undated, typewritten note signed by the director of nursing (DON) read, "On 1/15/15 DON counseled staff member (CNA #48) in regards to the male presence and caring for elderly women in LTC (long term care). (CNA #48) was asked not to go into (resident #14's) room (a different resident than resident #20, who was interviewed) without another female aide if possible. (CNA #48) was also counseled about his loud voice and that this could sometimes scare an elderly resident." The facility failed to update resident #14's care plan regarding male CNAs entering the residents room only when accompanied by female CNAs. There was no evidence to show how the facility identified CNA #48, who had been alternately described as a nurse and aide, whose first name only was provided, and whose gender was not provided in the resident statement. There was no evidence of an abuse investigation being conducted to protect resident #20 and other residents in the facility, as required by facility policy. There was no evidence to show how the facility protected resident #20 who expressed she was "worried" about the nurse/aide returning, or why the CNA was not to enter resident #14's room without a female aide present. There was no evidence the NHA was immediately notified of the allegation (no NHA signature until 2/11/15). b. Resident #74, interviewed during the investigation by an unidentified facility staff member, said she had been verbally abused by CNA #22. The staff person wrote the first name of the CNA and wrote, "Completing grievance as we speak." Review of the 1/15/15 grievance form, provided by the SSD, revealed the SSD, dietary manager and DON were listed on the form to investigate a concern from resident #74, titled "see back side." The top portion of the page was a handwritten note, signed by resident #74. The resident's statement read: "(1) I have caught (CNA #22) going through my belongings when she had no reason to be in my room. She is moving items that concern my computer. Refused to make my bed, refused to let me get my purse, watching movie in the dining room and she just got up and changed the channel to solid gold 80's. (2) Now about the food. It is always cold. Today 1/15/15 the waffle, cream of wheat was all cold. The only thing I ate was 1 pc (piece) of sausage & 1/2 a piece of waffle. The day before I was to get a chef salad, first they got me meatloaf then it took 2 hours to get my meal with nothing to drink and no dessert." The bottom portion of the form, under a wavy line, revealed a handwritten note, undated and unsigned, which read, "(CNA #22) states that she was cleaning up res room & putting things away. (CNA #22) said she told (resident #74) she needed to get housekeeping to clean bed before she could make her bed. (CNA #22) states that she never remembers changing the channel on her TV." Regarding the cold food complaint, the handwritten, undated response under the resident's note read: "I had (illegible) take her her drinks, who made the trays first and the CNA take them to the resident and sometimes things come up. On this day 1/15/15 the CNA started passing trays at 8:10 a.m. On the salad the CNA did not tell the cook so when she was finished with the meal she fix a salad." The note was signed with a first name only, which could have been the dietary manager or a cook. -A note dated 2/11/15 read, "Update. Oven fixed 1/16/15." There was no evidence of an investigation into the resident's (#74) concerns about CNA #22. An undated, unsigned note attached to the grievance form read, "Counseled (CNA #22) regarding complaint made. (CNA #22) will ask resident for permission before going through her belongings. If this res. refuses to have room cleaned or items put away CNA will respect her wishes. If CNA changes the channel for another resident she will ensure that nobody else is watching what is currently on." There was no signature from the person who wrote the "counseling" note, or from the CNA who was to have received it. The front of the grievance noted "counseled CNA" and "No further concerns re: (CNA #22), 2/12/15." This note, likewise, was unsigned. There was no evidence an abuse investigation was conducted although the resident had reported abuse. c. Four staff members who were interviewed said they had been informed of resident abuse, and made the following comments on 1/15/15: (a) CNA quoted by the ADON said, "Night CNA rude to res. Threw sandwich down in front of her. Nurse talked with resident who stated it was not an issue." (b) CNA quoted by ADON when asked if she reported, "No. It was already reported." (c) CNA quoted by the ADON said, "Reported to (NHA) that morning. It was last mth. Res reported CNA looking at breasts." (d) The NHA quoted by the ADON said, "Past years; resident to resident abuse reported to state." There was no evidence the above staff comments were investigated further, or that abuse investigations were initiated although the staff reported they had been informed of abuse. Although an abuse report was made to the NHA within the past month, the NHA's statement indicated he was not aware of the allegation and it was not investigated. 2. Resident #74 Resident Interview Resident #74 stated during an interview on 2/11/15 at 9 a.m., that CNA #1 had been abusive to her. The resident said she had written a letter and given it to the director of nursing (DON) before she was admitted to the hospital on [DATE]. When she was readmitted to the facility on [DATE], CNA #1 was still assigned to work with her, and the abuse continued. At 9:21 a.m. on 2/11/15, the resident provided a copy of the undated, unsigned letter, which read as follows: "To whom it may concern -Why did it take 2-1/2 (hours) for me to get lunch, was served ice cold -My bed was changed and I was given one sheet -Needed my diaper changed and it took 20 minutes for the aide to change it, then I got a lecture for sitting in it. -I do not appreciate being used as a rag doll, being told what time I need to wake up. -I do not need someone going through my items without my permission or when I'm not here. -Did not like being woke up at 4am for a 630 bath which I did not ask for. -Was told if I did not get up was told my bed would not be made. -I was left in my chair for 3-1/2 hrs on 3 different occasions, once for 1/2 hr and twice for 1-1/2 -Takes up to 30 minutes to answer the light -I was told to either hold it in or stay up. -For some reason she thinks this will keep her from having to change the sheets again. -Was told again not to sit in it, if she didn't wait 10 minutes I wouldn't have to. I am tired of being degraded for having an accident. -Not allowed to change a wet diaper so I get to sit in that also. -Was told she had 45 people and worked alone, then she started talking to someone behind the door. -I have a really bad diaper rash and the aide ripped off my diaper, not only did I bleed I also cried -Threw away my own personal food. -Took my bed pan away -Was told I could not bathe alone." The resident said that 95 percent of the letter was about CNA #1 and the other part was about CNA #2. The resident said both CNAs were "telling me I can't use the restroom at a certain time, telling me I needed to clean my own bed," and made her use the bedpan, because it was easier for them than helping her to the bathroom. "They make you feel this big (the resident gestured with a one-inch space between her thumb and index finger). So then I would stop telling (CNA #1) and clean up myself, then she would walk in right in the middle of me cleaning myself and say, 'What are you doing (resident #74)?'" The resident said she did not like the way CNA #1 treated her and other residents, that the CNA was "rude" to residents, and that CNA #1 "runs the operation when she gets into the room (and when residents ask her to help them with specific care in specific ways) says, 'We're going to do it my way.'" The resident said this was on the list of concerns that she gave to the DON on or about 2/2/15. The resident said that when she returned from the hospital (2/9/15), CNA #1 worked with her "my first day back and it just went back to the same stuff." The resident said she told CNA #40, both before and after her hospitalization , that CNA #1 was mistreating her. The resident said she had also reported to another CNA whose name she could not recall, about CNA #1's abusive treatment. However, nothing changed; CNA #1 continued to care for her and treated her the same. She said her first night back after hospitalization (2/9/15), CNA #1 "told me to take everything off, all the sheets and everything." The resident said she stripped her bed and removed her nightgown, and the CNA asked her why she removed her gown, then said, "'This is how it's going to be. If you're going to keep doing this yourself you don't need me. You're going to do it yourself.' It was like she was going to make me cry again. Then she said, 'Why are you crying?' She told me I couldn't go in the bathroom, it was too late, and that I had to use the bedpan. She said the CNA made her feel abused, and stated, "I don't like to be treated like that." She said that the day before, in the morning, CNA #1 had run over her toes with the lift, told her to lie about what time the CNA had awakened her, told her she couldn't bathe alone and then sat there and watched her bathe. She said, "Nobody else has done that and if she doesn't think you hurry enough, she'll just grab you and start washing you." She said all the nurses had a meeting about her letter after she gave it to the DON. She thought the meeting was at the end of January and before her discharge to the hospital. She said the DON did not say what she was going to do about it. 3. Resident Council 2/10/15 Resident council minutes, dated 2/10/15, revealed the following resident comment: "Resident states that there is a CNA that is unkind, rude and rough. SSD (social services director) reminded residents of their right to be free of abuse and that they can report abuse to any staff member." A handwritten note on the minutes under this resident comment read, "SSD filed grievance (with) SSD. (SSD initials)." The SSD did not report the above allegation from the resident council meeting to the nursing home administrator and the DON as expected per facility policy (see above) so that an immediate investigation could begin. Rather, the social services director (SSD) filed a grievance. 4. Staff interviews a. The Abuse Prevention Policy & Procedure under "Reporting" required in part: "All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, so that the resident's needs can be attended to immediately and investigation can be undertaken promptly." Staff interviews revealed staff was aware of resident abuse and/or mistreatment, including CNA #1's treatment of [REDACTED]. Some staff stated the abuse and/or mistreatment was discussed among themselves. Some staff stated it was reported to management staff. However, some staff was aware of complaints and allegations and failed to report. b. CNA #25 CNA #25, interviewed on 2/10/15 at 6 p.m., said she had received complaints from residents about abusive treatment and had reported it. Specifically, the CNA said: -"Abuse has been reported to me and I've taken it to management; (by resident #74), almost two weeks ago. I took it to my charge nurse and my charge nurse passed it along ... (Resident #74) reported that a certain aide had been rough with her. She was so afraid. That aide had flat out told her that none of us aides wanted to help her because of the multiple times she was on the call light. She went all night without using her call light. She went from being able to tell us that stuff to us having to dig it out of her. She said she was afraid to ask for help because that aide had told her she stunk and nobody wanted to help her because she stunk. -When I report it, I get the backlash. The aide was (CNA #1). She worked last night ... I know she's not working tonight. I'd sit down and talk to (resident #74) and see what she has to say. She had it all written out on a sheet of paper and she still has it ... (Resident #74) was that scared: she went a 12-hour shift without asking for help... -It was reported to my charge nurse that night ... and the next day it was reported to (the DON)." c. CNA #22 CNA #22, interviewed on 2/11/15 at 11 a.m., said a resident who speaks another language (which the CNA understood) had reported to her that some staff refused to provide care for her and "she doesn't know why ... She hasn't said anything for the last two weeks. She's scared to say something ... maybe they're going to get mad ... or something..." CNA #22 said she had reported the resident's concerns to other CNAs but the resident "doesn't want me to say anything to the head nurses ... She says, 'I'm just telling you'; I said you're telling me, so I have to say something. However, CNA #22 said "I just talked to (the other CNAs)," who denied refusing to care for the resident. d. CNA #30 On 2/11/15 at 12 noon, CNA #30 was interviewed. She said a resident had reported to her that "one of the nurses wasn't giving her enough time. She asked her to be more gentle when she was putting on her dressings because her backside was sensitive. I reported it to (the DON and Assistant DON)." CNA #30 said she did not recall who the nurse was; it was about a month ago. e. CNA #40 CNA #40 was interviewed on 2/11/15 at 3:50 p.m. She said resident #74 "is really terrified of (CNA #1). She's told me. She asks if (CNA #1) is working because she doesn't really want to put her call light on if she is. She asks to go to the bathroom and (CNA #1) will say 'Here's a bedpan, call me when you're finished.' She (resident #74) needs a Sara lift and two people and (CNA #1) will tell her there isn't enough help for her to pick her up from the bed for the toilet and she has to use the bedpan." CNA #40 stated, "(Resident #74) and I had talked about this before she went to the hospital ... She asked me (upon her readmission) who was working nights and (CNA #1) was going to be working and I felt so bad to tell her that tonight is going to be (CNA #1 and another CNA). So she