Every finding on record at Good Samaritan - Loveland Village

Based on record review and interviews, the facility failed to protect one (#3) of three residents reviewed for abuse out of eight sample residents. Specifically, the facility failed to ensure Resident #3 was kept free from physical abuse from Resident #2. Findings include:I. Facility policy and procedureThe Abuse and Neglect policy and procedure, revised 4/7/25, was provided by the nursing home administrator (NHA) of the campus on 4/2/26 at 12:03 p.m. It read in pertinent part, The resident/client has the right to be free from abuse, neglect, misappropriation of resident/client property and exploitation. Residents/clients must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents/clients, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals. II. Incident of physical abuse between Resident #3 and Resident #2 on 2/14/26A. Facility investigationThe 2/14/26 abuse investigation documented there was a physical altercation between two residents (Resident #2 and Resident #3). The residents were separated and assessed. Resident #3 had discoloration on her hands. Resident #2, Resident #3 and other resident witnesses were interviewed. Resident #2 and Resident #3 were placed on hourly checks. Resident #3 was interviewed on 2/14/26. Resident #3 said Resident #2 told her there was not enough room for her at the table. Resident #3 said Resident #2 shook his fists at Resident #3. Resident #3 said Resident #2 said just try it, just do it. Resident #3 said Resident #2 grabbed her hands and squeezed them for about two minutes. Resident #3 reported left hand pain of 7 out of 10. She said it felt like pinched nerve pain and shocks going up and down. Resident #3 stated she was not fearful of Resident #2 and that she wanted to go after him. Resident #3 thought Resident #2's actions were purposeful and he was a grouchy old man. Resident #3 stated Resident #2 meant to hurt her. The investigation documented Resident #3 was educated to always inform staff of any event or if she was uncomfortable in any situation. Resident #2 was interviewed on 2/14/26. Resident #2 stated that Resident #3 was crowding his space and there was not enough room for her. Resident #2 stated Resident #3 was not supposed to be there unless welcomed there. Resident #2 reported Resident #3 grabbed his hands and he grabbed Resident #3's hands. He said he could not remember who grabbed whose hands first. Resident #2 stated it was a little scuff. Resident #2 denied any pain or discomfort and did not think Resident #3 had pain or discomfort that he knew of. Resident #2 stated that he tried to get away and that there was a reason for everything. The investigation documented Resident #2 was educated to use communication and to notify staff of concerning events. The investigation documented Resident #8 was interviewed on 2/14/26. Resident #8 said Resident #2 and Resident #3 were goofing off. Resident #8 stated that Resident #2 took it to another level and got mad. Resident #8 stated Resident #2 grabbed Resident #3's left hand and twisted it using his other hand also. Resident #8 stated Resident #2 looked like he was going to punch Resident #3. Resident #8 stated that Resident #2 took it too far and there was not much conversation but just physical contact. Resident #8 stated Resident #2 was trying to show off his mighty man strength. Resident #8 reported Resident #3 laughed at him and that it was all Resident #2's doing. Resident #8 reported that he should have stopped it. Three nurses and five certified nurse aides (CNA) that were working on 2/14/26 were interviewed and nobody had witnessed the altercation. The investigation documented physical contact occurring between the two residents was substantiated. It was determined that it was a spontaneous conflict between both residents which was not predictable to occur and then escalated. It was determined to be an isolated incident and there were no threatening behaviors noted from these residents toward each other in the past. III. Resident #3 - victim A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included schizoaffective disorder (bipolar type), anxiety and depressive episodes. The 12/31/25 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. She was independent with activities of daily living (ADL) and mobility and required one-person assistance for showering. The MDS assessment documented no behaviors for Resident #3. B. Resident interviewResident #3 was interviewed on 4/1/26 at 1:20 p.m. Resident #3 said Resident #2 and Resident #8 were sitting in the common area together at a table. She said she went up to them because she wanted to talk with Resident #8. She said Resident #2 started to shake his fists at her and said there was not enough room for her. She said to Resident #2 to go ahead and try it. She said Resident #2 grabbed her hands and started squeezing them hard. She said he finally let go. She said one of the CNAs had seen it and reported it to her nurse. She said three of her fingers went numb and it took a couple weeks to get the feeling back in them. She said she was wearing a ring on one of her fingers and it dug into her hand. She said she tried to report it to her nurse and the nurse had told her she already knew about it from the CNAs report and would not let her report it to the nurse. She said the social worker came in the following Monday and Resident #3 had reported to her that she wanted to file a restraining order against Resident #2. She said the social services worker had said it was not worth them coming out for. Resident #3 said another nurse had told her to stay away from Resident #2. She said she tried to stay away from Resident #2 in the hallway and common areas. She said Resident #2 used to sit at her table prior to the incident and he would sometimes sass her and call her names, which she reported to staff. C. Record reviewThe mental health care plan, initiated on 2/17/26, revealed Resident #3 had diagnoses of bipolar disorder and schizoaffective disorder. The care plan documented the resident had poor self-awareness and boundaries and could be intrusive with others leading to frustration among peers. Interventions included removing the resident to a calm, safe environment and allowing the resident to vent/share feelings (initiated 2/17/26), observing for stressors which may be early warning signs of problem behavior (initiated 2/17/26), providing the resident with as many choices as possible which gives control over the resident's environment and care delivery (initiated 2/17/26), consulting with pastoral care and psychologist (initiated 2/17/26), assisting with identifying healthy/appropriate boundaries with peers (initiated 2/17/26) and monitoring interactions with peers and assist in redirecting and de-escalating as needed (initiated 2/17/26). The interdisciplinary team (IDT) note, dated 2/14/26, documented that the IDT reviewed the incident from 2/14/26 from 4:30 p.m. It documented a potential abuse or injury of unknown source. It documented that Resident #3's left hand was squeezed hard by another resident (Resident #2). Resident #3 sat too close to Resident #2 and Resident #2 was not okay with Resident #3 being so close and squeezed her hand. The staff ensured both residents were kept separate and that both residents were safe. Resident #3's family/responsible party and the physician were notified of the incident. A trauma assessment completed on 2/17/26 documented that Resident #3 was still feeling really upset about how Resident #2 treated her. Resident #3 stated she had bruising on her finger and three of her fingers were still tingling. A skin assessment completed on 2/22/26 documented that Resident #3 had resolving bruising to the back of both hands. IV. Resident #2 - assailant A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included chronic venous insufficiency, osteoarthritis, type 2 diabetes and mild cognitive impairment of uncertain or unknown etiology. The 12/31/25 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. He required one assist with mobility and ADLs. The assessment documented that he had no behaviors. B. Observations and resident interviewOn 4/1/26 at 1:50 p.m. Resident #2 was sitting in his wheelchair in the common area next to a side table. He was moved into his room and interviewed. Resident #2 said he did not get along with Resident #3 because she was obnoxious. He said he remembered the incident with Resident #3 a couple months ago. He said Resident #3 was trying to get between him and another resident that he was talking with. He said he cleared it up and got her out of the way. He said he wanted her to know he was in control and that was why he squeezed her hands. He said he did not remember who grabbed whose hands first. C. Record reviewThe care plan, initiated 1/16/24 and revised 2/17/26, documented Resident #2 had behavior symptoms related to advanced aging, poor impulse control, diminished filter based on antagonist behaviors toward his roommates and peers, verbal and physical aggression, argumentative, egging on of others and frequent complaints about others. Pertinent interventions included intervening as necessary to protect the rights and safety of others (initiated 8/9/24), providing opportunity for positive interaction (initiated 8/9/24), educating and assisting the resident to develop more appropriate methods of coping and interacting such as removing himself from the situation when frustrated and seeking assistance from staff to resolve conflicts with peers (initiated 2/17/26), monitoring the resident's interactions with peers, redirect, deescalate and separate from peers as needed (initiated 2/17/26), discussing the resident's behaviors if reasonable (initiated 2/17/26), praising any indication of his progress (initiated 8/9/26) and monitoring him during the shift for sexually inappropriate behaviors (initiated 1/16/24). V. Additional resident interviews Resident #8 was interviewed on 4/1/25 at 1:35 p.m. He said himself and Resident #2 were sitting next to each other at a table in the common area. He said Resident #3 came up to them and Resident #3 and Resident #2 exchanged a few words. He said Resident #2 had Resident #3's hand and he squeezed her hand. He said Resident #2 looked really mad and he looked like he wanted to hurt Resident #3. Resident #8 said to let her go and Resident #2 let go. He said it caused an injury to Resident #3's hand and that she was wearing a ring that dug into her hand. He said a staff member came and talked to him about what happened but he did not remember who it was. He said Resident #2 had a habit of grabbing mostly women's hands as they walked by him and holding their hand. He said sometimes the women would have to shake their hands to get them away from Resident #2. VI. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/1/26 at 2:05 p.m. RN #1 said she was the nurse working the day of the physical altercation between Resident #2 and Resident #3. RN #1 said Resident #2 had a usual spot where he preferred to sit in the common area that was next to a small table. RN #1 said a CNA had asked RN #1 if she had heard about what happened between Resident #2 and Resident #3 and told RN #1 about what she had heard. RN #1 said she made sure the two residents were separated and safe. She said an activities assistant had rearranged the common area furniture so that the table near where Resident #2 usually sat, was moved. She said she moved the furniture back in its place. She said a while back, Resident #2 was involved in another physical altercation in which she noticed the tables had been moved out of place. She said she moved them back into place if she noticed them being out of place and tried to keep others from getting too close to Resident #2. She said she talked to the director of nursing (DON) about this trigger for Resident #2. CNA #1 was interviewed on 4/2/26 at 8:40 a.m. CNA #1 said Resident #2 could be possessive of things he believed were his. She said an example of this was that he got possessive of the newspaper each day thinking that it belonged to him and would get upset if someone tried to take it. She said he preferred to sit in his usual spot in the living room in the corner next to the table. She said he liked to grab women's hands as they walked by him and hold their hand. She said Resident #3 did not really come out to the common area much. She said Resident #3 was independent with most things and would call staff if she needed assistance.The DON, the nurse manager, NHA of the campus and the social services director (SSD) were interviewed together on 4/2/26 at 1:25 p.m. The DON said a couple years ago Resident #2 had a history of sexual behavior with a roommate. She said he liked to sit in the common area and talk with people. She said Resident #3 had squeezed herself between Resident #2 and Resident #8 at a small round table where they were sitting. She said the root cause of the incident was due to Resident #3 wanting to sit next to Resident #8. The nurse manager said Resident #2 and Resident #3 were educated to tell staff to help them if they were uncomfortable and they made sure the residents were separated. She said the SSD checked in on them periodically after the incident. She said Resident #3 had a small bruise to her finger. The SSD said she reported the incident between Resident #2 and Resident #3 to the police, adult protective services (APS) and the state initially. She said when she checked in with Resident #3 and completed her trauma assessment a couple days after the incident, Resident #3 was scared of Resident #2 and avoided him in the common areas. She said she offered support through her psychologist and said Resident #3 had a lot of good peer support. She said when she checked in with Resident #2, he said he did not know why everyone was making a big deal about it. She said even though Resident #2 did not have a diagnosis of dementia, his memory ebbed and flowed but at the time of the incident, he acknowledged that it happened.