said, 'I can't use my call light.' -(Before) I was doing patient care and she was not using her call light for help. We'd go in to check on her. She was trying to take off her briefs and clean herself up. (CNA #25, CNA #14) and I would say we can help you, you can call us. She said no, because she'd already been told by (CNA #1) she had to do it herself because there wasn't enough help. CNA #40 said, "Several people reported (Resident #74) herself filled out (a grievance) before she went to the hospital. (CNA #14) saw her fill out the report. I reported (CNA #1) was being rough and refusing to help her. It had to have been (a report to) (the DON) or possibly (the MDS coordinator). I know it was one or both of them. I know (CNA #14) and possibly (CNA #24) reported." f. CNA #14 CNA #14 was interviewed at 12:35 p.m. on 2/12/15. She said she had heard of "people being rough," and reports were "turned in to department heads." She recalled resident #74 "complaining about (CNA #1) before she went to the hospital. (CNA #25) took the complaint; I don't know who she gave it to. (Resident #74) just said she didn't care for (CNA #1) being in her room. Most of it's about toileting; being able to go to the bathroom ... (Resident #74) said she felt she wasn't given the opportunity to go to the bathroom. She has said that several times and I have reported it. I've reported it to my nurse (RN #16) per chain of command. Whenever (CNA #40) and I work together we tell (resident #74) we'll help her any way we can ... (she) said she was afraid to use her call light." g. Licensed Practical Nurse (LPN) #35 LPN #35 was interviewed on 2/12/15 at 10:15 a.m. She said that two or three weeks ago, she heard CNA #25 telling RN #16, the nurse she was working with that night, about resident #74 writing up a list of things that were happening to her. The LPN said the resident "did show me the list. She had the list on her table and was kind of reading it to me. She was very shaken and shaky. She said she was going to rewrite the list, the handwriting was really bad. CNAs told her she couldn't take herself to the bathroom anymore, couldn't access wipes and briefs anymore. She felt very violated, that they were taking her food before she was finished with it and that the CNA was sort of bossy with her and told her when to do things. I just explained to her to report that ... and if she doesn't feel comfortable with them she could ask them to leave at any time. She (resident #74) said she wanted to talk to management. I didn't ask her who the CNA was. I didn't want to put her on the spot. I was there; (RN #16) was there. (CNA #25) was the one who told (RN #16). I can't remember specifically, who was there that night and it was at shift change. (RN #16) was working on (resident #74's) hall that night. ... (Resident #74) thanked me ... She cried a little bit. She hugged me. I told her that if she needed anymore help from me to let me know." LPN #35 said she was off for a few days after that, when she returned resident #74 had been admitted to the hospital. LPN #35 said she assumed the problem had been taken care of. LPN #35 said she did not report the resident's concerns because the resident had her list, she was going to write it up and RN #16 was going to turn it in to the DON. The LPN said, "I did work the next day and when (the DON) came in she went into (resident #74's) room to talk to her. I felt I didn't really need to talk to (the DON) about it. I just assumed resident #74's letter was turned in because (the DON) went into (resident #74's) room. The LPN said she talked to resident #74 after the DON visited and resident #74 told she was okay, but also said 'they' (CNAs) took her wipes away from her, put things up high." The LPN said CNA #25 told her resident #74 had said to CNA #25 that a CNA told her the other CNAs didn't like her, she was on her call lights too much, had a foul odor about her. She said she thought this was abusive. Asked why she didn't report, she said, "I really dropped the ball on that one. (Resident #74) never confided in me anymore. Seeing (the DON) go down there I just assumed it was all okay, and she told me she was okay. I'm not sure if (RN #16) reported it or not, I don't know." h. RN #16 RN #16 was not on duty and did not respond to three voice mail messages left on 2/12/15. i. RN #11 RN #11 was interviewed on 2/12/15 at 11:15 a.m. He said he recalled one or two residents had written out complaints or comment/concerns. He said he believed resident #74 was one of them and he thought it was "specific toward a CNA, (CNA #1), I think." He said the comment/concern was written by the resident, he "referenced it" with the ADON and believed "the letter was handed to (the ADON) two to three weeks ago." He said it was brought to him by floor staff, it was "just a general concern" and he knew for sure it involved resident #74. C. Additional Allegations of Abuse and/or Mistreatment 1. Report of abuse involving CNA #1 On 2/10/15 at approximately 6:30 p.m., the corporate consultant notified the survey team that they were in the process of investigating a report of staff-to-resident abuse involving CNA #1 against resident #57. The corporate consultant said CNA #1 was not scheduled to work in the facility until Friday, 2/13/15. On 2/11/15 at 3:50 p.m., CNA #40 said resident #57 had reported to her "yesterday morning," that a CNA he described as CNA #1 "has been throwing me around all night long. He was very scared." On 2/12/15 at 1:10 p.m. the ADON was interviewed. She said she had received a call from resident #57's wife saying "I think my husband has been abused" and "I turned the call over to (the DON) and she started the investigation. I think it was Tuesday (2/10/15)." 2. Review of the facility's investigative report According to the facility's investigative report, at 3:55 p.m. on 2/10/15, the DON documented she received a phone call (2/10/15) from the wife and medical durable power of attorney for resident #57. The resident's wife stated that resident #57 "had been abused last night. (The resident's wife) was very upset and crying at this time and stated that (resident #57) had told her earlier that day that the night aide (CNA #1) was throwing him around during a transfer and hurt him. She stated that (resident #57) was crying in pain and had stated to her that this aide hurt his legs and hips. (Resident #57) stated to her that he was afraid of her. At this time (the resident's wife) told me that she no longer wanted to talk about it and said she had to go and hung the phone up." According to the investigation report, the ADON and SSD interviewed the resident at 4:05 p.m. on 2/10/15. The resident said, "I told her it hurt my hips and told her not to hurt it that much ... It happened one other time," and it was the same employee. The resident

Based on observations, resident and staff interviews and record review, the facility failed to provide sufficient nursing staff to provide care and services to attain the highest practicable physical, mental and psychosocial well-being of each resident. This affected seven of 21 residents reviewed (#14, #21, #23, #48, #61, #76 and one resident who requested anonymity) of 32 sample residents. As a result, residents expressed feeling afraid, agitated, sorry and intimidated, per resident and staff interviews, and experienced episodes of incontinence. Cross-reference F165 - Right to file grievances without fear of reprisal; F223 - Abuse/mistreatment; F225 - Investigation of abuse allegations; F241 - Dignity and respect; F242 - Choices; F309 - Care and services; F312 - Assistance with activities of daily living; F314 - Pressure ulcers 1. Expectations a. The facility "Abuse Prevention Policy & Procedure," revised 3/1/13, under "Prevention through QA Policy," read in pertinent part: "The facility will identify, correct and intervene in identified at-risk situations in which abuse, neglect and/or misappropriation of resident property are more likely to occur (including)... -The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned has knowledge of individual care needs." b. The undated "Staffing: Assignment of Duties" policy read in pertinent part: "The director of nursing services and/or the nurse supervisor/charge nurse, at a minimum, is responsible for: -Making daily resident visits to observe and evaluate the resident's physical and emotional status; -Assigning work schedules and staffing to meet the needs of residents; -Providing direct resident care as necessary or appropriate; -Assigns and supervises CNAs (certified nurse aides) as applicable..." 2. Resident Census and Condition Report The facility Resident Census and Condition Report, signed by the MDS coordinator on 2/9/15, documented a census of 39 residents. The residents' functional, mental and psychosocial needs were described as follows: -14 residents needed assistance of one or two staff for bathing and 22 were dependent; 31 residents needed assistance with dressing and four were dependent; 24 residents needed assistance with transfers and six were dependent; 30 residents needed assistance with toilet use and four were dependent; 30 residents needed assistance with eating and one resident was dependent. -Four residents had catheters; 26 residents were occasionally or frequently incontinent of bowel and 11 were occasionally or frequently incontinent of bowel; one resident was on a urinary toileting program and no residents were on bowel toileting programs. -One resident was bedfast all or most of the time; 28 residents were in chairs all or most of the time; seven residents needed ambulation assistance or assistive devices; and three residents had contractures. -16 residents had documented signs and symptoms of depression; 11 had psychiatric diagnoses; 15 had dementia; 12 had behavioral healthcare needs. -Three residents had pressure ulcers and 33 residents received preventive skin care. -Two residents received hospice care; 14 residents received respiratory treatments; one resident received ostomy care; one resident received tube feedings; nine residents had mechanically altered diets; 18 residents received rehabilitative services and four residents used assistive devices while eating. -22 residents received psychoactive medications; eight received antipsychotics; seven received antianxiety medications; 21 received antidepressants; one resident received hypnotic medications; four residents received antibiotics and 38 residents were on pain management programs. 3. Resident Council Meeting Minutes Resident Council Meeting minutes, reviewed for 9/14 through 2/15, revealed the following: -On 9/15/14, "Old business - Filled out comments and addressed them by having head manager read and sign and nothing was addressed, same problems ... Nursing - Everyone said that the nursing staff is working hard but feels that they are understaffed, would like to get to call lights a little faster including the night staff. The nurses are not taking all the medications that the residents need and also not fast enough. When CNAs bring in the breakfast trays into the rooms the food is cold which could mean that they are not taking the trays down fast enough." -On 10/13/14, "Old business - Filled out comments and addressed them by having head manager read and sign and nothing was addressed, same problems ... Nursing - Everyone said that the nursing staff is working hard but feels that they are understaffed, would like to get to call lights a little faster including the night staff. When CNAs bring in the breakfast trays into the rooms the food is cold which could mean that they are not taking the trays down fast enough." -On 11/12/14, "Nursing - Residents stated that the nursing staff is doing good and is working hard, they say that the call lights are not getting answered in a timely manner and they realize that some days there is (a shortage) of help. They would also like to see restorative therapy more often." -On 12/9/14, "Nursing - Residents stated that the nursing staff is doing good and is working hard. They miss some of the CNAs when they are not here. CNAs are staying busy and are always there when the residents are needed. They would also like to see restorative therapy more often." -On 1/6/15, "Residents stated that the nursing staff is doing good and is working hard. CNAs are staying busy but they would like to see them answer the call lights in a timely manner. They would also like to see restorative therapy more often." -On 2/10/15, "Old business - Reviewed prior month comment/concern forms as addressed and signed by department managers" (no details were documented) ... Nursing - They are doing all right, stated that it takes longer than 15 minutes to answer call lights but is getting a lot better than it used to ... Suggestions of changes/additions - To get more help on the floor so call lights can get answered faster so they don't wait as long." 4. Resident and Family Interviews Six residents identified by the facility and by cognitive assessment as interviewable, and a family member, stated during interviews that the facility did not provide sufficient nursing staffing to meet residents' care and services needs in a timely manner. One resident requested anonymity. Resident interviews, conducted throughout the facility, and a family interview, revealed the following: Resident #23 was interviewed on 2/9/15 at 8:45 a.m. She said, "There's just not enough help at times. The bathroom is really not very handy because there are two women in each room (four residents shared a suite bathroom between two resident rooms). You wait a long time (for the call lights) to be answered and eventually they get to you. Sometimes we have (incontinence) because you haven't been able to hold your urine. It just happens ... I try to keep it from happening but I'm not able to, a lot of times." The resident said assistance to the bathroom was the main problem. -She added, "I have dentures and I have to have help putting them in, and sometimes I wait a long while. (When asked, the resident said there was no particular shift or time of day.) It's just a problem most of the time." -"Most of (the staff members) are very good, (but) it takes them so long to get to you." (Cross-reference F312) Resident #21 was interviewed on 2/9/15 at 11:30 a.m. He said it made him feel "very agitated, sorry and intimidated" that the staff did not answer the call lights quicker. He said he rang the call light, then had to [MEDICATION NAME] loudly and yell for staff to assist his (non-interviewable) roommate, who was trying to get out of bed. The resident said by the time staff arrived his roommate had fallen from the bed to the floor, and was crying. A resident who requested anonymity stated during interview the morning of 2/9/15 that the facility had "two CNAs and one nurse and (at) night - they're understaffed." The resident said, "Then they'll hire several people and they don't stay long." The resident said s/he "waits too long for medications ... you can be in severe pain and think you can't stand it ... sometimes they ignore the call lights." Resident #48 was interviewed on 2/9/15 at 11:30 a.m. The resident said, "I sometimes have had to wait an hour to go to the bathroom, or at least it seemed like it was. It takes awhile to get things (like) water ... (getting) cleaned up. Their favorite line is, 'I'm working on it.'" Resident #76 was interviewed on 2/9/15 at 1:30 p.m. She said, "Sometimes when I (use) the call light they take a long time to get here. ... I can't stand up, so I'll just be waiting and waiting. So I just ... hit cancel and do whatever I need to do. The first time when I got here, it would take a long time. The longest (wait) was about an hour and a half (for staff) to get here. I timed it. I was already falling asleep and once they got here I pushed my (cell) phone and saw the time. I needed ... someone to ... help me to the commode." The resident said she had "scooted across the sliding board and went by myself," which was not safe in her condition after hospitalization and surgery. (Cross-reference F312) Resident #14 was interviewed on 2/9/15 at 3:55 p.m. She said there was "not enough" staff "all the time." Family Interview: Resident #61's family was interviewed on 2/9/15 at 1:45 p.m. The family said the resident "wants a bath more (often) and they say no," and "at night time (there are) not a lot of staff." 5. Staff Interviews CNAs interviewed on 2/9, 2/10, 2/11, 2/12 and 2/13/15 made the following comments: -"We don't have enough staff. We have call-offs and short staffing more days than not. ... I've been asked to work sick. Call lights are not answered in a timely fashion leading to ... overall patient discomfort." -"(Residents #74 and #21) have complained about short staffing and slow call light response. (Resident #23) complains that her call light doesn't get answered in a timely fashion and she can't go anymore, or by the time we get there she's had an accident." -"Showers and baths are not getting done timely. Our bath aide got pulled (to work the floor) so she doesn't fill out her list most days. Some days (showers) don't get done at all because (the bath aide is) working the floor to cover." -"Meals are getting cold. Our room trays sit 15 to 20 minutes at a time before we can get them (delivered). Residents are complaining that their food is cold." -"(Resident #76) has complained a lot of times about her call light situation." -"It's frustrating seeing the lack of care that some of these (residents) get." -"You don't ever see management out, ever, unless (surveyors) are here. They answer call lights today. ...They'll turn off the call light so it's not going off and come and get an aide who's already overwhelmed instead of providing (for the resident's needs)." 6. Daily Staffing Reports A. Review of the Nursing and CNA Calendars for February 2015 revealed the staffing expectations with a resident census of 39 residing on four hallways, 20 of whom required two-plus person assist per MDS review, were documented as follows: Day Shift: Three nurses, four to five CNAs (at least one CNA per hall), one shower aide, one float CNA Night Shift: One nurse, two CNAs and one part-time CNA -Only one shower aide was designated, and only during the day shift. No restorative aide was ever designated. B. Staffing daily reports Many of the daily reports were incomplete, several days were missing, no resident census was documented, and reports were provided only from 1/10/15 through 2/12/15. The daily reports documented the following: -On 1/10/15 day shift, there were 2 nurses, 4 CNAs and 1 shower aide. There was no restorative aide, the float position was blank, and all of night shift was blank. -On 1/11/15 day shift: 3 nurses, 4 CNAs, 1 shower aide, no restorative and no float. Night shift: 1 nurse and 2 CNAs. -On 1/12/15 day shift: no nurses, 4 CNAs, 1 shower aide, no float, no restorative, no night shift nurses or CNAs. -On 1/13/15 day shift, no nurses, 4 CNAs, 1 float CNA, no shower aide, no restorative, no night shift nurses or CNAs. -On 1/14/15 day shift: no nurses, 4 CNAs, 2 floats, 1 shower aide, no restorative. Night shift: no nurse, 2 CNAs. -1/15/15 day shift: 3 nurses, 4 CNAs, 1 shower aide. Night shift: 1 nurse, 2 CNAs, 1 part time CNA. -1/16/15 day shift: 4 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/17/15 day shift: 4 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/18/15 day shift: 2 nurses, 4 CNAs, 1 shower aide, 1 float. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/19/15 day shift: 2 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/20/15 day shift: 2 nurses, 4 CNAs, 1 part time float, 1 shower aide. Night: 1 nurse, 2 CNAs. -1/21/15 day shift: no nurses, 4 CNAs, 1 shower aide. Night: no nurse, 2 CNAs. -1/22/15 day shift: 2 nurses, 5 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/23/15 day shift: 2 nurses, 5 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/24/15 day shift: 2 nurses, 5 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/25/15 day shift: 2 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/26/15 day shift: no nurses, 4 CNAs, 1 shower aide. Night: no nurse, 2 CNAs. -1/27/15 day shift: 3 nurses, 4 CNAs, 1 shower aide. Night: no nurse, 2 CNAs, 1 part time CNA. -1/28/15 day shift: 3 nurses, 5 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/29/15 day shift: 2 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -1/30/15 day shift: no nurses, 5 CNAs, 1 shower aide. Night: no nurse, 2 CNAs, 1 part time CNA. -1/31/15-2/3/15 missing -2/4/15 day shift: 2 nurses, 5 CNAs, 2 part time CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -2/5/15 day shift: 2 nurses, 5 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -2/6/15 day shift: 2 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -2/7/15 day shift: 2 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -2/8/15 day shift: 2 nurses, 3 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs, 1 part time CNA. -2/9/15 day shift: 2 nurses, 4 CNAs, 1 shower aide. Night: 1 nurse, 2 CNAs. -2/10/15 missing -2/11/15 day shift: no nurses, 4 CNAs, 1 shower aide. Night: no nurse, 2 CNAs, 1 part time CNA. -2/12/15 day shift: 2 nurses, 4 CNAs, 1 shower aide. Night: no nurse, 2 CNAs, 1 part time CNA. A restorative aide was never included in the scheduling or the daily reports. Nursing staffing was less than the expectation on 21 out of the 29 days documented. Administration Interview: The nursing home administrator (NHA) and director of nursing (DON) were interviewed at 3:30 p.m. on 2/12/15. They acknowledged that improvements were needed in the facility's staffing to ensure resident needs were met.

Based on observations, record review, and interviews the facility failed to ensure two (#2 and #10) of five residents reviewed for pressure ulcers out of 32 sampled residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, the facility failed to ensure: -Resident #2 received necessary treatment and services to promote wound healing, thus resulting in the resident's wound progressing to an unstageable pressure ulcer on her spine. -Resident #10's alternating air mattress settings were being followed. Findings Include: I. Professional Reference The National Pressure Ulcer Advisory Panel, "NPUAP Pressure Ulcer Stages/Categories" 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (2/2015), read in part: NPUAP Pressure Ulcer Stages/Categories The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal [MEDICAL CONDITION] and those due to deep tissue injury. The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. International NPUAP-EPUAP Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones and may indicate " at risk " persons. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. II. Resident #2 A. Resident Status Prior to Admission According to the hospital history and physical dated 12/22/14, resident #2 was a [AGE] year old female with a history of hypertension, [MEDICAL CONDITION], and B12 deficiency who presented to the emergency department (ED) for left hip pain after a fall at the assisted living facility. She did not recall how she fell , she stated, "I guess I just fell and I guess I'm in the ED for my hip pain." The nurses found the resident lying on the floor and were unable to get her up and so they called the ED. Her skin was warm, dry and without any rashes, wounds, or infections. She was diagnosed with [REDACTED]. B. Resident status after admission to the facility Resident #2, age 98, originally admitted to the facility on [DATE], was readmitted to the facility on [DATE]. According to the facility face sheet her pertinent admission [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] revealed the resident did not have any cognitive deficits (memory problems). She had clear speech, usually understood others, and usually made her needs known. She was hard of hearing and visually impaired. She required extensive assistance from two staff members for bed mobility, transfers, dressing and toileting. She had a Foley catheter in place and was occasionally incontinent of her bowels. She was at risk for developing pressure ulcers; however, she did not have any unhealed pressure ulcers. C. Observations The resident was observed eating breakfast in the main dining room on 2/11/15 at 8:21 a.m. She was noted to have a cushion in the seat of the wheel chair and a padded cushion in the back of the wheelchair. An observation of the resident's room revealed a regular pressure reduction mattress on top of the resident's bed frame. There was a deflated air mattress rolled up and placed on the floor in the resident's room. On 2/12/15 at 8:00 a.m. the air mattress was observed to be deflated and rolled up and sitting on top of the resident's bed side table. Observations of the resident's wounds were conducted on 2/12/15 at 9:47 a.m. with the resident's permission. The observations were conducted in the presence of the licensed practical nurse (LPN) #35 and certified nurse aide (CNA) #14. The wound to the resident's mid back measured approximately three centimeters (cm) x 2.5 centimeters in diameter. There was black eschar (dead tissue) covering 90 percent (%) of the wound bed and approximately five to 10% of granulation tissue noted around the edges of the wound bed. The outer peri-wound skin was reddened and slowly blanched when pressure was relieved. Additionally, the resident was also noted to have a buttock wound to the right upper buttock, which measured 1.5 cm x 0.5 cm, the wound bed was covered with 100% eschar. The air mattress was noted in place on the resident's bed frame. CNA #14 stated that she had changed out the air mattress earlier in the morning on 2/12/15. D. Record Review a. Physician Telephone Orders (TOs): Review of the resident's record revealed the following TOs: -1/7/15: provide eight ounces of house supplement twice daily for prevention of skin breakdown -1/11/15: cleanse buttock with wound cleanser, apply [MEDICATION NAME] dressing, and change every 72 hours and as needed. -1/29/15: cleanse wound to mid back with wound cleanser, apply medi-honey alginate sheet and cover with foam dressing. Change every 48 hours and as needed. -2/5/15: cleanse wound to mid back with wound cleanser, pat dry apply medi-honey gel and change every 48 hours and as needed. -2/12/15: discontinue the [MEDICATION NAME] to buttock. Resident has 1.5 cm by 0.5 cm open area to the right upper buttock. Cleanse with wound cleanser; apply medi-honey gel and foam dressing every day and as needed. Change gel to mid back to medi-honey alginate. b. physician progress notes [REDACTED]. The physician progress notes [REDACTED]. c. Nutritional Risk Review and Assessment The initial nutritional risk review and assessment dated [DATE] revealed the resident was on a regular diet with thin liquids. She was receiving an eight ounce nutritional supplement twice a day (BID). Her skin was intact; however, she was at high risk for the development of pressure ulcers. Her [MEDICATION NAME] levels were low at 1.8 g/dl (grams per deciliter). d. Nursing Admission Assessments According to the initial nursing admission assessment dated [DATE], the resident was admitted with surgical wounds. There were no other skin issues noted. According to the nursing admission assessment dated [DATE] (re-admission), the resident had surgical wounds, bruises, and a rash noted. e. Nursing Risk Assessment According to the nursing risk assessment dated [DATE], the resident was at risk for developing pressure ulcers. f. Care plans According to the resident's care plan initiated 1/5/15, the resident was at risk for pressure ulcers. The care plan was updated (undated) to reveal the resident had an unstagable pressure ulcer to her mid back. The goal of the care plan was for the area to the resident's back to heal by 4/5/15. The initial care plan approaches included: pressure reduction devices to the resident's bed and wheelchair, encourage the resident to weight shift while sitting up in chair, teach the risk factors for development of pressure ulcers, maintain the head of the bed at an angle less than 30 degrees, refer to the registered dietician to evaluate nutritional status, encourage good nutritional intake, offer supplemental nutritional support (8 ounces of house supplement) twice