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#1) of three residents reviewed for neglect out of eight sample residents.Specifically, facility staff failed to report an allegation of injury of an unknown origin to the facility's abuse coordinator and the State Agency. Findings include: I. Facility policy and procedureThe Abuse and Neglect policy and procedure, revised [DATE], was provided by the nursing home administrator (NHA) of the campus on [DATE] at 12:03 p.m. It read in pertinent part, The purpose is to ensure that all identified events of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. The program coordinator, charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. If applicable, Adult Protective Services will be notified where state law provides for jurisdiction in long-term care centers. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency within five working days of the event, or sooner as designated by state law. If the alleged or suspected violation is verified, appropriate corrective action will be taken.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and expired on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, dysphagia (difficulty swallowing) and anxiety. The [DATE] minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She required maximal assistance with toileting and dressing and moderate assistance with mobility. B. Record review A nursing progress note, dated [DATE], documented that Resident #1 complained of right leg pain. A nursing note, dated [DATE], documented that Resident #1 was yelling out, had a furrowed brow and was complaining of left hip pain. It documented that as needed (PRN) Tylenol and aspercreme with Lidocaine was administered. A review of Resident 1's hospice notes from [DATE] revealed that Resident #1's nurse called the hospice nurse to notify her of Resident #1's increase in pain in her left hip that radiated down to her groin. There was a new physician's order for morphine placed at this time. A review of Resident 1's hospice notes from [DATE] revealed that Resident #1 had a noticeable outward rotation of her right leg and when asked if she was in pain, she stated no. When the nurse initiated inward rotation of the right leg, Resident #1 winced and grimaced and had noticeable non-verbal signs of pain. It documented that Resident #1 had not been out of bed in about a week and that Resident #1 had pain with cares and rolling in bed and the facility staff were pre-medicating with morphine prior to care. Review of the State Agency reporting portal did not indicate the facility reported Resident #1's injury of unknown origin. III. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on [DATE] at 4:35 p.m. LPN #3 said Resident #1 had dementia and would sundown in the evening. LPN #3 said Resident #1 would get up and walk with one-person assistance and her walker. She said she never complained of pain. LPN #3 said around the beginning of February 2025, Resident #1 had stopped getting out of bed and complained of pain in her left side. Certified nurse aide (CNA) #2 was interviewed on [DATE] at 4:40 p.m. CNA #2 said Resident #1 was slightly confused, but pleasant. CNA #2 said Resident #1 walked and would often get up and try to do things on her own, although she required one-person assistance. She said if Resident #1 needed something, instead of using her call light, she would scream out for help. CNA #2 said she heard about a potential fall Resident #1 had in February 2026. CNA #2 said after that potential fall when she was working with Resident #1, she tried to get her up and Resident #1 heavily favored her right side and CNA #2 had to help support Resident #1's left side because it was so weak. CNA #2 said Resident #1 screamed out in pain and complained of pain in her left hip and leg after the incident of a potential fall. CNA #2 said she told the nurse when Resident #1 was experiencing pain. -Review of the resident's electronic medical record (EMR) revealed documentation that the resident had pain in her left and right leg. CNA #3 was interviewed on [DATE] at 4:50 p.m. CNA #3 said Resident #1 was very confused and thought she could do things by herself. CNA #3 said Resident #1 required assistance for activities of daily living. She said she walked with her walker and supervision from staff. CNA #3 said she had heard about a potential fall and noticed after that incident, Resident #1 experienced a lot of pain. CNA #3 said she could tell by the grimace on her face at all times. CNA #3 said Resident #1 would try to sit up in bed but it would hurt too badly. CNA #3 said she did not see Resident #1 get out of bed once she started having the pain. CNA #3 said she would tell the nurse right away when she saw Resident #1 was in pain. The DON, the nurse manager and the NHA of the campus were interviewed together on [DATE] at 1:25 p.m. The NHA said the steps taken when investigating an incident included ensuring resident safety, notifying the appropriate people (physician, management, resident representative), reporting the incident, calling the police, interviewing all the staff members that were working that shift, interviewing both cognitively intact residents and residents not cognitively intact that were in similar situations, meeting up again as an interdisciplinary team to talk through what had been found and determining what changes had to be made. She said if there was education required, they provided that and figured out whether they could substantiate it. She said they documented interviews, notification to ombudsman, family, physician, police and adult protective services if needed. She said some incidents required a safe event (incident report) and this included finding a root cause for the incident.

Based on record review and interviews, the facility failed to notify the resident's provider about a change in condition. Specifically, the facility failed to ensure staff reported a change in condition to the resident's provider for Resident #1.Findings include: I. Facility policy and procedureThe Interact-Change in Condition Evaluation policy, revised [DATE], was provided by the nursing home administrator (NHA) of the campus on [DATE] at 12:58 p.m. It revealed in pertinent part, Before completing a change in condition evaluation , review the resident's medical record including diagnosis, medications, recent progress notes from a medical doctor/nurse practitioner/physician's assistant (MD/NP/PA) and consultants, as well as the most recent interdisciplinary notes. Check with other staff members who have regular contact with the resident to obtain an accurate picture of the change in condition. Staff members who can provide useful information about the situation include the nursing assistants, rehabilitation staff members, social workers and activity staff members. Environmental staff members may be able to provide useful information about the situation, as well as others such as family members, visitors, chaplains and beauticians. Review advance directives if available. A conversation with a family member or healthcare proxy may be needed to clarify advance directives.As the Change in Condition Evaluation is completed, questions will appear based on information entered. The INTERACT Care Paths and Change in Condition File Cards have been incorporated into the Change in Condition Evaluation. These decision support tools are designed to assist in evaluating the resident's condition, collecting information that will allow and will help the provider/practitioner to make the best possible decision regarding the resident's condition.Notify the provider of the change in condition as indicated by the Notifications hyperlink.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and expired on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, dysphagia (difficulty swallowing) and anxiety. The [DATE] minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) score of five out of 15. She required maximal assistance with toileting and dressing and moderate assistance with mobility. C. Record reviewA nursing progress note on [DATE] documented that Resident #1 complained of right leg pain. A nursing note on [DATE] documented that Resident #1 was yelling out, had a furrowed brow and was complaining of left hip pain. It documented that as needed (PRN) Tylenol and aspercreme with Lidocaine was administered. A review of Resident 1's hospice notes from [DATE] documented that Resident #1's nurse called the hospice nurse to notify her of Resident #1's increase in pain in her left hip that radiated down to her groin. There was a new order of morphine placed at this time. A review of Resident 1's hospice notes from [DATE] documented that Resident #1 had a noticeable outward rotation of her right leg and when asked if she was in pain, she stated no. When the nurse initiated inward rotation of the right leg, Resident #1 winced and grimaced and had noticeable non-verbal signs of pain. It documented that Resident #1 had not been out of bed in about a week and that Resident #1 had pain with cares and rolling in bed and the facility staff were pre-medicating with morphine prior to care. -However, there was no documentation that the facility contacted Resident #1's physician regarding the increase in pain. D. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on [DATE] at 4:35 p.m. She said Resident #1 had dementia and would sundown (increased confusion) in the evening. LPN #3 said Resident #1 would get up and walk with one assist and her walker. She said she never complained of pain. LPN #3 said around the beginning of February 2026, Resident #1 had stopped getting out of bed and complained of pain in her left side. -However, review of Resident #1's electronic medical record (EMR) did not reveal documentation indicating the physician was notified that the resident was not getting out of bed as often due to the increased pain.Certified nursing aide (CNA) #2 was interviewed on [DATE] at 4:40 p.m. She said Resident #1 was slightly confused, but pleasant. CNA #2 said Resident #1 walked and would often get up and try to do things on her own, although she required one assist. She said if Resident #1 needed something, instead of using her call light, she would scream out for help. CNA #2 said she heard about a potential fall Resident #1 had in February 2026. CNA #2 said after that potential fall when she was working with Resident #1, she tried to get her up and Resident #1 heavily favored her right side and CNA #2 had to help support Resident #1's left side because it was so weak. CNA #2 said Resident #1 screamed out in pain and complained of pain in her left hip and leg after the incident of a potential fall. CNA #2 said she would tell the nurse when Resident #1 was experiencing pain. CNA #3 was interviewed on [DATE] at 4:50 p.m. She said Resident #1 was very confused and thought she could do things by herself. CNA #3 said Resident #1 required assistance for activities of daily living. She said she walked with her walker and supervision from staff. CNA #3 said Resident #1 needed encouragement to eat her meals. CNA #3 said she had heard about a potential fall and noticed after that incident, Resident #1 experienced a lot of pain. CNA #3 said she could tell by the grimace on her face at all times. CNA #3 said Resident #1 would try to sit up in bed but it would hurt too badly. CNA #3 said she did not see Resident #1 get out of bed once she started having the pain. CNA #3 said she told the nurse right away when she saw Resident #1 was in pain. -Review of the resident's EMR revealed documentation that the resident had pain in her left and right leg. The DON, the nurse manager and the NHA of the campus were interviewed on [DATE] at 1:25 p.m. The DON said the steps taken when a resident falls included assessing the resident, notifying the provider, notifying the resident representative, hospice agency if applicable, and management, complete neurological checks, create a safe event (incident report), huddle with the CNAs working and create an intervention and follow any additional orders from the provider. She said the interdisciplinary team (IDT) reviewed it the next day and changed the intervention if needed. The nurse manager said they reviewed the fall as an IDT a week post fall to ensure the intervention was successful. The DON said when she was made aware of Resident #1 potentially having a fall. She said she mentioned it to the provider. -However, there was no documentation that the resident's physician was notified of an increase in pain.

Based on record review and interviews, the facility failed to notify the resident's representative about a change in condition. Specifically, the facility failed to ensure staff reported a change in condition to the resident representative for Resident #1.Findings include: I. Facility policy and procedureThe Interact-Change in Condition Evaluation policy, revised [DATE], was provided by the nursing home administrator (NHA) of the campus on [DATE] at 12:58 p.m. It revealed in pertinent part, Before completing a change in condition evaluation, review the resident's medical record including diagnosis, medications, recent progress notes from a medical doctor/nurse practitioner/physician's assistant (MD/NP/PA) and consultants, as well as the most recent interdisciplinary notes. Check with other staff members who have regular contact with the resident to obtain an accurate picture of the change in condition. Staff members who can provide useful information about the situation include the nursing assistants, rehabilitation staff members, social workers and activity staff members. Environmental staff members may be able to provide useful information about the situation, as well as others such as family members, visitors, chaplains and beauticians. Review advance directives if available. A conversation with a family member or healthcare proxy may be needed to clarify advance directives.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and expired on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, dysphagia (difficulty swallowing) and anxiety. The [DATE] minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) score of five out of 15. She required maximal assistance with toileting and dressing and moderate assistance with mobility. C. Record reviewA nursing progress note on [DATE] documented that Resident #1 complained of right leg pain. A nursing note on [DATE] documented that Resident #1 was yelling out, had a furrowed brow and was complaining of left hip pain. It documented that as needed (PRN) Tylenol and aspercreme with Lidocaine was administered. A review of Resident #1's hospice notes from [DATE] documented that the hospice provider added as needed morphine to Resident #1's plan of care and the hospice nurse spoke to Resident 1's daughter (representative). A review of Resident 1's hospice notes from [DATE] documented that Resident #1's nurse called the hospice nurse to notify her of Resident #1's increase in pain in her left hip that radiated down to her groin. There was a new order of morphine placed at this time. A review of Resident 1's hospice notes from [DATE] documented that Resident #1 had a noticeable outward rotation of her right leg and when asked if she was in pain, she stated no. When the nurse initiated inward rotation of the right leg, Resident #1 winced and grimaced and had noticeable non-verbal signs of pain. It documented that Resident #1 had not been out of bed in about a week and that Resident #1 had pain with cares and rolling in bed and the facility staff were pre-medicating with morphine prior to care. -However, review of Resident #1's electronic medical record (EMR) did not reveal documentation regarding the facility discussing the resident's increased pain or reviewing treatment decisions with the resident or her representative. D. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on [DATE] at 4:35 p.m. She said Resident #1 had dementia and would sundown (increased confusion) in the evening. LPN #3 said Resident #1 required one person assistance for walking with her walker. She said Resident #1 never complained of pain. LPN #3 said around the beginning of February 2026, Resident #1 stopped getting out of bed and complained of pain in her left side. Certified nurse aide (CNA) #2 was interviewed on [DATE] at 4:40 p.m. She said Resident #1 was slightly confused, but pleasant. CNA #2 said Resident #1 walked and would often get up and try to do things on her own, although she required one person to assist her. She said if Resident #1 needed something, instead of using her call light, she would scream out for help. CNA #2 said she heard about a potential fall Resident #1 had in February 2026. CNA #2 said after that potential fall when she was working with Resident #1, she tried to get her up and Resident #1 heavily favored her right side. She said CNA #2 had to help support Resident #1's left side because it was so weak. CNA #2 said Resident #1 screamed out in pain and complained of pain in her left hip and leg after the incident of a potential fall. CNA #2 said she would tell the nurse when Resident #1 was experiencing pain. CNA #3 was interviewed on [DATE] at 4:50 p.m. She said Resident #1 was very confused and thought she could do things by herself. CNA #3 said Resident #1 required assistance for activities of daily living. She said she walked with her walker and supervision from staff. CNA #3 said Resident #1 needed encouragement to eat her meals. CNA #3 said she had heard about a potential fall and noticed after that incident, Resident #1 experienced a lot of pain. CNA #3 said she could tell by the grimace on her face at all times. CNA #3 said Resident #1 would try to sit up in bed but it would hurt too badly. CNA #3 said she did not see Resident #1 get out of bed once she started having the pain. CNA #3 said she told the nurse right away when she saw Resident #1 was in pain. -Review of the resident's EMR revealed documentation that the resident had pain in her left and right leg. The DON, the nurse manager and the NHA of the campus were interviewed on [DATE] at 1:25 p.m. The DON said the steps taken when a resident falls included assessing the resident, notifying the provider, notifying the resident representative, hospice agency if applicable, and management, complete neurological checks, create a safe event (incident report), huddle with the CNAs working and create an intervention and follow any additional orders from the provider. She said the interdisciplinary team (IDT) reviewed it the next day and changed the intervention if needed. The nurse manager said they reviewed the fall as an IDT a week post fall to ensure the intervention was successful. The DON said when she was made aware of Resident #1 potentially having a fall, she mentioned it to the provider. She said Resident #1's representative was notified and offered to evaluate and treat the resident further. The DON said the representative declined. The DON said it was the responsibility of the hospice provider and the nurse at the facility to discuss who was going to contact the resident's representative and in this case the hospice nurse spoke to the representative when there was an increase in pain and morphine was needed. -However, there was no documentation that the resident's representative was notified of the resident's increase in pain.

Based on record review and interviews, the facility failed to ensure one (#108) of eight residents reviewed for accidents out of 35 sample residents remained free from accidents.Specifically, the facility failed to ensure staff consistently implemented fall interventions for Resident #108, which resulted in a fall with major injury.Resident #108 was admitted to the facility on [DATE] with diagnoses of severe obesity, pain in the right knee, muscle weakness, and a right lower extremity hematoma (a solid swelling of clotted blood within the tissue) sustained prior to admission to the facility due to a fall at home from rolling out of bed while asleep. Resident #108 had moderate cognitive impairments, per staff interview, and was at risk for falls related to obesity, right lower extremity hematoma and muscle weakness. Resident #108 required two to three staff members for maximum assistance to roll in bed.Resident #108 experienced an unwitnessed fall on 8/11/25 when staff failed to position a floor mat appropriately in front of the resident's bed, resulting in a traumatic subdural hemorrhage (a condition where blood leaks from damaged veins into the brain) with loss of consciousness.During the facility's investigation of the fall, it was discovered that the floor mat was not positioned in front of the resident's bed, the resident's bed was not in a low position, and the resident was using a standard-size bed despite her body habitus. Staff failed to reposition the resident's fall mat after it had been removed to provide adequate space for the resident's care.Due to the facility's failure to ensure that staff adequately assessed the resident to obtain the proper bed size and to staff placement of a fall mat, Resident #108 sustained a fall on 8/11/25, which resulted in a subdural hemorrhage with loss of consciousness requiring immediate surgery. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 1/26/26 to 1/29/26, resulting in the deficiency being cited as past noncompliance, with a correction date of 8/15/25.I. Incident on 8/11/25On 8/11/25 at 9:30 p.m. staff moved Resident #108's extended sleep surface (floor mat) to provide care for the resident but failed to replace it afterward.At 11:00 p.m. a nurse rounded on Resident #108 and observed her sleeping. However, the nurse failed to notice or correct the missing floor mat.At 11:15 p.m. Resident #108 fell from the bed, hitting her head. The fall was discovered after another resident heard a noise and alerted the nurse.II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #108The corrective action plan implemented by the facility in response to Resident #108's fall on 8/11/25 was provided by the nursing home administrator (NHA) on 1/27/26 at 2:15 p.m.The plan read:On 8/12/25, the facility conducted an investigation of Resident #108's fall. The facility interviewed staff on duty who were involved in care for the resident on the day of the fall (8/11/25) and a few days prior to the fall.Review of Resident #108's admission assessment revealed the resident was provided a standard-size bed, and the fall mat was folded by the window and not in position (on 8/11/25). The staff failed to place the floor mat in front of the resident's bed after removing it to provide care to Resident #108.All interviewed staff on duty providing care for Resident #108 reported that the floor mat was not in place and the resident's bed was not lowered to the floor.The last interaction with the resident was reported around 8:06 p.m., about 3 (three) hours prior to the fall, when a certified nurse aide (CNA) reported that Resident #108 was hallucinating. The CNA reported the resident believed a lady was living in her closet.On 8/12/25, Resident #108's room was set up with additional fall precautions pending the resident's return (from the hospital), which included a bariatric bed, two extended sleep surfaces (floor mat) and an edge-defining mattress pad.On 8/14/25, all direct care staff who were working during the fall and cared for the resident were interviewed.Education was provided to all direct care staff who were involved the night of the resident's fall. (Date not provided).B. Identification of other residentsOn 8/11/25 the facility conducted a root cause analysis to identify other residents who may have been affected by the deficient practice.On 8/14/25 the facility completed four separate audits and identified other residents in the building who were at risk for falls. Ten identified residents were reviewed for appropriate fall interventions, and five of the 10 had the potential to be affected. Two of the five residents had already been discharged from the facility, but their care plans were not updated. The other three residents had their care plans updated on 8/15/25.A fall intervention equipment audit on residents who have had a fall in the last 30 days was completed.On 8/14/25, the initial audit identified 14 residents within the audit criteria who were potentially affected, with no action required.C. Systemic changesOn 8/12/25, education for admissions personnel on Pre-admission Data Collection was completed, and a verbal check was added with the director of nursing (DON) for high-risk admissions to the admission checklist.The interdisciplinary team (IDT) re-educated staff on SAFE: Speaking up for safety, along with examples of how to escalate safety concerns up the chain of command. Training completed on 8/15/25.Nurse management clinical educator re-educated licensed nurses on change of condition policy, SAFE: Speaking up for safety, baseline care plan policy, clinical alerts, and bariatric resource packet. Training completed on 8/15/25.D. MonitoringThe director of nursing (DON) or designee was responsible for completing monthly audits times two, quarterly audits times three, and as needed thereafter.The report summarizing the audit findings was to be completed and forwarded to the Quality Assurance Performance Improvement (QAPI) Committee.The QAPI Report Out was to be reviewed by the QAPI Committee for compliance and trends, and to make additional