daily, daily observation of skin with routine care, full skin evaluation weekly with bath or shower, float heels on pillows, use pillows or other supportive protective devices to assist with positioning, avoid use of restrictive clothing. The facility failed to update the care plan on 1/29/15, when the area on the resident's mid upper back opened (see below). The following approaches were added to the care plan (undated) when the resident was noted to have an unstageable pressure ulcer to her mid back: "cleanse and apply dressing to area as ordered by the physician, monitor for infection, monitor area for slow healing." g. Progress Notes According to the resident progress notes dated 12/30/14 thorough 2/12/15 the following was noted: -12/30/14 (readmission), read in part that the resident's skin was pink, dry and not intact. The resident had a surgical incision to the inferior and superior left hip. Staff measured the superior incision at four cm in length and 0.2 cm in width. The inferior incision measured three cm in length and 0.2 cm in width. The resident's dressings were intact with scant amount of drainage present. The resident had a healing bruise to her left hip, coccyx, right inner arm and left inner arm. Staff noted blanchable redness to the resident's sacrum and midline back (spine). There was no further description of the blanchable redness to the resident's sacrum and spine. -1/1/15 at 4:27 p.m. the resident agreed to doing some physical therapy. She complained about pain in her back "from lying here so long." The resident refused to get out of bed. Therapeutic exercise to the resident's lower extremities, which included PF/DF (plantar flexion/dorsal flexion), SAQ (short arch quad), active range of motion (AAROM) heel slides, hip abduction and hip adduction two times ten each ... therapist asked nurse to change patient to side lying multiple times daily ... -1/4/15 at 11:03 a.m. vital signs ... patient complained of back pain this morning, medicated once ... -1/9/15, the resident had bruising to her right and left upper arm, left hip, surgical wound to left hip, abrasion to inner thigh, redness to mid upper back and sacrum and bruising to her coccyx. -1/11/15 at 2:38 p.m., the resident was noted to have an open area between her buttocks, which measured 2cm x 0.5cm. Per standing order, wound cleansed with wound cleanser and dressed with [MEDICATION NAME] dressing, to be changed every 72 hours and as needed. -1/16/15 at 6:54 a.m., the resident had bruising to the left upper arm, left hip, abrasion to the left inner thigh, redness to mid upper back and sacrum, bruising to the coccyx. Bilateral lower extremities were red and shiny and an open area to the resident's buttocks. Resident repositioned throughout the day and night. Wound care nurse to assess the resident's buttocks ... -1/22/15 at 2:52 p.m., the resident had a surgical incision to her left hip, bruising to the left hip, abrasion to her left inner thigh, bruise to the right lateral shin, open area to her mid upper back, blanchable redness to sacrum and bruising to her coccyx ... -1/29/15 at 12:09 p.m., the resident had a surgical incision to the left hip, bruising to the left hip, abrasion to the left inner thigh, redness to mid upper back, blanchable redness to the sacrum, bruising to the coccyx, right lateral shin and left lower leg ... -1/29/15 at 3:12 p.m., staff cleansed the resident's wound to her mid back with wound cleanser, applied medi-honey alginate and covered with a foam dressing. The treatment was done every 48 hours and as needed. 1/29/15- integumentary and skin concern notes revealed the resident had a wound to her buttock that was now closed and blanchable. The resident had a wound to her mid back that measured 2.0 cm x 1.7 cm. the wound bed was scabbed over and the surrounding tissue was red and blanchable. The wound was treated according to the physician's orders [REDACTED]. -2/5/15 at 2:29 p.m., the resident had a wound on her mid back that measured 2.6 cm by 2.0 cm with no depth ... the wound bed was 90% eschar and 10% slough (dead tissue). The surrounding tissue was red and blanchable. Upper portion of the surrounding tissue at 12 o'clock was slow to blanch. The wound was cleansed and a dressing applied per the physician's orders [REDACTED]. -2/12/15 at 7:44 a.m., the resident had a wound on her mid back that measured 3.0 cm by 2.5 cm with no depth. The wound bed was 90% eschar with 5% slough and 5% granulated tissue. The surrounding tissue was red and blanchable; however at 12 o'clock the wound edge was slow to blanch ... E. Facility failures a. Failure to change wound treatment when wound deteriorated According to the nurses progress note dated 1/22/15 (see above), the resident's wound on her mid upper back changed from a blanchable red area to an open wound. The facility failed to change the treatment to the wound when the wound deteriorated on 1/22/15. The facility continued to apply a foam dressing, which was the treatment for [REDACTED]. b. Failure to provide dietary interventions for a deteriorating wound, and to have the resident's nutritional needs re-evaluated for existing wounds. The nutritional assessment revealed the resident was receiving eight ounces of nutritional supplement BID, as of 1/7/15, for the prevention of skin breakdown; however, the resident had open wounds on her upper mid back and her buttock (see below). Additionally, the resident had a low [MEDICATION NAME] and the nutritional assessment failed to address the resident's wounds and low [MEDICATION NAME] levels. c. Failure to provide proper pressure reducing mattress for an unstagable wound Observations of the resident's bed revealed a standard pressure reducing mattress (see above observations). Additionally, the facility had an air mattress, deflated and rolled up in the resident's room (see above observations). The facility changed out the pressure reduction mattress with an air mattress on 2/12/15 prior to the wound obeservation. d. Failure to update care plan The facility failed to update the resident's pressure ulcer care plan as the wound deteriorated. The care plan was not updated until the resident's wound progressed to an unstageable wound; however, the care plan was not dated when the update occurred. F. Interviews The director of nursing services (DNS) was interviewed on 2/12/14 at 5:00 p.m. The DNS stated that the resident was admitted to the facility on [DATE] with redness to her back. The resident was discharged back to the hospital on [DATE] and readmitted to the facility on [DATE] and she continued to have redness to her back. The DNS reported that the area to the resident's mid back opened on 1/19/15 and staff continued to apply a foam dressing to the area. The DNS stated that the wound orders were changed on 1/29/15 (see above). The DNS stated that the area to the resident's back was considered a deep tissue injury that had come to the surface and would get worse before it got better. The DNS stated that although the wound increased in size, the wound was showing improvement because the redness was getting better and there was now granulation tissue in the wound bed and 5% of slough. The DNS stated that the registered dietician (RD) receives a report regarding residents who need to be seen. The DNS stated that the RD did review the resident on 1/20/15. The DNS reviewed the RD's nutritional risk assessment and acknowledged that the nutritional risk assessment showed that the resident was on a dietary supplement for the prevention of skin breakdown and that the resident's skin was intact, contrary to the resident progress notes (see above). The DNS stated she was not sure why the RD's assessment would show the resident's skin was intact. The DNS stated the resident had excoriation and bruises to her buttock upon admission. The DNS stated the resident was receiving [MEDICATION NAME] (an anticoagulant medication) and was admitted to the facility with bruises and excoriation to her buttock. The DNS stated she assessed the resident's buttock wound on 2/12/15 and the area appeared to be superficial and not over a bony prominence. The DNS stated that she thought the area on the resident's buttock re-opened and that she would need to reassess the wound. The resident's physician was interviewed on 2/13/15 at 10:00 a.m. The resident's physician was not in his office and could not refer to any documentation regarding the resident. The physician stated he believed the facility notified him of the resident's wound and that the resident was having a rough time taking care of herself when she became ill. The resident's physician was unable to state the last time he or the physician's assistant was in to see the resident's wounds. III. Resident #10 A. Resident Status Resident #10, age 46, was admitted to the facility on [DATE], according to the facility face sheet. Her pertinent admission [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident did not have any cognitive deficits (memory problems). She required extensive assist of two staff members for bed mobility, and total assist for mobility, locomotion, and personal hygiene. B. Record Review a. Hospital Wound Notes According to the hospital wound notes dated 11/20/14, the resident was referred for wound care follow up. The resident had a history of [REDACTED]. All incisions were currently approximated and sutures were in place. the resident returned to surgery twice for repair of dehisced (reopened) incision sites ... current wound care included daily dressing changes with xeroform to incision sites and ABD (abdominal pad) cover dressing ... the resident was to be repositioned for dressing changes with no pressure on the buttocks ... the resident was to remain supine per the physician orders [REDACTED]. b. Computerized Physician Orders According to the 2/2015 CPOs, "the resident must maintain a supine position at all times. Use shoulders and knees to reposition the resident. Avoid pulling any skin surrounding the resident's wounds. The resident may be repositioned, but no pressure to her buttocks. The air mattress settings were to be set at 140 pounds with a full turn every 30 minutes." c. Care Plans According to the resident's activities of daily living (ADL) care plan, dated 11/27/14, the resident was bedfast and she required the assistance of two staff members. The care plan failed to reveal the physician ordered settings for the resident's air mattress (see above). According to the resident's surgical incision care plan, dated 11/27/14, the resident had a surgical incision/wound across her coccyx and lower back. The care plan failed to reveal the physician's orders [REDACTED]. According to the resident's at risk for pressure ulcer care plan, dated 11/27/14, the resident was at risk for pressure ulcers. The care plan revealed the resident was utilizing a pressure-reducing air mattress; however, the care plan failed to reveal the physician's orders [REDACTED]. C. Observations Observations of the resident and mattress settings conducted on 2/9/15 through 2/11/15 revealed the following: -2/9/14 at 4:30 p.m., the resident was observed lying in bed. She had an air mattress in place. -2/10/15 at 8:12 a.m., the resident was observed lying in bed. She had an air mattress in place. -2/11/15 at 2:30 p.m., the resident was observed lying in bed. She had an air mattress in place. The settings for the air mattress were set on 175 lb and 3/4 turn every 30 minutes. -2/11/15 at 3:06 p.m., the resident was observed lying in bed. She had an air mattress in place. The settings for the air mattress were set on 175 lb and 3/4 turn every 30 minutes. -2/11/15 at 5:33 p.m., the resident was observed lying in bed. She had an air mattress in place. The settings for the air mattress were set on 175 lb and 3/4 turn every 30 minutes. -2/11/15 at 6:10 p.m., the resident was observed lying in bed. She had an air mattress in place. The settings for the air mattress were set on 175 lb and 3/4 turn every 30 minutes. The resident's licensed practical nurse (LPN) acknowledged the air mattress settings were incorrectly set to 175 lbs with a ? turn every 30 minutes. The LPN adjusted the resident's air mattress setting to 140 lbs and a full turn every 30 minutes. D. Interviews CNA #23 was interviewed on 2/11/15 at 6:06 p.m., and stated the resident had an air mattress in place. The CNA was not sure if there were any special instructions for the air mattress and stated she had recently been off from work. LPN #35 was interviewed on 2/11/15 at 6:10 p.m. and stated the resident's air mattress should be set on 140 lbs with a full turn every 30 minutes. The assistant director of nursing (ADON) was interviewed on 2/11/15 at 6:24 p.m. and stated that the resident came in with a stage four pressure ulcer to her buttock/sacrum. She was admitted to the facility in the past because of a previous surgical flap repair. The ADON stated that because at the time they were unable to do another surgery the resident was admitted to the facility to work on getting her wounds smaller so that she could have another surgical flap repair. The ADON stated that the resident was discharged to the hospital where she had a surgical flap repair done and readmitted to the facility. The ADON stated that the resident was on a rotating air mattress and would expect the air mattress setting to be on the settings ordered by the physician. The ADON acknowledged that if the bed was not on the proper setting there would be a potential risk of reopening the resident's wounds. The DNS was interviewed on 2/11/15 at 6:30 p.m. and stated that the resident's surgical wounds were healed. She stated that the resident had not been weighed because she was bed bound and could not get out of bed. The DNS stated that when the physician recently came in to see the resident the physician wanted the mattress to be a little firmer; however, no new orders were noted. The DON stated that since the resident had not been weighed and appeared as she had gained weight, the determination was made to increase the air mattress settings. The DNS stated that she would expect the staff to follow the physician orders.