recommendations as needed to support continued improvement.The facility would be in substantial compliance by 8/15/25.Interviews and record reviews during the investigation revealed corrective actions to identify the resident and other residents who may have been affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place at the time of the survey from 1/26/26 to 1/29/26.III. Facility policy and procedureThe Fall Prevention and Management- Rehab/Skilled, Therapy & Rehab (rehabilitation) policy, revised 10/14/25, was provided by director of nursing (DON) #1 on 1/29/26 at 1:50 p.m. It read in pertinent part, The policy's purpose is to promote resident well-being by developing and implementing a fall prevention and management program, to identify risk factors and implement interventions before a fall occurs, to give prompt treatment after a fall occurs, and to provide guidance for documentation. On admission or readmission, review the applicable documents (discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors.IV. Resident #108A. Resident statusResident #108, age greater than 65, was admitted on [DATE] and discharged to the hospital on 8/11/25. According to the August 2025 computerized physician orders (CPO), diagnoses included muscle weakness, pancytopenia (a serious blood disorder defined by a simultaneous, significant reduction in all three major blood cell types), severe obesity and pain in the right knee.The 8/11/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required maximum assistance from staff with mobility, moderate assistance with personal hygiene and setup assistance with eating.B. Record reviewResident #108's fall care plan, initiated 8/9/25 and revised 8/21/25, revealed the resident was at risk for falls. It documented Resident #108 was hospitalized prior to admission for rolling out of bed while asleep with self-reported head injury, weakness, impaired mobility, balance, endurance and safety awareness. Interventions included reviewing the resident's medical record for medications or a combination of medications that could increase fall risk, reviewing the status of any medical conditions that predisposed the resident to falls or that could increase the risk of injury from falls.According to the facility's fall incident report, dated 8/11/25, Resident #108, who required total assistance for all mobility and had been assessed as a low risk for falls, was found lying face down on the floor next to her bed on 8/11/25 at 11:15 p.m. Earlier that evening, staff provided care at 9:30 p.m. and had moved her extended sleep surface (floor mat), but failed to put it back in place. At 11:00 p.m., the nurse had rounded on the resident and observed her sleeping in bed, but did not notice the missing sleep surface (floor mat).At 11:15 p.m., the resident fell out of bed, hitting her head. She was wearing a CPAP at the time of the fall, which had caused a seven-inch indentation on the right side of her face. She also sustained facial swelling and a right subdural hemorrhage.The fall was discovered when another resident had heard a noise and alerted the nurse.According to the hospital Discharge summary, dated [DATE], Resident #108 was admitted to the hospital on [DATE] after a fall at a long-term care facility. She was diagnosed with traumatic brain injury and soft tissue hematoma. The resident did not return to the facility.V. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 1/27/26 at 4:08 p.m. LPN #4 said a resident with a history of falls should be rated as a high fall risk until proven otherwise. She said it was the nursing staff's responsibility to ensure that all safety equipment was in place to prevent accidents. LPN #4 said she was re-educated about fall prevention.Registered nurse (RN) #2 was interviewed on 1/29/26 at 9:20 a.m. RN #2 said it was the responsibility of every admissions nurse to ensure all safety precautions and equipment were available to the resident upon admission. RN #2 said a resident with a history of recent falls would be assessed as high risk for falls for at least the first four weeks after admission to ensure their safety. She said the admission nurse should ensure the resident was assigned the appropriate bed size based on the assessment. RN #2 said she had received education on safe universal reliability skills.The DON #2 was interviewed on 1/28/26 at 5:00 p.m. The DON said Resident #108 had experienced a fall at home and had been hospitalized prior to admission. He said Resident #108 was a high fall risk and was assessed as low risk upon admission to the facility. The DON said his investigation revealed staff on duty the night of the fall (8/11/25) failed to position the floor mat by the resident's bed. DON #2 said the facility staff should have provided a bariatric bed for the resident due to her size. He said he did not know why the staff failed to place the floor mat at the appropriate position. DON #2 said facility staff were all trained on safety measures and facility protocols.The nurse practitioner (NP) was interviewed on 1/28/26 at 4:40 p.m. The NP said Resident #108 was admitted to the facility on [DATE], but he did not meet the resident until 8/11/25, in the morning. The NP said during his assessment of Resident #108 on the morning of 8/11/25, the resident did not exhibit signs of distress or confusion. The NP said he did not recall being notified by staff of the resident's change in condition. He said blood pressure outside the normal parameters was considered a change in condition. The NP said the staff should have notified him earlier in the day of the resident's hallucinations and confusion and ensured the resident's floor mat was in place. The NP said he could not speak to the reason why the resident's floor mat was not in place. He said the floor mat being in place could have prevented or reduced the extent of the resident's injuries.The NHA and DON #1 were interviewed together on 1/29/26 at 5:40 p.m. The NHA said she was involved in the 8/11/25 fall investigation for Resident #108. The NHA said all fall incidents were reviewed by the interdisciplinary team (IDT). The NHA said the rounding nurse on 8/11/25 should have noticed that Resident #108's floor mat was not in place during her rounds, which could have prevented the resident's injury. She said education was provided to all nursing staff on the safety measures to prevent recurrence.DON #1 said the root cause analysis and the fall investigation revealed Resident #108 had her CPAP on, which might have caused the facial injuries. She said wearing a CPAP mask without supplemental oxygen could decrease oxygen saturation but could not say that the resident not having her CPAP on had contributed to the resident's fall.

Based on record review and interviews, the facility failed to prevent abuse for one (#44) of three residents reviewed for abuse out of three sample residents.Specifically, the facility failed to protect Resident #44 from mental abuse involving certified nurse aide (CNA) #4, CNA #5 and CNA #1. Findings include:I. Resident #44A. Resident statusResident #44, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes, obesity and foot drop (the inability to lift the front part of the foot due to weakness).The 12/31/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent upon staff for helping with lower body dressing. The resident used a manual wheelchair and was able to self-propel herself for mobility. B. Resident interviewResident #44 was interviewed on 1/29/26 at 9:54 a.m. Resident #44 said CNA #1 came into her room and asked her if she wanted to help her and CNAs #4 and #5 pull a prank on CNA #3. Resident #44 said she told CNA #1 it was okay. She said CNA #1 hid under Resident #44's bed with a blanket on top of her and waited for CNA #3 to come into the room so she could grab her ankle and scare her. She said CNA #4 was also present in the room, waiting for CNA #3. Resident #44 said CNA #4 put her phone up against the wall and began recording. Resident #44 said none of the CNAs asked her for her permission to set the phone up and record in her room. Resident #44 said the phone was angled toward her bed, while she was sitting in her wheelchair, off to the side of the room. Resident #44 said the phone screen was facing away from her so she could not see herself on the screen and could not tell what was being recorded. Resident #44 said CNA #3 came into her room and CNA #1 attempted to prank her by grabbing her ankle. Resident #44 said after the prank, the CNAs transferred her to her bed and started taking her shorts off when Resident #44 realized the phone was still set up. Resident #44 said she told CNA #4 that her phone was still set up. Resident #44 said CNA #4 apologized and started pushing buttons on her phone and then said Believe me, I don't want that on my phone anyway. Resident #44 said CNA #4 did not show her the phone or what was recorded. Resident #44 said it made her feel very uneasy. She said it bothered her because she did not know what had been filmed. She said she did not know if the video got posted online either.C. Record reviewResident #44's psychosocial care plan, initiated 9/10/25, revealed the resident had a psychosocial well-being deficit related to actual reliving of trauma related to a recent prank as evidenced by heart palpitations, feeling on guard and detached. Interventions included mental health counseling with a psychologist and avoiding discussing the traumatic event with or around the resident.A Trauma Assessment, dated 9/26/25 at 4:00 p.m. identified that in the past month, Resident #44 continued to be affected by her experience with staff members (prank video) earlier in the month. The document further identified that in the past month, Resident #44 was constantly on guard, watchful or was easily startled. It further identified that in the last month, Resident #44 had felt numb or detached from people, activities or her surroundings. The assessment identified that in the past month, Resident #44 had tried hard not to think about the incident and went out of her way to avoid situations that reminded her of the events. The assessment identified that Resident #44's trauma symptoms and triggers included interacting with certain staff members and hearing the event (prank video) discussed. The assessment additionally identified Resident #44's support and coping strategies and indicated Resident #44 began counseling services to help support her psychosocial needs and to help identify helpful coping mechanisms for reliving traumatic experiences. The assessment documented a trauma care plan was added to the resident's medical record.II. Staff interviewsCNA #1 was interviewed on 1/28/26 at 5:30 p.m. CNA #1 said she was part of the prank involving Resident #44 in September 2025. CNA #1 said there was no video taken of the resident, to her knowledge. CNA #1 said she did not discuss the phone with the resident as she was on the floor throughout the prank. CNA #1 said she had nothing to do with the phone. CNA #1 said the facility conducted an investigation into the incident and all CNAs were assigned education on patient privacy.CNA #4 was interviewed on 1/29/26 at 3:14 p.m. CNA #4 said she had worked at the facility for eight years and she was familiar with Resident #44. CNA #4 said she was involved in the prank video that occurred in September 2025. CNA #4 said she agreed to play a prank on CNA #3 with CNA #1 and CNA #5. CNA #4 said the goal of the prank was to scare CNA #3 when she came into the room. She said CNA #1 hid under the bed and was going to try to grab CNA #3's ankle. CNA #4 said Resident #44 wanted to be a part of the prank and was okay with the prank taking place in her room. CNA #4 said she set her cell phone up against the wall in Resident #44's room to record the prank on Snapchat, an app which limited recording time to two to three minutes and then stopped recording automatically. CNA #4 said she did not ask Resident #44 if it was okay to prop the phone up and record in the resident's room. CNA #4 said she did not ask Resident #44's permission because Resident #44 seemed happy to be a part of the prank, and the CNAs had a close relationship with the resident.CNA #4 said the phone was positioned up against the wall and was facing Resident #44's curtain and bed. CNA #4 said she recorded the video on Snapchat, which captured two to three minutes of video. CNA #4 said the recording only captured herself, standing by the bed and the curtain, waiting for CNA #3 to come into the room. CNA #4 said Resident #44 was not present in the video at any point in time. CNA #4 said it took about 10 minutes for CNA #3 to come into the room, and by that time the Snapchat video had automatically stopped after a limited two to three minutes. CNA #4 said CNA #3 finally came into Resident #44's room, saw CNA #1 hiding under the bed and the prank did not work. CNA #4 said once the prank was over, she un-propped her phone, deleted the video, and put her phone flat on the sink. CNA #4 said she told Resident #44 that she deleted the video before the CNAs began transferring Resident #44 back to her bed. CNA #4 said she told Resident #44 the video was deleted but did not show Resident #44 her phone.The campus administrator was interviewed on 1/29/26 at 4:45 p.m. The campus administrator said the CNAs should not have created the video in Resident #44's room. The campus administrator said management discussed the incident and reviewed the social media policy with the CNAs. The campus administrator said the CNAs were suspended pending investigation and they were all assigned online education on resident privacy. The campus administrator said all three CNAs had received a written discipline for the incident involving Resident #44.The nursing home administrator (NHA) was interviewed on 1/29/26 at 4:45 p.m. The NHA said CNA #1 was no longer allowed to work with Resident #44. Director of nursing (DON) #1 was interviewed on 1/29/26 at 4:45 p.m. DON #1 said the other CNAs (CNAs #3,#4, and #5) involved in the incident with Resident #44 were kept off of Resident #44's hallway as much as possible and were scheduled to work other hallways as much as possible.III. FACILITY FOLLOW-UPThe facility investigation was provided by the NHA on 1/27/25 at 4:02 p.m. The investigation documented an interview with Resident #44. It read, as follows, The resident indicated on September 5th, 2025 she turned on her call light as she was ready for bed. One of the CNAs came in and stated she wanted to pull a prank on another CNA by getting under the resident's bed and grabbing the ankle of the other CNA. The resident stated she didn't care if they played pranks and agreed to the prank. Another CNA came in while the first CNA got under the bed and was covered with a blanket. The second CNA propped up her phone by the resident's sink while the resident was still in her wheelchair. The resident stated the fourth CNA did not fall for the prank as she saw the blanked under her bed. The third CNA came into the room and the second and third CNAs placed the sling under her and transferred her into bed with the total lift that the fourth CNA subsequently brought in (the CNA who was having the prank played on). The CNAs were assisting with removing her [Resident #44] shorts and brief. The resident then told the second CNA to turn the phone off as she gave permission to the prank, but not permission to be recorded. The resident stated the second CNA told her she wouldn't want that on her phone. After the initial interview and obtaining the residents statement, the next day the resident went to the Director of Social Services office and stated she wanted to make sure none of the CNAs were fired. She stated she likes that the girls like to have fun at work,, she just wanted to make sure her butt was not all over social media.Interviews were completed with involved staff as well as other staff who may have had direct knowledge of the allegation. The investigation identified that most CNAs involved in the incident (CNA#1, #4, and #5) were suspended until the facility completed the investigation. The three CNAs involved in the incident received written corrective action for violating the facility's photography and video policy. The facility provided education regarding privacy and confidentiality to the CNAs involved and to all facility staff. The investigation identified that the facility required care in pairs (two people to perform care for the resident together) to ensure Resident #44 felt supported. The facility conducted a trauma assessment for Resident #44 and was offered counseling. The investigation indicated the resident remained at the facility and at her baseline with no lingering signs or symptoms of mental anguish or distress identified. The investigation indicated Resident #44 had been observed participating in her normal daily routine.The investigation conclusion identified the facility did not substantiate neglect of Resident #44's psychosocial wellbeing. The conclusion identified Resident #44 agreed to be part of the prank and laughed during that time. The resident only became concerned when she thought she was being recorded. The facility conclusion identified no recording of the resident occurred. The three CNAs did not intend to record the resident, post it on social media, or hurt the residents feelings in any way. The facility substantiated that the three CNAs violated the facilities' photography and video policy.A Resident Rights Violation documentation was provided by the NHA on 1/20/25 at 4:49 p.m. The document reads in pertinent part, A CNA put her cell phone on the sink facing the resident bed, the curtain between the two residents beds was pulled, the resident was in her wheelchair at the end of the bed. The video started while they waited for the CNA to answer the call light. The CNA they were waiting for did not come for several minutes. The video had stopped recording and the prank did not work, the CNA picked up her phone and x'ed out of the video (which does not save the video) and did not send the video to anyone. The video was not saved or sent from this incident, however the CNAs should never have attempted to video or take photos in a resident room even when the resident was not going to be in the video. It documented this was a violation of the resident's right to privacy as she did not give written consent. It was determined the recording that was deleted did not have the resident on the screen, instead it was of the bed with a CNA hiding under the bed with a blanket over them. This situation does not fall under abuse because there was never intent to demean or humiliate the resident, rather it was the staff playing a prank on the other staff member that the resident had asked to be a part of. The facility concluded the CNAs involved failed to follow the Policy for Resident Dignity under procedure 2 (m): Refraining from taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment, e.g., cameras, smart phones and other electronic devices, and or/keeping or distributing unauthorized photographs or recordings of residents through multi-media messages or on social media.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one of four units.Specifically, the facility failed to ensure enhanced barrier precautions (EBP) were followed during wound care for Resident #10.Findings include: I. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), (4/2/24), retrieved on 2/5/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO. Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing). II. Facility policy and procedure The Standard, Enhanced Barrier, and Transmission-Based Precautions policy, revised 7/7/25, was provided by director of nursing (DON) #1 on 1/29/26 at 1:50 p.m. It read in pertinent part, Enhanced Barrier Precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi drug-resistant organism (MDRO) to staff hands and clothing. EBP are also used for residents with wounds and residents with indwelling medical devices and during high-contact resident care activities, including transfers, dressing, assisting during bathing and providing hygiene. III. Observations During a continuous observation on 1/27/26, beginning at 4:08 p.m. and ending at 4:20 p.m., a sign was observed posted on Resident #10's doorframe which indicated the resident was on EBP. The sign indicated staff should wear a gown and gloves for high-contact care. Licensed practical nurse (LPN) #4 entered Resident #10's room to administer medication to the resident. LPN #4 said Resident #10 had a wound on her right heel and offered to show the wound's location. LPN #4 donned (put on) gloves and obtained the resident's permission to show where the wound was located. She held the resident's feet and removed a heel suspension boot from the resident's foot. LPN #4 removed the dressing on the resident's wound, touched the surface, and gently pressed on it. LPN #4 said the wound was opened, dried, and blanchable. She proceeded to reposition the resident's foot in the heel suspension boot, removed her gloves and returned to her cart. She returned to the room with a new dressing for the resident's wound. -LPN #4 failed to don a gown prior to touching Resident #10's wound. On 1/28/26 at 1:32 p.m. Resident #10's wound care was observed with the wound care nurse. The wound care nurse entered Resident #10's room and approached the resident who was in bed. She proceeded to remove the dressing from the wound on the resident's heel. The dressing was saturated with yellow drainage. The wound care nurse disposed of the dressing in the trash, removed her gloves and stepped out of the room. -The wound care nurse failed to put on a gown prior to removing Resident #10's soiled wound dressing. IV. Staff interviews LPN #4 was interviewed on 1/27/26 at 4:40 p.m. LPN #4 said Resident #10 was on EBP. She said EBP meant appropriate precautions should be taken when caring for the resident. LPN #4 said there was a sign by the resident's door frame alerting everyone to the precautions required when caring for the resident. LPN #4 said she should have worn a gown before she touched Resident #10's heel wound. The wound care nurse was interviewed on 1/28/26 at 3:33 p.m. The wound care nurse said she forgot to put on a gown before she removed Resident #10's dressing, but she was aware that the resident was on EBP. Certified nurse aide (CNA) #6 was interviewed on 1/29/26 at 9:20 a.m. CNA #6 said she was familiar with Resident #10. She said the facility's CNAs provided personal care, such as incontinence care and showers. CNA #6 said she did not know what the EBP sign on Resident #10's door frame meant. She said only gloves were required to provide incontinence care and showers for Resident #10. The infection preventionist (IP) was interviewed on 1/29/26 at 9:45 a.m. The IP said facility staff had been trained on all precautions. She said a gown and gloves were required for any care that would require staff to come into close contact with a resident on EBP. The IP said LPN #4 should have put on a gown prior to touching the resident's heel wound. She said CNA 6 should have known what the EBP sign meant and the precautions needed to care for Resident #10. She said she did not know why CNA #6 was unable to explain the meaning of the EBP sign. The IP said she would immediately initiate retraining for the staff involved. Director of nursing (DON) #1 was interviewed on 1/29/26 at 4:45 p.m. DON #1 said Resident #10 was on EBP due to the wound on the resident's heel. She said nurses should wear gowns when providing wound care to Resident #10. DON #1 was interviewed again on 1/29/26 at 5:10 p.m. DON #1 said EBP should be used for residents with wounds and during personal care, such as showers and incontinence care, to prevent the spread of harmful germs and disease. She said staff received training during orientation and as needed. DON #1 said she did not know the reason the staff did not know what the EBP sign on Resident #10's bed frame meant . She said she would ensure staff were retrained on EBP immediately.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of three certified nurse aides (CNA) reviewed. Specifically, the facility did not complete a performance review for CNA #1 and CNA #2.Findings include: I. Record review CNA #1 was hired on 3/12/24. A request for a performance review was made on 1/29/26.-The facility was unable to provide documentation indicating a performance review for CNA #1 was completed in the past 12 months.CNA #2 was hired on 9/19/24. A request for a performance review was made on 1/29/26.-The facility was unable to provide documentation indicating a performance review for CNA #2 was completed in the past 12 months.II. Staff interviews The nursing home administrator (NHA) and director of nursing (DON) #1 were interviewed together on 1/29/26 at 5:40 p.m. DON #1 and the NHA said a skills competency fair was conducted annually and as needed to complete an annual performance review for CNAs. DON #1 said she knew a skills fair took place in summer 2025 but she was unsure of the exact date because it was before she started working at the facility in August 2025. The NHA said the skills fair took place in June 2025. She said the clinical nurse educator was responsible for ensuring an annual performance review was completed for CNAS and she would know when the annual competency skills fair and the annual performance reviews were completed. The clinical nurse educator was interviewed on 1/29/26 at 5:56 p.m. The clinical nurse educator said an annual performance review was not completed for CNA #1 and CNA #2. She said she was not employed when the annual performance reviews were done in summer 2025 and she did not know why CNA #1 and CNA #2 did not have an annual performance review completed.