Based on resident and staff interviews and record review, the facility failed to provide an environment where residents felt safe reporting grievances, and to protect the residents' right to file grievances without fear of retaliation for four of 39 facility residents, and potentially all residents who resided in the facility. The residents expressed during interviews that they had concerns about staff retaliation, and staff stated they had heard residents express fear of retaliation. Specifically: -A resident (A) who requested anonymity said s/he was "afraid of repercussions" and did not want his/her concerns reported; -A second resident (B) who requested anonymity said s/he did not "want to get in trouble" by having his/her complaints reported; -A third resident (C) who requested no investigation said, "I hate it because I'm here and I can't do anything about it." -A certified nurse aide (CNA) said a resident (D) reported care concerns, but was "scared" to have it reported to management. -The facility management team handled resident allegations of abuse and mistreatment as grievances and failed to initiate abuse investigations and ensure resident protection, creating an atmosphere where retaliation could occur. Cross-reference F223 - Abuse and mistreatment; F225 - Thoroughly investigate, screen, report and protect; and F226 - Operationalize facility abuse policy and procedures. The findings included: 1. Resident A who requested anonymity was interviewed on 2/9, 2/10, 2/11 and 2/12/15, and made the following comments: -The resident said s/he had been verbally abused, had seen other residents being abused and mistreated, and had reported abuse, but "it doesn't do any good" and "of course I was the trouble-maker." The resident said s/he had seen and heard staff yell at residents with dementia who were unable to speak for themselves, "What do you want? What's wrong with you? (Staff are) overworked and they take it out on the residents with Alzheimer's ... They don't pay attention. (A resident with dementia) will just sit, and you can see her going down and down and down..." The resident said s/he did not report abuse any more due to being "afraid of repercussions." Asked what would happen, the resident said, "(Repercussions) will happen. It goes all the way to the top." In an interview on 2/11/15 the resident reiterated that s/he did not want follow-up on his/her stated concerns because s/he did not "want retaliation..." 2. Resident B who requested anonymity was interviewed on 2/11/15 and made the following comments: "I have a problem with one of the employees. I do not know her name or her title. I did not see her yesterday or today. I saw her last week ... The staff person stated she could not help me ... The staff person said it in a harsh tone and she did not tell me who to go see to get the help that was needed." The resident stated s/he reported the problem to a management staff person and added, "I do not want you to do anything. Just forget it. I do not want to get in trouble. Do not tell anyone about what I have said to you." 3. Resident C who requested no investigation was interviewed on 2/9/15 and made the following comments: "One of the night nurses doesn't like me. She said sometimes you just have to deal with it, when I told her I was in pain. I had a fall one night, reported it, and the nurse said I didn't have a fall. That nurse said she was going to talk to the doctor about getting me an antidepressant because I'm crying all the time ... When I asked her for something for sleep she said she was going to try to get me an antidepressant. She was not listening. I hate it because I'm here and I can't do anything about it. I'm in pain, I can't sleep, and she kept going on and on about the antidepressant. I reported it to one of the nurses. I think it was (RN #16)." "(CNA #1) gets impatient when I ask her to empty my bedside commode or take my tray. My (family) cleaned the commode for me. Now I've started [MEDICATION NAME] going to the toilet myself. The CNA would just get mad at me. I told her I feel bad asking her to do these things but she doesn't respond, just cleans up and asks 'anything else before I leave?'" 4. CNA #22, interviewed on 2/11/15 at 11 a.m., said resident D who speaks another language (which the CNA understood) had reported to her that some staff refused to provide care for him/her and the resident "doesn't know why ... (S/he) hasn't said anything for the last two weeks. (S/he is) scared to say something ... maybe they're going to get mad ... or something..." CNA #22 said she had reported the resident's concerns to other CNAs but the resident "doesn't want me to say anything to the head nurses ... (S/he) says, 'I'm just telling you'; I said you're telling me, so I have to say something." However, CNA #22 said, "I just talked to (the other CNAs)" who denied refusing care for the resident. 5. Refer to F223 and F225 for details on the facility's method of filing grievances instead of conducting abuse investigations. The facility did not consistently and completely document resident grievances; did not thoroughly investigate the grievances; did not notify the nursing home administrator immediately; and did not protect the residents during investigation, thereby leaving residents vulnerable to retaliation. The facility further failed to provide follow-up monitoring of staff, failed to document the actions taken, and failed to notify residents of the actions taken.

Based on staff interview and record review, the facility failed to provide the highest practicable quality of care for one of three residents reviewed (#1) out of a sample of eight residents. Specifically, resident #1 suffered a fractured femur during a Hoyer lift transfer on 10/4/14, with delayed physician notification, lack of adequate and timely assessment, pain management, [DIAGNOSES REDACTED]. These failures contributed to the resident experiencing pain from an undiagnosed , untreated fracture. The findings included: 1. Resident #1, age 85, was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. 2. Resident Status According to the 10/22/14 significant change Minimum Data Set (MDS), the resident's [DIAGNOSES REDACTED]. The resident had a BIMS (cognition) score of three, indicating severe cognitive impairment. Mood symptoms, at a high severity score of 13, included: feeling down, depressed, hopeless; sleep problems; no energy; and appetite issues. The resident had no behavioral symptoms. -She was dependent on two-plus staff members for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing. She had an indwelling catheter (discontinued on 10/26 per nurses' notes), and was incontinent of bowel. -She had range of motion limitations to both lower extremities and one-sided upper extremity, and used a wheelchair for ambulation. -She had a fracture, no falls, and no pressure ulcers. She received scheduled and as-needed (PRN) pain medications, no pain was present during the interview, pain frequency and rating were not listed. According to the 8/18/14 previous quarterly MDS, the resident had a BIMS score of 13 indicating she was cognitively intact, and a mood score of three with some depression indicated. Her activities of daily living assessments were the same, except that she was noted as always incontinent of bowel and bladder. Comparison of the two MDSs showed a marked decline in cognition and mood status. The resident's Medical Orders for Scope of Treatment (MOST) form, signed by the medical durable power of attorney (MDPOA) on 9/19/14 and the physician on 10/1/14, noted the resident wanted no cardiopulmonary resuscitation, comfort measures only, no antibiotics, artificially administered nutrition and hydration for a defined period of one week. Comfort measures only were noted to include in pertinent part: "First follow these orders, then contact physician, advanced practice nurse or physician assistant for further orders if indicated: -Pain management, -Oxygen, suction and manual treatment of [REDACTED]. -No transfer to the hospital for life-sustaining treatment, and -Transfer only if comfort needs cannot be met in current location; EMS-contact medical control." 3. Accident with Femur Fracture on 10/4/14 Review of nurses' notes, incident report and investigation, and a fax to the physician revealed the resident suffered a femur fracture during a Hoyer lift transfer on the evening of 10/4/14. (Cross-refer to F323 for further details) 4. Facility failures in notification, assessment, pain management, and treatment a. Delayed Physician Notification and Treatment Although the resident was injured on 10/4/14, there were no nurses' notes in the medical record until the director of nursing (DON) charted on 10/9/14, five days later. The 10/4/14 incident report noted the physician was notified two days later, on 10/6/14, via fax. According to the 10/6/14 fax to the physician, "10/4: Resident (#1) having increased pain after possible injury to knee due to malfunction of Hoyer lift. As of 10/6 resident experiencing increased pain. Vital signs stable." According to nurses' notes on 10/9/14 at 2:44 p.m., the X-ray results showed a "left femoral acute displaced fracture." b. Delayed treatment, including pain management According to a 10/9/14 physician visit form, signed by the physician assistant, "Roxinol is not effective for her pain control. Pt is comfort care. Requests return to [MEDICATION NAME] ER Q (every) 12 hr. Previously was effective. Also needs refill on [MEDICATION NAME] (illegible) 5/325 1-2 tabs PO (by mouth) Q 6 hrs PRN (as needed) pain. New orders: left knee pain. (1) Portable X-ray knee 3 view, (2) Appt with (physician) or avail MD for left knee strain, trauma evaluate." Faxed orders from the PA included: "D/C (discontinue) Roxinol. [MEDICATION NAME] ER 45 mg tab, take one tablet PO BID (twice daily). Dx (diagnosis): pain. Q# (quantity) 120, no refills..." The resident's care plan, dated 9/13/14 and revised 10/22/14, identified, "I have chronic pain and I experience pain related to fractured left femur." The goal was an acceptable pain level. Approaches were: "Complete pain assessment; notify MD if pain meds become ineffective; administer pain meds as needed; I will require assistance with applying left leg splint daily." The care plan further noted to "Report any changes in pain type/location frequency/intensity to my physician promptly." -Although CNA interviews revealed the resident needed pain medications prior to transfers and repositioning (see interviews below), this instruction was not included in the care plan. -Moreover, pain assessments and Medication Administration Record [REDACTED] According to pain assessment flow sheets, reviewed 10/1 through 11/6/14, the resident's pain was rated on a faces scale for cognitively impaired residents as follows: zero=no hurt, 2=hurts a little bit, 4=hurts little more, 6=hurts even more, 8=hurts whole lot, 10=hurts worst. The pain ratings were inconsistent and sometimes blank. (Nursing staff worked two 12-hour shifts). Specifically: -The resident's pain had been rated zero from 10/1 through the 10/4 day shift. -The resident had pain at level 8 (0 crossed out and 8 added) on the 6 p.m. to 6 a.m. shift on 10/4/14, and on both shifts on 10/5/14. -The resident's pain was rated 0 for both shifts on 10/6, 5 on night shift 10/7, blank (no rating) and 0 on 10/8, 0 both shifts 10/9, 0 day shift and 8 night shift on 10/10. -The resident's pain was rated 0 day shift and 7 night shift on 10/11, 4 and 8 on 10/12, 4 and blank on 10/13, 6 and 0 on 10/14, 5 on both shifts 10/15. -The resident's pain was rated 4 and 5 on 10/16, 5 and blank on 10/17, 5 and 6 on 10/18, 5 and 8 on 10/19, 6 and blank on 10/20, 6 and 0 on 10/21, 0 both shifts on 10/22, illegible and 0 on 10/23, illegible and blank on 10/24, 0 and blank on 10/25, -The resident's pain was rated 0 both shifts on 10/26-10/29, 6 and 0 on 10/30, illegible and blank on 10/31,0 and 5 on 11/1, 4 and 5 on 11/2, 6 and 0 on 11/3, 4 and 5 on 11/4, 4 and 0 on 11/5, and 6 on day shift 11/6/14. According to the October 2014 Medication Administration Record [REDACTED] -[MEDICATION NAME] 5-325 tablet, 1-2 tablets PO Q6hrs PRN generalized pain, start date 9/18/14; -[MEDICATION NAME] 325 mg tablet, 1-2 tablets PO Q4hrs PRN joint pain, left lower leg, start date 9/18/14; -[MEDICATION NAME] 20mg/1ml. Give 10 mg (0.5ml) sublingual Q2hrs PRN air hunger/pain, start 9/19/14; -[MEDICATION NAME] 45 mg PO BID, start date 10/9/14 (see order above). The MAR indicated [REDACTED]. Nothing was noted on back of the MAR indicated [REDACTED]. -[MEDICATION NAME] was initialed as given on 10/12 and 10/19, but not before. -[MEDICATION NAME] was initialed as given 10/4, 10/5, 10/7, 10/8 and 10/9, then noted as discontinued on 10/9/14. [MEDICATION NAME] was documented inconsistently on the back of the MAR indicated [REDACTED]. MAR review [REDACTED] - The resident was given [MEDICATION NAME] when she was rated with 0 pain per assessment on 10/8 (blank and zero). -There was no documentation about [MEDICATION NAME] on the back of the MAR indicated [REDACTED]. -There was insufficient documentation of effectiveness of the [MEDICATION NAME], which was never noted as given more than twice in a 24-hour period, although the resident could have it every two hours if needed per physician orders, and even though her pain ratings when done were 8 and 5. -Even after the [MEDICATION NAME] was started on 10/9/14, and [MEDICATION NAME] discontinued due to ineffectiveness (see PA note above), the resident continued to experience pain at 5 and 6 levels, but there was no evidence the physician was notified of the resident's breakthrough pain, which continued until 11/6/14 (see pain assessment flow sheets above). Review of the November 2014 MAR indicated [REDACTED]. c. Delayed Mobilization of the Resident's Fractured Leg to Prevent Further Injury and Discomfort Nurses' notes revealed in pertinent part: -10/8 at 2:18 p.m., "Res. knee continues to be swollen and redness noted to back of left knee ... warmer than right. Res. is on comfort care at this time. Left message with POA and informed PA." -10/9 at 10:16 a.m., "Voice message left for MPOA that PA would like to have left knee X-rayed because of continued pain." At 10:18 and 10:34 a.m., new orders for X-ray and [MEDICATION NAME] were