Based on observations and interviews, the facility failed to provide a safe, clean, sanitary and comfortable environment on the 700 unit. Specifically, the facility failed to ensure the common area at the end of the 700 hallway was available to residents for activities.Findings include:I. ObservationsDuring the initial tour of the facility's 700 hallway on 1/26/26 at 9:30 a.m. the following was observed:-Multiple pieces of unused equipment and furniture, such as bed frames, dressers, wheelchairs, and shower chairs were being stored in the common area at the end of the 700 hallway. The area's access was blocked off by yellow tape and two yellow cones. -The area remained a storage area and was unaccessible to residents during the survey on 1/26/26 to 1/29/26. II. Resident group interviewA group of seven alert and oriented residents (#38, #44, #49, #4, #3, #9 and #95), who were deemed interviewable by assessment and the facility, were interviewed on 1/28/26 at approximately 1:00 p.m. The residents said the common area at the end of the 700 hallway had been used as a storage area since summer 2025. The residents said before the area was cluttered with furniture, it used to have tables and chairs where residents could meet with family members and friends. Resident #3 said she used to have a puzzle table in the area at the end of the 700 hallway and now she could not have it because her room was too small for a puzzle table. Resident #44 said she used to meet with her friends and family for a private conversation in the area at the end of the 700 hallway. The residents said they had discussed their concern about not having access to the area at the end of the 700 hallway with management and were told that management was currently working on resolving the matter, however they said it was not resolved. III. Staff interviewsThe maintenance director (MTD) was interviewed on 1/29/26 at 4:30 p.m. The MTD said the common area at the end of the 700 hallway was currently used as a storage area for furniture and equipment. He said when residents moved out and rooms required deep cleaning or renovations, the furniture was moved to the common area on the 700 hallway. He said three sheds (storage areas) that the facility had on the premises were completely full and they had run out of space for storage. The nursing home administrator (NHA) was interviewed on 1/29/26 at 4:50 p.m. The NHA said she was aware of the concerns that residents brought to her regarding the storage area at the end of the 700 hallway. She said residents submitted a petition in early January 2026 asking the facility to clear the area for use and activities. She said the facility was actively searching for other options to store additional equipment. IV. Facility follow upOn 2/1/26 at 3:28 p.m., after the survey exit, the facility submitted electronic pictures of the area. The pictures revealed that the area at the end of the 700 hallway was cleared and supplied with tables and chairs for residents.-However, the concern was not addressed until it was brought to the facility's attention during the survey.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for three (#1, #4 and #110) of 10 residents out of 35 sample residents. Specifically, the facility failed to: -Ensure an assessment was conducted to determine whether the self-administration of inhaler medications was clinically appropriate for Resident #1 and Resident #110; and, -Ensure an assessment was conducted to determine whether the self-administration of nasal sprays was clinically appropriate for Resident #4.Findings include:I. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure, and chronic obstructive pulmonary disorder (COPD). The 6/13/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required moderate assistance with toileting, bathing, dressing and set up assistance with eating and oral hygiene. B. Resident observation and interviewOn 1/26/26 at 1:00 p.m. Resident #1 was observed in bed in his room. He held an inhaler in his right hand and said he was using it whenever he felt short of breath. He said he had used it for many years but was not sure what kind of inhaler it was. C. Record reviewA review of Resident #1's December 2026 CPO revealed the following physician's order:Albuterol Sulfate (medication used to treat lung diseases) two puffs inhaled orally every four hours as needed for shortness of breath or wheezing, ordered 6/4/25. -A review of Resident #1's electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #1 was able to safely administer his own medications.-The EMR did not reveal a physician's order for Resident #1 to self-administer the albuterol inhaler and approval for it to be kept at the resident's bedside.II. Resident #110A. Resident statusResident #110, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included chronic respiratory failure and chronic obstructive pulmonary disorder (COPD). The MDS assessment for Resident #110 was not completed at the time of the survey due to the resident's recent admission. B. Resident observation and interviewOn 1/26/26 at 3:00 p.m. Resident #110 was observed in a recliner in her room. Next to her on the table, the resident had an Anora Ellipta (medication used to treat COPD) inhaler. She said she was self-administering the inhaler every morning. C. Record reviewA review of Resident #110's December 2026 CPO revealed the resident did not have a physician's order for the Anoro Ellipta inhaler that she had at her bedside. -A review of Resident #110's EMR did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #110 was able to safely administer her own medications.-The EMR did not reveal a physician's order for Resident #110 to self-administer the Anoro Ellipta inhaler and approval for it to be kept at the resident's bedside. III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included Parkinson's disease and COPD. The 1/7/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required moderate assistance with toileting, bathing, dressing and set up assistance with eating and oral hygiene. B. Resident observation and interviewOn 1/26/26 at 2:00 p.m. Resident #4 was observed sitting in a recliner in his room. Next to him on the table he had a bottle of normal saline nasal spray and fluticasone propionate nasal spray (medication used to treat allergies). He said he self administered both medications independently. C. Record reviewA review of Resident #4's December 2026 CPO revealed the resident did not have a physician's order for the normal saline or fluticasone propionate nasal sprays that he had at the bedside. -A review of Resident #4's EMR did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #4 was able to safely administer his own medications.-The EMR did not reveal a physician's order for Resident #4 to self-administer normal saline or fluticasone propionate nasal sprays and approval for it to be kept at the resident's bedside. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 1/26/26 at 1:31 p.m. LPN #1 said she did not know that Resident #1 and Resident #110 had inhalers at their bedside or whether or not the residents were able to administer the inhalers themselves. She reviewed the EMRs for both residents and said Resident #1 and Resident #110 did not have an assessment for self- administration of medications. LPN #1 said there should have been an assessment completed to make sure they were capable of administering their own medication. She said if the resident had a self-administration of medications assessment, the assessment would be located in the resident's EMR. -However, there was no self-administration of medications assessment in Resident #1's or Resident #110's EMRs (see record review above). -LPN #1 was not able to locate a physician's order for Resident #110's Anoro Ellipta inhaler. LPN #2 was interviewed on 1/27/26 at 11:10 a.m. LPN #2 said she was unaware Resident #4 had two nasal sprays at his bedside. She said medications should not be left at the resident's bedside without a physician's order. LPN #2 walked to Resident #4's room and observed the normal saline and fluticasone propionate nasal sprays at his bedside. She took the nasal sprays and said she would keep them until the resident was evaluated for self-administration of medications. She said before a resident was able to self-administer their own medications, the nursing staff should determine if the resident knew how to administer their own medications correctly through an assessment. LPN #2 reviewed Resident #4's physician's orders and said the resident did not have a physician order for the nasal sprays that he had at his bedside.Director of nursing (DON) #1 was interviewed on 1/29/26 at 4:50 p.m. DON #1 said if a resident had requested to self-administer medication, the nursing staff would be responsible for completing a self-administration assessment. She said there should be a physician's order in the EMR for the resident to be allowed to self-administer medications. DON #1 said she was not aware that Resident #1, Resident #110 and Resident #4 were self-administering medications without a physician's order and an appropriate assessment. She said she would provide education to the nursing staff to ensure medications were not kept at residents' bedsides without an appropriate self-administration physician's order and a self-administration assessment.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents out of three sample residents. Resident #1, who was known to be at risk for falls, fell seven times between 12/8/24 and 2/1/25. The resident suffered a hip fracture as a result of one of the falls. The facility could not determine which fall resulted in the hip fracture. Resident #1 had one fall because his bed moved and six falls were because he attempted to self-transfer in or out of bed. Most of his falls were before or after meals and the resident was often incontinent at the time. According to staff, Resident #1 was very routine and would want to go to meals early, return to his room, use the urinal on the edge of his bed and lay down. He would self propel in his wheelchair to and from the dining room. Staff identified difficulty arriving to his room before he self-transferred to and from his bed. Resident #1 had a significant memory deficit and would be frequently reminded to use the call light as an immediate intervention. The facility failed to identify and implement timely interventions for Resident #1 in order to prevent multiple falls of similar occurrence that resulted in a hip fracture, a decrease in ability and a decision to place the resident on hospice services. Additionally, observations and record review during the survey revealed facility staff failed to consistently implement care planned fall interventions when Resident #1 was in bed (see observations below). Findings include: I. Facility policy and procedure The Fall Prevention and Management policy, revised 7/29/24, was provided by the nursing home administrator (NHA) on 2/27/25 via email. The policy's purpose read in pertinent part, To promote resident well-being by developing and implementing a fall prevention and management program; to identify risk factors and implement interventions before a fall occurs; to give prompt treatment after a fall occurs; and, to provide guidance for documentation. The policy identified the facility should review and update the care plan with any changes/new interventions and continue to monitor the condition and the effectiveness of the interventions. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included other sequelae of cerebral infarction (long term complications that can occur following a stroke), unspecified dementia without behavioral disturbance, cognitive communication deficit, fracture of unspecified part of the neck of right femur, subsequent encounter for a closed fracture with routine healing, difficulty walking, unsteadiness on feet, muscle weakness, lack in coordination, need for assistance with personal care and urgency of urination. According to the February 2025 CPO, the resident had repeated falls. The 1/31/25 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. According to the MDS assessment, there was not evidence of an acute change in mental status from the resident's baseline. The resident was dependent on staff for most of his activities of daily living (ADL), including transferring from surface to surface. He used a wheelchair for mobility. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment identified Resident #1 had a history of falls in the past six months and one fall without injury since his last assessment. Resident #1 had a life expectancy of six months or less. B. Resident observation and interview On 2/25/25 at 12:46 p.m. Resident #1 was lying in his bed. The bed was flush against the wall, his bed wheels were locked and his call light was within reach. -Resident #1 did not have his bed in the low position, as identified as a fall intervention in the resident's care plan (see care plan below) or a pool noodle under the fitted sheet between his body as recommended by the occupational therapist (OT) (see progress notes below). Resident #1 said he did know the details of his falls or why he fell . He said he only knew that he had a fall. He said he was not currently in pain. On 2/26/25 at 1:04 p.m. Resident #1 was lying in bed. His bed was in a low position and a pool noodle was between his body and the wall. -However, the pool noodle was on top of the blanket and sheets and not under the fitted sheet, as identified in the occupational therapy recommendation (see OT notes below). C. Visitor interview A visitor for Resident #1 was interviewed on 2/26/25 at 1:06 p.m. The visitor said he had visited with the resident everyday for the past couple of years. He said the pool noodle was placed on the bed so Resident #1 would not fall between the bed and the wall. D. Record review 1. Care plan Resident #1's fall care plans for an actual fall, initiated 5/3/23 and revised 2/18/25, and the resident's at risk for falls care plan, initiated 3/7/24, indicated the resident was at risk for falls related to deconditioning, cognitive deficits, confusion, gait imbalance and decreased safety awareness. The resident had a history of falls, poor communication/comprehension and was unaware of his safety needs. The fall care plan for actual falls indicated other fall factors included cerebral infarction, fracture of the left femur, fall history and anger issues. According to the actual fall care plan, Resident #1 sustained the following falls: a fall on 5/2/23 without injury; a fall on 5/6/23 without injury; a fall on 5/11/23 without injury; a fall on 4/13/24 without injury; a fall on 4/27/24 with a minor injury; a fall on 8/8/24 without injury; a fall on 12/8/24 with a head injury requiring stitches; a fall on 12/9/24 without injury; a fall on 12/13/24 without injury; a fall on 12/19/24 without injury; a fall on 12/30/24 without injury; a fall on 1/2/25 without injury; a fall on 1/24/25 with laceration to the forehead and complaints of hip pain, and the resident was sent to the hospital; and, a fall on 2/1/25 with a minor injury of a skin tear to his left elbow. The following interventions were added to the resident's care plan on 3/7/24, after the facility determined Resident #1 was at risk for falls: Remind the resident not to bend over to pick up dropped items, encourage him to use a grabber/reaching device or to ask for assistance, ensure the resident was wearing appropriate footwear of fully enclosed slip resistant shoes or gripper socks when ambulating or mobilizing in wheelchair, monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function, monitor visual and auditory impairments, ensure correct bed height by having bed in lowest position when resident was in room alone and reviewing as indicated for significant changes in cognition, safety awareness and decision-making capacity. The fall intervention initiated on 5/1/23 and revised on 5/1/23 documented the staff was to remove the resident's foot pedals from the wheelchair when staff was not pushing him. The fall interventions initiated on 5/3/23 and revised on 5/9/23 documented the staff should review Resident #1's history of recent or recurrent falls, ensure correct bed height by keeping in low position. According to the intervention, most of the resident's falls occurred at the bottom of the bed related to himself ambulating to the bathroom. The intervention indicated the resident had urinals available. Another fall intervention initiated on 5/3/23 and revised on 5/9/23 documented staff should ensure the resident was wearing appropriate footwear. According to the care plan, the resident would refuse gripper socks and non-slip shoes and liked being barefoot. According to the care plan intervention, the resident's fall on 5/6/23 identified the resident had gripper socks on but the gripper side was on top of his foot. The staff was educated and directed to monitor for proper placement of the socks with grips on the bottom of foot. The fall intervention initiated on 5/3/23 and revised on 4/16/24 documented that on 4/15/24, staff added Dycem (non-slip material) to the resident's recliner to help prevent the resident from sliding and falling. The fall intervention initiated on 12/11/24 and revised on 2/6/25 documented staff requested a physical therapy (PT) consult for strength and mobility and OT on 12/13/24 for transfers, PT, OT and activities to assess weakness, room safety, falls and boredom on 1/8/25 and on 2/1/25, the resident's bed was placed in low position and OT was to assess for noa (positioning) bars and bed positioning. The fall intervention initiated on 5/6/23 and revised on 1/31/25 directed staff to educate the resident not to bend over to pick up dropped items and encourage the resident to use a grabber or to ask for assistance. The care plan intervention documented the resident refused to allow staff to standby for assistance to the toilet. The 5/6/23 intervention directed staff to make sure the resident's call light was always visible and continue to encourage him to use it. According to the intervention, staff was educated on 12/19/24 to frequently monitor the resident, offer to transfer from bed to wheelchair before and after meals as well as in the morning and at night to prevent falls. The fall intervention initiated on 5/6/23 and revised on 1/31/25, documented that on 2/1/25 the resident needed his environment to be modified for maximum safety. The fall intervention initiated on 2/1/25 and revised on 2/3/25 directed staff to ensure Resident #1's bed was locked and against the wall in a low position. The fall intervention initiated on 5/3/23 and revised on 2/6/25 directed staff to review the resident as indicated for significant changes in cognition, safety awareness and decision-making capacity. According to the intervention, staff obtained laboratory work (labs) to rule out infections on 2/1/25. The fall intervention initiated on 5/3/23 and revised on 2/18/25 directed staff to provide activities that promoted exercise and strength building where possible, round before and after meals to stand/assist with transfers on 12/8/24 and add an art volunteer for social interaction. According to the care plan intervention, on 12/30/24 the resident's friend returned from vacation and the resident was no longer attempting to self-transfer. The friend would speak to the resident about safety and remind him to use the call light. The care plan intervention directed staff to encourage activities and offer one-to-one activities in the resident's room to fill the void while the friend was out of town to help prevent falls. -However, Resident #1 self-transferred on 1/2/25 and fell again. The end of life care plan, initiated on 1/30/25, documented Resident #1 had a terminal prognosis related to non-operative management of a right femoral fracture. Hospice services were put into place. The care plan directed staff to adjust the provision of ADLs to compensate for the resident's changing abilities and encourage participation to the extent the resident wished to participate. Resident #1's activities of daily living (ADL) care plan, identified the resident had an ADL performance deficit. The ADL transfer between surfaces intervention, revised 1/28/25, directed staff to use a two-person total lift transfer. 2. Pattern of falls Review of Resident #1's electronic medical record (EMR) from 12/1/24 through 2/25/25 revealed Resident #1 sustained seven falls during that time frame, including falls with injury. The falls were as follows: a. Fall with injury on 12/8/24 The 12/8/24 incident note documented someone was heard yelling for help down the hall. The certified nurse aide (CNA) reported Resident #1 was found on the floor. The resident was sitting on his bottom on the floor with his back to the dresser. The resident's wheelchair laid in a folded position on the floor at his feet. The resident had gripper socks on and his pants were slightly pulled down. According to the note, the resident had significant bleeding from a scalp wound. The note identified the wound as a quarter-sized skin tear with a two inch indentation to his scalp that continued to bleed when paramedics arrived. The incident note documented there was dried blood on the floor and it was undetermined how long the resident was on the floor. The registered nurse (RN) assessed for other injuries and no other injuries were identified. The 12/8/24 hospital emergency department notes identified Resident #1 had a laceration on his forehead requiring sutures and a hematoma (a localized collection of blood under the skin and outside the blood vessels). The 12/8/24 fall scene huddle worksheet was provided by the director of nursing (DON) on 2/25/25 at 10:20 a.m. The fall huddle worksheet documented Resident #1 was found on the floor incontinent of urine at 8:45 a.m., 45 minutes from when he last had contact with staff. The worksheet identified the resident was sitting in front of his dresser with his wheelchair on one side of him and blood on the floor on the other side of him. The 12/8/24 incident report was provided by the DON on 2/25/25 at 9:35 a.m. The incident report identified the fall occurred at 9:35 a.m. According to the incident report, predisposing physiological factors of the fall included impaired memory, confusion and incontinence. -The incident report documented the fall occurred at a different time than was identified on the fall huddle worksheet. The 12/8/24 hospital emergency department notes documented Resident #1 fell on [DATE] and was sent to the hospital. He had a laceration on his forehead requiring sutures and a hematoma. A 12/8/24 progress note identified the resident returned back to the facility from the emergency roiagnom on [DATE] with stitches applied to the artery that he opened during the fall. b. Fall on 12/9/24 The 12/9/24 fall tool identified Resident #1 was at high risk for falls. The 12/9/24 incident note identified Resident #1 had a total lift assist from the floor and was placed in his wheelchair. The note documented the resident denied hitting his head and would not allow a skin assessment because he was agitated and impatient. He had no pain with range of motion but he had slight pain with palpation to the right hip. According to the note, the resident fell on his right side the day before (12/8/24). The resident was assessed by the nurse practitioner (NP). The incident note identified the immediate intervention was education to the resident on the importance of using the call light for assistance before trying to get himself out of bed. The 12/9/24 fall huddle worksheet documented Resident #1 fell when he was attempting to self-transfer. He was last seen 20 minutes prior to the CNA finding him on the floor. The drawing on the fall huddle worksheet indicated the resident was found on the floor next to his bed. The resident was incontinent of urine and bowel. According to the fall huddle worksheet, the root cause of the fall was the resident's cognition and not using his call light. The 12/9/24 fall incident report identified the fall happened at 11:00 a.m. The report indicated the resident did not have injuries observed at the time of the incident. According to the report, the factors of the fall were weakness, gait imbalance, impaired memory, incontinence and not using his call light. The incident report identified the resident said he was trying to get out of bed to go to lunch. The 12/9/24 NP note identified the resident was seen for follow-up after multiple falls with a temporal artery laceration requiring sutures. The NP note documented Resident #1 was seen on 12/9/24, self-propelling his wheelchair to the dining room. The note indicated he was alert and oriented per his baseline and was calm and pleasant. He denied chest pain, palpitations or shortness of breath. The resident denied headache or dizziness. The note documented he had a recent fall (12/8/24) where he struck his head and sustained a laceration to the temporal artery which required an emergency department evaluation and multiple sutures. A CT (computed tomography) scan was conducted and he was negative for further acute process or brain bleed. Resident #1 denied pain and appeared comfortable on the exam since returning from the hospital. The resident had had another unwitnessed fall on 12/9/24 without injury. According to the note, Resident #1 had a memory impairment with dementia. The note identified he was impulsive and needed to be monitored for acute changes in his cognition and behaviors. The 12/10/24 communication visit with the physician note documented PT orders were requested for weakness, transfers and falls. According to the note, Resident #1 had changes of weakness as well as refusal of oral care and dental care. The resident had severe halitosis that could indicate an infection, a request for evaluation and orders were made. The 12/11/24 falls/interdisciplinary team (IDT) note documented the IDT met on 12/11/24 to review the 12/9/24 fall. Resident #1's medications, mobility status, room arrangement and interests and preferences were reviewed. According to the note, the intervention was for PT to evaluate and treat and staff would continue to monitor through the next evaluation date. The 12/31/24 PT note documented Resident #1 would benefit from continued assistance with all transfers due to his cognitive impairment. According to the note, he responded well to gentle guidance on proper set up. c. Fall on 12/13/24 The 12/12/24 at 3:52 a.m. (the day prior to the 12/13/24) fall) health status note revealed an increase in Resident #1's behaviors after the resident had a recent two falls. The note documented Resident #1 was very agitated on the 12/12/24 overnight shift and tried to get out of bed several times, yelling for help instead of using his call light and was able to communicate incontinence. Resident #1 told the staff that he had not slept in three days. The note identified lab work and a urine analysis would be obtained on the morning of 12/13/24 due to the resident's increase in behaviors. -The note did not identify if the resident was asked if he was in pain. The 12/13/24 incident note identified the resident had another unwitnessed fall. According to the note, the resident was found on the floor by a CNA. The resident was assessed and no injuries were identified. The note documented Resident #1 said he was trying to get into bed when he fell . The 12/13/24 fall huddle worksheet documented Resident #1 was found in his room on the floor next to his bed at 8:30 a.m. The resident was attempting to self-transfer when he fell . According to the worksheet, he was last seen at 7:00 a.m., one hour and 30 minutes prior to the fall. The worksheet identified the resident was wearing regular socks and not the gripper non-skid socks. The resident was incontinent of urine when he was found. The worksheet did not identify when the resident was last toileted. According to the fall huddle worksheet, the root cause of the fall was he was self-transferring. The 12/13/24 fall incident report documented Resident #1 was trying to get into bed. According to the report, there were no injuries observed at the time of the incident, the resident's range of motion was at baseline and he had weakness and a noted decline over the past few weeks. The fall incident report identified confusion as a factor to the fall. The 12/13/24 communication to the physician note identified the resident's lab results did not identify an infection. According to the note, the decline appeared to be a disease progression. The 12/16/24 physical therapy (PT) evaluation and plan of treatment was provided by the NHA on 2/26/25 at approximately 4:30 p.m. The PT goal was to improve ease of transfers to decrease Resident #1's risk for falls. According to the evaluation, the resident's 12/16/24 baseline for transfers was partial to moderate staff assistance needed for bed mobility, toilet transfers, sit-to-stand and chair-to-bed-to-chair transfers. The PT evaluation identified the resident had decreased functional capacity, decreased safety awareness, pain, strength impairments and procedural memory limitations. The 