received from the PA. At 2:44 p.m. a fracture was noted and two options discussed: comfort care and consult with orthopedic associates for any nonsurgical interventions. "Res. is not a candidate for surgery." -10/10 at 12:24 p.m., "Call from MPOA on (10/9 at 5 p.m.) Per MPOA provide comfort care and knee brace per PA's recommendations. Will contact PA for knee brace." At 3:03 p.m., "PA would like to consult with orthopedic docs for their recommendations and will then follow up with this facility with knee brace recommendations." At 5:38 p.m., "Received call from PA, new order for standard knee immobilizer left lower leg to be worn at all times. May remove for shower. Asked therapy and they do not have any available. Placed on 24 hr report to be ordered." -10/22/14 at 9:32 p.m., "Res wears a knee brace immobilizer for left femur fx at all times to help with mobility in bed." There were no nurses' notes about the resident's injury, pain or treatment (immobilizer) in the chart on 10/4/14 or afterward, until the DON documented on 10/9 that the resident had an injury. There was no documentation in the nurses' notes or elsewhere in the medical record about the brace, when the first one was acquired, that it did not fit, and when the proper brace was applied. -The October 2014 treatment administration record (TAR) was requested but not provided. -The November 2014 TAR revealed "apply standard knee immobilizer to L leg to be worn at all times, may remove for showers," noted on 11/1/14 with no start date documented. -There was no order or indication for nurses to remove the immobilizer to check the condition of the resident's skin. By this time, the resident had a "boggy" heel and orders to "float heels at all times," and "apply skin prep to left heel and cover with foam dressing, change every other day" and "multi-podus boot to left foot at all times while in bed." The care plan was not updated with instructions for the left leg immobilizer until 11/6/14, when "potential for decline in present level of function related to fracture to left femur" was identified. Approaches were: "I will wear a brace to immobilize my left leg; I require assistance to apply brace to left leg daily; I will be assessed for pain and provided with pain control as needed; New Hoyer batteries will be used when I am transferring." -The care plan did not include instructions for nurses to remove the brace to check the resident's skin, to assess for the resident's comfort with use of the immobilizer, how or how many staff were to reposition and transfer the resident to protect her leg and ensure comfort. 5. Resident Interview and Observations Resident #1 was interviewed on 11/6/14 at 3:30 p.m. When asked if she remembered what happened when her leg was injured, she said, "It's kind of bleary. I said, 'Oh you hurt me.' He said, 'It was just a little bump.' I said, 'It was more than that.' I cried a lot. I don't remember much." -When asked how they provided care for her now, she said, "Very gently. They hold my leg and my upper leg and they do it very carefully. Usually with two or three people." -Asked if two people were enough, she said, "I don't know. It hurts almost every time, and for awhile after that. They're very caring here except for one person ... She is very rough. I've told a few people about it." -The resident's right heel was observed lying directly on the mattress. Her left heel was floated and in a protective boot. 6. Staff Interviews Certified nurse aide (CNA) #5, who worked with resident #1 on 10/5-10/9/14, was interviewed on 11/4/14 at 3:30 p.m. CNA # 5 said: -"I've known (resident #1) forever and she's fantastic, and I feel like this is going to be a huge decline for her. The whole way it happened, I just feel like follow-up was awful. When I got here that morning (10/5/14) night shift reported (the accident and that they) heard something pop ... -When I went in to get her up and her knee is this big and she's screaming in pain and we're reporting and telling the nurses you need to get her an X-ray or something, and they said she's on comfort care. Well you have to do something to help this woman. -It was a day or two before an incident report and before management knew about it ... She had pain for at least two or three days, and we were saying something is going on ... (Resident #1) was telling us her pain scale was a 9 or 10 ... I don't know the exact time frame, then the portable X-ray person comes in and says she has a fractured femur. They just didn't listen to what we were telling them and it's frustrating." -"It's my job to come in and take care of these people to the very best of my ability, and it's difficult when you don't see follow-through from the rest of the team." -" They gave us a brace for her leg. The brace was two feet longer than her leg, and they finally got her another brace. ... Having to stay in bed, she's complaining her hip hurts, it's uncomfortable and she wants to get up. Now she just stays in her room. This brace is supposed to stay on 24/7 - I don't know how long something like that takes to heal. They say she can't have surgery because she's not a candidate." -"The part I don't like is that I feel there's nothing I can do for her. Her pain wasn't in control from the beginning ... I tell the nurse before I need to take care of her - I don't know if all the other CNAs do that, I know most of them do, but sometimes it's hard, too, with the nurse you have on, because some will say they have five other things to do first." -"I just hope they follow through and I hope this brace works to keep her leg immobilized." CNA #6, who was familiar with resident #1, was interviewed on 11/4/14 at 4 p.m. She said: -"The next day (10/5/14) (resident #1) was in a lot of pain obviously. We weren't sure what happened or why she was in such pain ... So we were just really tender with her, tried to keep her immobile because she made it clear her leg, 'It hurts, it hurts, it hurts.' It was bending when her knees normally don't bend. We were like, 'That's kind of unusual.' -Everything was reported to the nurse on duty that day ... I think that went on for a couple days until the nursing staff suddenly decided an X-ray was warranted and the mobile guy came and figured out (her leg) was indeed fractured." -"She's pretty much staying in bed. But we have to roll her. We try to team up and keep that injured leg as immobile as possible so we're not hurting her when we roll her over. Usually it takes a third person to immobilize her leg during a rollover. We usually don't have that; we tend to be short staffed." -"She can definitely let you know when she's in pain; she does cry out and let you know. We would move her and she would say, 'Ow, ow, ow; that hurts, my leg hurts; are we done?' She would grimace for sure and she would definitely talk louder than her normal voice." -"I think they could have responded a little quicker with getting that X-ray order. There was obviously something very wrong." CNA #7 was interviewed on 11/4/14 at 4:24 p.m. She said she worked with resident #1 the day after her injury. -"We got report that something happened to her leg and she was complaining of pain. When we went to get her for breakfast and she was screaming in pain, we looked at her leg and saw it wasn't facing the right way. Her knee was swollen and the lower part of her leg was tilted out to the left a little bit. We went and got the nurse ... -(The nurse) was going to call the on-call person because it was a Sunday and she needed to find out what the plan was for her, because she was going to get an X-ray. We only knew it was decided she was on comfort care, so there was nothing they could do about it." -"They got her pain under control ... gave her [MEDICATION NAME]. I would say at least every couple hours because we were asking for it often, because we were turning her every two hours so we'd ask for it any time we went in to perform care. (The DON) taught us how to transfer and provide care for her, two days later. There are always three of us at a time, one specifically there to immobilize the leg while the rest of us turn her." -"As a caregiver ... I don't think it was good for them to wait so long to get her X-rayed, whether she was on comfort care or not. That was tough." CNA #8 was interviewed on 11/4/14 at 4:37 p.m. She said: -"Her leg was swollen and we thought it was the knee that was bumped ... If we went to move her she just said it hurt. She'd had pain in that leg before, so we'd put pillows between her legs to turn her. They were giving her stuff for pain that day. I only work Saturday or Sunday. It was Thursday or Friday when I came back and that's when they said that leg was broken. We left her in bed the next day because she was not wanting to get up. Every time she said anything (about pain) we reported it to the nurse ... Her pain seems to be managed now even during transfers." CNA #9 was interviewed at 5 p.m. on 11/4/14. She said, "I'm the bath aide so I don't transfer her much ...We ask for pain meds prior to transfers." Licensed practical nurse (LPN) #1 was interviewed on 11/4/14 at 5:30 p.m. She said, "(Resident #1's) pain level is better with [MEDICATION NAME] and PRN [MEDICATION NAME] (but see pain assessments above showing frequent breakthrough pain)..." LPN #2 was interviewed at 5:37 p.m. on 11/4/14. According to the schedule, she worked with resident #1 on 10/5, 10/6 and 10/10/14. -"I looked at her leg, she has [MEDICAL CONDITION]. I didn't see any discoloration. I never really looked at (resident #1's) leg prior to that to inspect it. Compared to her other leg, there was a slight difference. She wasn't warm to the touch, no redness, no discoloration. -She was having more complaints of pain, more restless, but other than that, I couldn't see anything visually. She guards, moans very loudly, has facial grimacing, becomes more agitated and anxious." -"That day I worked with her ... I don't remember noticing anything major. I believe I started noticing her pain maybe like five to seven days later. She started having more pain, crying out more, during my shifts I was giving more PRN pain meds, things like that. CNAs were reporting pain when I came back a few days later ... From what I remember the X-ray was the day after. I don't remember calling, I'm not sure who did." -"The knee immobilizer - we ordered it, it came in, it was a little bit too long. I'm not sure how long she's had the one that actually fits." -"Three people transfer her, we stabilize her legs during transfer and now she has the brace ... When I came back, therapy and I did it together, and the first time I used the brace I went to therapy and asked them to show me ... The therapy director trained me. My CNAs were with me (she could not recall which CNAs)." -When asked to describe her assessment of the resident's leg, she said, "I got report, me and my aides were talking about it. When they went in to do cares I asked them to let me know because I wanted to look at her. I just looked at it. One of the aides said she thought it looked different. She said she thought it was more swollen than usual. I looked at her legs together, checked for [MEDICAL CONDITION], when I was palpating her she would holler out in pain and then you would let go and go to that same spot and you wouldn't get the same response. She wasn't being consistent ... -(Resident #1) likes attention a lot, and it might have been me thinking she was liking the attention she was getting, because she wasn't being consistent in her response. I went to my DON and told her what I found, and she went with what I told her. I'm not sure if she went in and assessed her after I left the office. I didn't ask her to go look, but I did report. It didn't seem that (resident #1) was having any more pain than usual that day." The assistant director of nursing (ADON)/marketing director was interviewed at 5:53 p.m. on 11/4/14. She said it had been about a week after the resident's injury before she saw the resident again. "She was having quite a bit of pain at that time, but they got it under control." The DON was interviewed on 11/6/14 at 1:30 p.m. She said she was notified the next day or the day after the resident's accident, and there was no evidence of a fracture. -"After the incident I asked several of my nurses how she was doing. (LPN #2) said she's a hard person to assess. She couldn't be exact about where the pain was. It was just that leg (where she had pain). We were medicating her and giving her ice. -I do a 24-hour assessment after getting an incident report. It was inflamed and warm to touch. My first thought was a blood clot. I called (the PA) who came in the next day and said, 'We really need to do an X-ray.' We did the X-ray and it showed a femur fracture. We called (the POA) and the second MPOA and told them the options per (the PA) were: comfort care at (the facility) or take her to an orthopedic surgeon. The POA wanted to do a leg brace. -(The PA) contacted the orthopedic surgeon, who ordered a leg brace. The first one was too long. It had been measured by our therapist. She's supposed to have that on at all times, except showers. We did med changes for pain management, added a catheter but she had issues with that. We told CNAs we need to do good continence and peri care. -We did teaching with the knee brace. They continued to roll her the same as before her leg brace. I've encouraged my staff to place a pillow between her legs. We do a three-person when she gets up with the Hoyer lift. -Two to three staff to turn and reposition. I tell staff if her pain is increasing let her nurse now. If she's in more pain and you need to turn her, we'll go in there and support those legs. I showed them how to reposition. I discussed the best way with therapy. -I feel we're managing her well and doing the best we can. During an interview on 11/6/14 at 5:30 p.m., the nursing home administrator (NHA), DON and MDS coordinator were informed of the findings above. Although the DON had stated in the interview above what the facility had done to follow up on the resident's injuries, staff interviews and record review revealed there had been delays in notification, pain management and in obtaining a proper brace to immobilize the resident's leg, all of which contributed to the resident experiencing pain.

Based on observation, record review, and resident and staff interview, the facility failed to ensure one of three residents reviewed for falls and accidents (#1), out of eight sample residents, received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to: -Provide safe, functioning equipment and a safe transfer of resident #1. -Report and investigate resident #1's transfer in a timely manner. -Take steps to prevent additional unsafe transfers of resident #1 and other residents requiring a mechanical lift. Resident #1 suffered a fractured femur during a Hoyer transfer, as well as pain and a decline in her psychosocial well-being. Cross-refer to F309, highest practicable quality of care regarding delayed response and treatment for [REDACTED]. The findings included: 1. Resident #1, age 85, was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. 2. Resident Status According to the [DATE] previous quarterly Minimum Data Set (MDS), the resident had a BIMS score of 13, indicating she was cognitively intact, and a mood score of three with some depression indicated. -She was dependent on two-plus staff members for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing. -She had range of motion limitations to both lower extremities and one-sided upper extremity, and used a wheelchair for ambulation. -She was noted as always incontinent of bowel and bladder. The resident's [DATE] care plan identified "risk for fall r/t (related to) immobility," and the goal, "I should not have any fall related injuries through next review." Approaches included Hoyer lift for transfers, wheelchair primary mode of mobility, and "staff to ensure I am properly positioned prior to releasing Hoyer." The care plan dated [DATE] identified "use of a Hoyer as a transfer aid," and the goal of "transfer without injury." Approaches included: "Refer staff to therapy for training for use of the Hoyer as needed. Provide me with the assistance of two people when transferring me. Report any unsafe use or change in ability to transfer with the Hoyer to my nurse. Stabilize the sling of the Hoyer when transferring me so as not to bump my feet and help me feel safer." The [DATE] care plan identified "assistance with ADLs r/t immobility," with the goal of no complications. Approaches included: "Hoyer lift for all transfers, ensure availability and cleanliness of equipment such as wheelchair and devices such as the sling from the Hoyer lift; take measures necessary to ensure my health and safety; I utilize a wheelchair as my primary mode of mobility; staff will have to propel my wheelchair for me; I require two person total dependence when transferring (with) Hoyer lift; at times I prefer to nap in the lobby in my wheelchair." 3. Transfer with injury [DATE] a. Incident report An incident report, dated [DATE], noted "increased pain to left knee," related to "Hoyer lift," in "resident's room," reported by "CNAs (certified nurse aides) on duty ,[DATE] night." First aid was noted as given by the RN (registered nurse) at 8 p.m., "cold pack to left knee - pain medication." Vital signs were blank and pain scale was blank. The narrative of the event read, "Battery died while using Hoyer lift. Difficulty getting resident in bed. CNAs heard a pop from knee. Left leg knee, no redness or discoloration to skin. Possible swelling, difficult to observe due to normal edema ... ice pack to knee and pain medication." b. Resident #1 interview Resident #1 was interviewed on [DATE] at 3:30 p.m. When asked if she remembered what happened [DATE], she said, "It's kind of bleary. I said (to CNA #1), 'Oh you hurt me.' He said, 'It was just a little bump.' I said, 'It was more than that.' I cried a lot. I don't remember much." c. Injury and resident #1's decline Review of nurses' notes dated [DATE] at 2:44 p.m. revealed the resident sustained [REDACTED]. Review of the [DATE] significant change MDS revealed in contrast to the resident's [DATE] MDS, the resident was coded with a BIMS (cognition) score of 3 (previously 13), indicating severe cognitive impairment, and mood symptoms were coded with a high severity score of 13 (previously 3) and included feeling down, depressed, hopeless; sleep problems; no energy; and appetite issues. Interview with CNA #3 on [DATE] at 1 p.m. revealed that following the transfer on [DATE], "(Resident #1) was always complaining of pain. She kept telling us her leg hurt. We kept telling the nurse about it ... (Resident #1) did seem like she was in a lot more pain than usual ... She was complaining of pain the entire weekend." Cross-reference F309 for further details. 4. Failures [DATE] a. Failure to timely document and report the resident's injury and identify the extent of the resident injury - femur fracture Review of the incident report, dated [DATE], revealed family notification was blank, and the witnesses line was blank. The physician was notified via fax on ,[DATE] (two days later.) The form was noted as having been completed by a different RN on [DATE] (one day later), and signed by the DON (director of nurses) on [DATE] (four days later). -Twenty-four hour follow-up was dated [DATE], four days later, vital signs blank, new orders blank, with 24-hour condition and injury appearance noted as, "Left knee is swollen & back of knee is warm to the touch." Additional follow-ups were noted on ,[DATE], ,[DATE] and [DATE] as "See N.N. (nurses' notes)." There was no nurses' note on [DATE], when the injury occurred and no nurses' notes from ,[DATE] until [DATE]. According to the fax to the physician on [DATE] (two days after injury), ",[DATE]: Resident (#1)'s left knee having increased pain after possible injury to knee due to malfunction of Hoyer lift. As of ,[DATE] resident experiencing increased pain. Vital signs stable." According to a nurse's note by the director of nursing (DON), dated [DATE] at 2:18 p.m. (four days after the injury), "It was noted that on ,[DATE] res(ident) hurt her left knee during a Hoyer transfer. Ice has been applied to Res. left knee for swelling and comfort. Res. knee continues to be swollen and redness noted to back of left knee. Left knee is warmer than right. Res. is on comfort care at this time. Left message with POA and informed (name) PA (physician assistant). Will cont(inue) to monitor." A nurse's note, dated [DATE] at 10:16 a.m., read, "Voice message left for (name) pts MPOA (medical power of attorney) that the PA (physician assistant) would like to have left knee X-rayed because of continued pain in it." At 10:18 a.m., a note read, "New order from (name) PA for stat X-ray of left knee, 3 view. Dx (diagnosis): knee strain. Appt with MD/PA for left knee exam post trauma." A nurses' note, dated [DATE] at 2:44 p.m., read, "Results from x-ray show left femoral acute displaced fracture." b. Failure to provide safe, functioning equipment and failure to provide a safe transfer. (1) CNA #1 was interviewed on [DATE] at 6:15 p.m. He said it was his second night of training with CNAs #3 and #4, and although he was an experienced CNA, he had never transferred resident #1 before. He said he was asked to help, entered the resident's room, and saw that "they were trying to get her ready for bed, had her in her nightgown, and they were picking her up to put her in bed, had a problem with the lift at this point. She was in the air, her knees are stiff, they don't bend, so they had her in the air, both legs lifted up where the main part of the lift would've been three-quarters of the way up her leg." He said the resident's legs "were on either side of the bar and her butt's caught on her wheelchair. Her feet are straight out, so I went in there ... assessed the situation, said the first thing we need to do is move her wheelchair so she had one foot on either side of the lift, her butt was caught on the wheelchair, the wheelchair wouldn't move. She was almost horizontal hovering over her chair, both legs out on either side ..." He stated, "I had to get the chair out of the way. In order to do that I took it by the handles and pulled up on it and pulled it out from under her. The lift wouldn't move up or down. The chair was out, she was in the air and you could put her in bed normally. Both feet are on either side of the main part of the lift, and she has to turn this way to be set down into the bed. So the CNA at her back, right where the sling was, was pulling back to bring her feet this way. I was trying to protect her feet and swing her feet where she missed the main part of the bar, get her sideways and move her to the bed to set her down." The CNA said he was trying to move her leg down and around the bar, by holding her knee with one hand and her lower shin with the other, to ensure her foot didn't hit the lift when he swung her. "It wasn't an immense amount of pressure I was applying ..." "Meanwhile while we're doing this, we hear a pop. I was like, 'Oh, that didn't sound good. It didn't sound like a bone to me. It sounded like a tendon might have popped. She didn't do a lot of screaming and yelling or anything like that. She said, 'I hurt a little bit,' and I immediately went and told my nurse." He further stated, "Their lifts are older here. One of the things I've learned is that you have the bar to one side or the other of both legs, instead of the bar coming between their legs. You just push up a bit. Not every CNA knows that, and it comes from experience ... "I don't think there would have been a problem with proper equipment. If the lift hadn't stopped ..." (2) CNA #2 was interviewed on [DATE] at 6:50 p.m. She also stated that she was an experienced CNA, but had never transferred resident #1 before. She said, "I remember me and my trainer (CNA #4) were in there and we had put (resident #1's) roommate to bed. (Resident #1) wanted to go next, so we hooked her up to the lift and the battery was dead, so we tried to change the battery and the other battery was also dead. So we unhooked the sling from the one lift to the other lift." "(Resident #1) was sitting in her wheelchair. So we hooked her up to the other lift which had a battery, we got her up in the air and it stopped. We'd already gotten her past the point of getting her back in the chair." CNA #2 said she asked CNAs #1 and #4 for help and explained to them the problem. "(CNA #1) came in and pulled the wheelchair out like this. She was past getting into her chair the way the footrest is. He pulled the chair out, her legs were sticking straight out, we're trying to get her into bed, so we had to clear the bar in the middle, so (CNA #1) gently moved her leg sideways while I pulled the back of the sling, and we heard a pop ..." "We told the nurse immediately that we heard a pop. I know she did go in and check on (resident #1) and gave her some pain medication. Later (resident #1) was still complaining of pain and asked me for an ice pack. The nurse told me to give her one because she couldn't give her anything else for pain ... (Resident #1) just kept saying she was in pain." "It was my first time to transfer (resident #1). Two different Hoyer's were unusable. (3) CNA #3 was interviewed by phone on [DATE] at 1 p.m. She said she and CNA #4 were orienting CNAs #1 and #2 that night. She stated that although CNAs #1 and #2 were experienced, "they didn't know (resident #1) and I don't believe they had transferred her before." She said CNA #4 came out of the room and asked for help because the batteries on both lifts they were trying to use were dead, and the resident was "hanging between the lift and the wheelchair right in the middle." CNA #3 said she and CNA #4 would transfer resident #1 "where she's actually facing the front of the lift where her legs are between the bars. A lot of CNAs there transfer her from the side ... you're supposed to transfer with the resident facing the lift, so that's what we (she and CNA #4) did." -"While we were turning her I noticed (CNA #1) pulled the sling back so we could clear her feet. As he was pulling her back I turned my back to grab wet wipes and I heard (resident #1) yell 'Ow!' really loud and I asked what happened. (CNAs #1 and #2) both told me they heard a loud pop ... (Resident #1) said, 'My leg hurts.' CNA #3 said, "Other than that I didn't see how they turned her. I just knew he (CNA #1) took the sling and pulled (resident #1) back so her legs would clear the pole, but (CNA #2) was also pulling her back. (CNA #4) was getting the bed prepared, bringing the covers down, I turned my back to go grab wet wipes that were in the closet." (4) CNA #4 did not return phone calls and was not interviewed. 5. Failures after [DATE] a. Failure to timely investigate the incident [DATE] and the root causes of resident #1's injury. Attachments to the incident report included an incident/event committee review and recommendation for corrective actions, which stated, "Transfer education for staff & prevention battery inservice." Committee signatures were from the DON, nursing home administrator (NHA) and MDS Coordinator, dated [DATE]. On [DATE], the NHA noted that no abuse, neglect or misappropriation was identified. Written statements were provided by the four CNAs who witnessed the transfer with injury. However, the statements were dated [DATE] and [DATE], two to three weeks after the resident's injury was incurred. CNA #1 wrote on [DATE] that there was a "problem with the Hoyer" and he was called to help, found the resident "in the air and the lift was not working. Resident's butt was caught in wheelchair because lift stopped working, but was high enough in the air that she was laying almost flat. Her legs are stiff and straight and do not bend at the knee. Both legs were stretched out about mid-thigh past the main part of Hoyer on other side. So I had to first get resident clear from wheelchair so I tilted wheelchair forward. This gave enough clearance for resident's butt to be unstuck from chair. That fixed first problem. Now resident is in the air with both legs stuck on the lift, one on one side and one on the other side..." (The other side of the written report was missing.) CNA #2 wrote on [DATE] that CNA #1 "started to turn res, heard res leg pop. Reported to nurse ASAP (as soon as possible), found out res has fractured leg." CNA #3 wrote on [DATE] that she "was present in the room (number) when resident was transferred by lift to her bed. The lift's batteries went dead and the resident was hanging in mid air between her wheelchair and the lift. (CNA #4) came to get me off of hall two and asked for my help. I was orienting (CNA #1) at this time. -As I got into the room I noticed resident hanging in the middle of the air a foot and a half off the wheelchair. (CNA #1) went ahead and removed the wheelchair and proceeded to get resident into bed. (CNA #2) pulled back on the sling, I turned to grab wipes and all of a sudden I heard resident yelling ouch. I turned around and resident was already turned around to where she was sideways but she was also saying she was in a lot of pain. -I asked what happened and (CNAs #1 and #2) both told me they heard a loud pop. We got resident into bed and asked the resident what was wrong. Resident told us her leg hurt, I can't remember who told the nurse first, but I did tell her a few moments later what happened and that she was in a lot of pain." CNA #4 wrote on [DATE] that she was "present in room (number) when the event occurred. That evening myself and (CNA #2) went into the room to put resident to bed. The first lift (the one with the scale on it) all the batteries were dead. So we switched to the other lift which is the regular lift. -We got (resident #1) strapped in and went to use it and it only went up so far and it got stuck between mid air and her wheelchair. So I told (CNA #2) we needed help, so I went to go get (CNAs #3 and #1). We got back, (CNA #1) removed the wheelchair out beneath resident. At this point (CNAs #2 and #1) had her under control and I turned around to get the bed ready and lowered it. -In the process of doing this I heard resident yell ouch. I turned around and say what's wrong. (CNAs #1 and #2) had her turned and both said they heard a pop. Both (CNA #3) and I did not hear anything until we heard her yell ouch. From that point on we got her in bed, got her comfortable and told the nurse right away." The above statements were not timely obtained. In addition, there was no evidence of a review by therapy of the CNAs' actions and whether, under the circumstances, they were appropriate. Moreover, there was no investigation why the batteries were not working on the lift and when the batteries had last been checked and would be checked in the future. b. Failure to take timely steps to prevent future incidents with mechanical transfers of resident #1. (1) Failure to provide timely and adequate staff training on mechanical lift transfers Training documentation revealed that following resident #1's injury during transfer [DATE], she was to be a three-person transfer. Specifically: The DON provided inservice documentation, dated "Oct-[DATE]" upon request on the afternoon of [DATE]. When asked, she said the training was provided "starting [DATE] and ongoing." The training curriculum read: "Inservice for (Resident #1) Transfers and Bed Mobility: 1. Hoyer Lift transfers with long sling 2. One CNA to stabilize affected leg 3. One CNA to maneuver resident 4. One CNA to control Hoyer lift 5. All CNAs will lift from angle so that feet away from the bar 1. Leg brace to be worn at all times, excluding showers 2. With pillows between legs and log rolling from side to side 3. Inform nurse if verbal or non-verbal signs of pain are observed Batteries: Make sure that batteries are secured on base of charger and charging light illuminated. Ensure that batteries are fully charged prior to use." -The DON provided sign-in sheets for the 19 nursing staff in attendance at the above training. There were no signatures for CNAs #1, #2, #3 or #4 on the attendance list. -Interviews with CNA #2 and CNA #3 confirmed they had not received training following the incident and did not transfer resident #1 with three staff. Specifically: CNA #2, during her interview on [DATE] at 6:50 p.m. said, "No follow-up training was provided after that on how to transfer (resident #1) ... When I reposition her I have a pillow in between her legs and try to roll her without moving that leg ... We roll her and immobilize her leg with two people. There are only two (CNAs) on the night shift, (CNA #1) and me and one nurse. It's hard ... No extra training was provided since she hurt her leg, no. As far as I know, yes, they're the same old Hoyer's ..." CNA #3, during her interview on [DATE] at 1 p.m. said, "They've never showed us how to transfer (resident #1) ... We (she and CNA #4) work graveyards and they always have meetings at every paycheck on Fridays. (CNA #4) and I work Friday, Saturday, Sunday night shift. We try to sleep as late as we can, so we don't make Friday meetings. They haven't come out at night to provide training for us." -The CNA said she was told to transfer resident #1 "sideways," but she and CNA #4 told them they would not do that because it wasn't safe. -The CNA said, "They just showed us, told us 'you're supposed to transfer (sideways)' and that's it. I've been a CNA for over ten years ... and I told them, 'You can't transfer sideways because of safety issues.' There was no follow-up ... Somebody should come in to the night shift to show us who can't go to meetings, how to transfer certain people ... They need to get something better in there to lift the lady ... -The CNA said, "We're supposed to have three people in there at all times to get her up in the lift and we've been told not to get her up or down with the Hoyer at night anyway. We only have two CNAs at night and the nurse. The nurse doesn't help because she's all by herself and has to pass meds. (CNA #4) and I take a draw sheet turn her with the draw sheet. We stabilize her leg with the sheet." -The CNA said the facility needed a better system to ensure the facility had working batteries. She added that she would be happy to get training on the new lift, but "it hasn't been offered yet." The therapy director was interviewed on [DATE] at 4 p.m. and said therapy staff had not been asked to do training on Hoyer transfers or turning and repositioning resident #1 but would be happy to do so. The therapy director said they would need two or three people to transfer resident #1 with a Hoyer. She said she was not aware of the resident's fracture and how she received it, but added, that kind of injury "would take a lot of force." (2) Fall/accident risk assessment failures The [DATE] fall risk assessment identified the resident at high risk for falls, with a score of 32 (more than ten indicated high risk) due to: vision and hearing impairments, non-ambulatory status, unsteady balance, taking three or four medications that could increase fall risk, and weakened strength in right hand. -Interventions were noted as follows: "Resident is at risk for falls secondary to recent fx (fracture) of left femur while being lifted in mechanical lift. Resident uses grab bars to turn and reposition herself with support from staff due to her weakness. Bed is in lowest position and call light is within reach. Able to make needs known and taking MS (morphine sulfate) ER (extended release) 45 mg BID (twice daily) and PRN (as needed), Hydrocodone ,[DATE] for pain as well as Xanax 0.5 mg TID (three times daily) PRN anxiety all of which increases her fall risk. We will continue to support and monitor resident and consult with MD/PA (medical doctor/physician assistant) for changes in care as needed." The Hoyer accident occurred on [DATE], but the updated fall risk assessment was not completed until [DATE], two weeks later. (3) Care plan failures Review of the [DATE] care plan "risk for fall r/t immobility," (see above) revealed the care plan was not updated with fall or accident prevention measures after the resident's injury during a Hoyer transfer on [DATE]. No nursing or therapy assessment or staff training and return demonstration were included in the care plan. There was no care plan for how the resident should be positioned in the Hoyer lift or how she should be turned and repositioned to ensure safety and comfort. Review of the care plan dated [DATE] "use of a Hoyer as a transfer aid," (see above) revealed it was not updated to include three-plus person transfers in the Hoyer after the resident's fracture (see in-service training above). Review of the resident's care plan revealed an [DATE] care plan that identified "potential for decline in present level of function related to fracture to left femur." The goal was no decline in level of function through next review, and tolerable pain level. Approaches were: "I will wear a brace to immobilize my left leg. I require assistance to apply brace to left leg daily. I will be assessed for pain and provided with pain control as needed. New Hoyer batteries will be used when transferring." This care plan was not developed until one month after the resident's injury and no system was noted for ensuring batteries were available. Further, there was no care plan for how to ensure the resident was safe and pain was managed during turning, repositioning and transfers after the injury. Review of the [DATE] care plan "assistance with ADLs r/t immobility," (see above) revealed the only care plan update, on ,[DATE], noted a left upper arm contracture with an approach to apply splint as tolerated. Although the resident required three-plus person assist with Hoyer transfers after her fracture, this care plan was not updated, nor were instructions provided on how to reposition the resident to keep her fractured leg immobile. 6. Staff interviews (1) The DON was interviewed on [DATE] at 1:30 p.m. She said the facility had ordered a new Hoyer lift, which arrived Tuesday or Wednesday. She said she had conducted one-on-one training for the staff members involved, and would provide documentation and sign-in sheets for additional staff training provided. She said they had instructed staff on "turning (resident #1) to an angle rather than the bar being between her legs. I think the staff didn't put the battery on the battery pack correctly. We trained all staff on changing batteries and transferring with the Hoyer." She said, "I feel we're managing her well and doing the best we can. She has a [DIAGNOSES REDACTED].#1) feels horrible about it." She said that for training on the new Hoyer lift which arrived this week, "I'll be there, the therapist will be there, and as much staff as needed for training purposes." (2) On [DATE] at approximately 2 p.m., the NHA wheeled the new Hoyer lift into the DON's office. CNA #5 entered the room to demonstrate how the Hoyer could be used to safely lift resident #1, and that the lift had higher clearance than the older Hoyer lifts used in the facility. The NHA and DON said the Hoyer would not be used until staff training was provided.