12/16/24 PT treatment encounter note revealed Resident #1 required total setup of his wheelchair in front of his bed with moderate assistance for a stand-pivot transfer and moderate assistance of bilateral leg management to move from a sitting position to laying down. The 12/18/24 care plan change note documented the IDT met and reviewed his fall on 12/13/24. According to the note, the intervention was for staff to round before and after meals to assist with transfers. The note indicated OT continued to work with him and a volunteer was requested to visit with him. d. Fall on 12/19/24 The 12/19/24 incident note identified Resident #1 had another unwitnessed fall in his room. The note documented Resident #1 fell on [DATE] at 7:15 p.m. He was observed sitting on the floor with bilateral hands grabbing the transfer bar on his bed to sit upright. His range of motion was at his baseline with all of his extremities but he had a slight redness on his left lateral back near his spine. According to the incident note, the resident was incontinent of bowel and bladder when he was found. The resident was assisted from the floor to his bed by use of a mechanical lift. The staff provided incontinent care and his bed was placed in a low position and his call light was placed within reach. The resident was reminded to use the call light for staff assistance. -Review of the progress notes did not identify Resident #1's 12/19/24 fall was reviewed by the IDT. -The 12/19/24 fall huddle worksheet did not identify when the resident was last seen by staff or when he was last toileted. The fall huddle worksheet did not identify the root cause of the fall. The 12/19/24 fall incident report documented Resident #1 was found sideways on the floor, parallel to the bed, facing towards the head of the bed and sitting on his bilateral buttock and his feet extending away from the bed and his bilateral hands gripping the transfer bar to keep himself upright. According to the incident report, Resident #1 said he didn't do anything. According to the incident report, factors of the fall included confusion, impaired memory and incontinence. The 12/19/24 physician note documented Resident #1's orientation level was stable but globally worsening over time. The note indicated the resident refused care intermittently and was agitated but was never aggressive. According to the note, the resident had functional impairments, bowel or bladder complications, new or worsening wounds, and significant cognitive deficits with high risk for falls with injury that required frequent monitoring. e. Fall on 12/30/24 The 12/30/24 incident note identified Resident #1 had another unwitnessed fall in his room while self-transferring. The note documented the resident was found on the floor by his family member. According to the note, the nurse had given the resident his medication on 12/30/24 at 12:06 p.m. The nurse then told the resident to wait for someone to help him go to bed and not transfer himself to bed. The note read the resident said he would wait. The note documented there were nine minutes between the time the resident was told to wait for help and when the resident's family member found him on the floor. The resident refused the skin assessment after the fall. Range of motion was conducted and the resident denied pain. The note indicated there were no new obvious injuries observed and the resident was assisted to bed per his request. The 12/30/24 fall huddle worksheet identified the 12/30/24 fall occurred at 12:15 p.m. The worksheet documented he was incontinent of bowel and bladder at the time of his fall. The brakes to his wheelchair were not locked and the resident was found sitting next to his bed. The fall huddle worksheet documented the root cause/intervention was because the resident did not wait for help like he was told to do and transferred anyway. -However, according to the resident's fall care plan, staff was educated after the resident's 12/19/24 fall to offer to transfer the resident to bed, not direct him to wait (see care plan above). The 12/30/24 fall incident report documented Resident #1 was educated again to wait for help before attempting to self-transfer. The incident report indicated the factors of the fall were gait imbalance, weakness, impaired memory and incontinence. According to the incident report, there were no injuries observed at the time of the fall. Review of the progress notes did not identify Resident #1's 12/30/24 fall was reviewed by the IDT. The 12/31/24 PT note documented Resident #1 would benefit from continued assistance with all transfers due to his cognitive impairment. According to the note, he responded well to gentle guidance on proper set up. f. Fall on 1/2/25 The 1/2/25 incident note identified Resident #1 had another unwitnessed fall in his room while self-transferring. The note documented the nurse was walking to another room when the nurse heard Resident #1 yelling help me. The nurse entered Resident #1's room and observed the resident sitting on the floor on the side of his bed. According to the note, the resident said he was trying to go to bed and slipped. The nurse assessed the resident and there were no concerns with his range of motion and the resident denied pain with palpation. The resident was lifted to his bed after he was assessed. The note documented the staff stressed the need for Resident #1 to listen when asked to wait for help and not to self-transfer. -The incident note documented the resident did not listen or wait for assistance, however, review of the resident's EMR and staff interviews identified he had a significant memory deficit and was impulsive (see record review above and staff interviews below). The 1/2/25 fall huddle worksheet documented Resident #1 fell on [DATE] at 8:45 a.m. According to the worksheet, the resident used a walker but was not using it at the time of the fall. The worksheet identified the resident was last toileted at 7:50 a.m. He was found incontinent of bowel and bladder at the time of the fall. The root cause/intervention documented Resident #1 did not listen, was impulsive and had a poor memory. -However, staff interviews identified the resident did not use a walker (see interviews below). The 1/2/25 fall incident report documented Resident #1 did not have injuries observed at the time of the incident. According to the incident report, gait imbalance, weakness, poor safety awareness and impaired memory and incontinence were factors of the fall. -The incident report did not include new interventions put in place after the unwitnessed fall. The 1/8/25 care plan change progress note documented the IDT met on 1/8/25 and reviewed Resident #1's 1/2/25 fall. The note identified Resident #1 was probably going to be discharged from PT because he did not want to participate. The note identified the facility attempted to have Resident #1 visit with a volunteer but he was not receptive to the volunteer. The note indicated the resident's friend was going to begin visiting again. -The care plan change note did not identify what new interventions the facility was going to put into place to prevent repeated falls of a similar nature. g. Incident of unknown source on 1/24/25 with major injury The 1/24/25 incident note identified that on 1/24/25 Resident #1 complained of pain to his right leg. The nursing assessment identified his right foot was pointing laterally outward. The resident denied pain but was moaning in pain. His leg was not able to go back to a neutral position, identifying a possible issue. The note documented the fall on 12/8/24 identified the resident was found on his right side and was sent to the hospital to repair a skin tear. The resident did not express right leg or hip pain as a result of the 12/8/24 fall. The note identified out of 33 pain ratings between 12/8/24 and 1/24/25, five of the pain ratings were identified at a pain level of 3 out 10,two of the pain ratings were identified at a pain level of 2 out 10, two of the pain ratings were identified at a pain level of 1 out 10 and 24 of the pain ratings were identified at pain level of zero out 10. The incident note indicated the resident often denied pain. The incident note documented Resident #1 continued to get out of bed and into his wheelchair. According to the note, the facility was unsure if that was the cause of the fracture or if any of the other falls were a result of the injury. Resident #1 denied any new fall or injury on 1/24/25 other than some pain in his hip and needed to be encouraged to go to the hospital for an assessment. Review of Resident #1's level of pain log between 12/8/24 and 1/24/25 revealed the resident's pain rating was logged everyday at least once a day, except between 1/11/25 and 1/22/25. The pain log on 1/23/25 identified the resident complained of pain at a rating of 7 out 10 at 1:52 p.m. He had a pain level of 3 out 10 on 1/23/25 at 5:06 p.m. Resident #1's pain level was 7 out of 10 on 1/24/25 at 11:25 a.m. and again at 2:07 p.m. The 1/24/25 nurse practitioner note revealed Resident #1 told the NP on 1/24/25 that his pain was primarily in his right leg and had been increasing over the last week. The NP note indicated an x-ray, conducted on 1/24/25, identified an acute femoral neck fracture and the resident would be sent to the emergency room (ER) for further evaluation. The 1/24/25 injury of unknown source incident report documented Resident #1 had a very close friend who visited often and the resident was very calm and happy during these visits. He would listen to the advice of his friend and the friend could also often get the resident to be compliant. The friend went on a long vacation and the resident was upset and lonely. The facility attempted different people to try to visit with the resident, including the resident's family. The report indicated the resident had several falls while the friend was absent from the facility. The incident report identified the falls on 12/8/24, 12/9/24, 12/13/24, 12/19/24, 12/30/24 and 1/2/25. The incident report identified one of the falls resulted in a laceration to Resident #1's forehead and he was sent to the hospital to evaluate his head injury. -The review of the falls identified the resident would continue to self-transfer in and out of bed and was frequently incontinent when the falls occurred. The falls would often occur after meals (see interviews below). The 1/26/25 admission/readmission note revealed Resident #1 returned to the facility on [DATE] from the hospital with a right femoral neck fracture. The resident and his family had chosen not to do surgical intervention of the fracture. According to the note, the resident was returning to the facility on hospice services. The 1/29/25 care conference note identified members of the IDT, hospice and the resident's family attended the conference. The members of hospice explained their role and how often they would be visiting Resident #1. The care conference note indicated the resident had a fall that resulted in a broken hip which could not be repaired so he returned to the facility on hospice services. The note documented Resident #1 had his own routine and was able to self propel his wheelchair. The 1/31/25 OT evaluation and treatment plan, beginning on 1/31/25, indicated OT was to help the resident with pain management with positioning in b[TRUNCATED]

Based on record review and interviews, the facility failed to prevent two of six sample residents (#2 and #3) from sexual abuse by certified nurse aide (CNA) #1. Record review and interviews revealed Resident #2, cognitively impaired and physically dependent, was sexually abused by CNA #1 on 7/27/24. The CNA was suspended immediately and terminated on 8/13/24. Resident #3, cognitively intact but visually impaired, reported on 10/11/24, that she, too, was sexually abused by CNA #1 before his suspension. Findings include: Record reviews and interviews confirmed the facility corrected the deficient practice before the onsite investigation from 10/21/24 to 10/22/24. The deficiency was cited as past non-compliance with a correction date of 8/2/24. I. Situation of serious harm Record review and interviews revealed Resident #2, cognitively impaired and physically dependent, was sexually abused by CNA #1 on 7/27/24. The CNA was suspended immediately and terminated on 8/13/24. Resident #3, cognitively intact but visually impaired, reported on 10/11/24, that she, too, was sexually abused by CNA #1 before his suspension. I. Facility policy The Abuse and Neglect policy and procedure, dated 7/22/24, was provided by the nursing home administrator (NHA) at approximately 12:00 p.m. on 10/21/24. It read in pertinent part, The resident has the right to be free from abuse, misappropriation of resident's property and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to, location, employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members, legal guardians or other individuals. If an employee receives an allegation of abuse, neglect, exploitation or misappropriation of resident property, the employee will take measures to protect the resident. The employee will then report the allegation to a supervisor. II. Sexual abuse of Resident #2 A. Resident status Resident #2, age over 65, was admitted to the facility on [DATE]. According to the October 2024 computerized physician orders (CPO), pertinent diagnoses included Huntington's disease (a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability), muscle weakness, encephalopathy (brain disease that alters brain function), anxiety and cognitive communication deficit (difficulty paying attention, remembering, responding, understanding, following direction). The 8/14/24 minimum data set assessment (MDS) revealed Resident #2 was severely cognitively impaired based on a staff assessment of her mental status. She was dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, bathing, eating, and locomotion on and off the unit. A review of Resident #2's care plan, revised 9/26/23, revealed the resident had impaired cognitive function and thought process related to Huntington's disease, as evidenced by impaired memory and decisions, impaired executive functioning, impulsivity, poor safety awareness, delayed processing and responses, trouble concentrating, and inattention. Interventions included the resident understood consistent, simple, direct sentences. Staff were to ask yes/no questions to determine the resident's needs, to present one idea, question, or command at a time, to allow time for Resident #2 to process and respond, and to validate the resident's message by repeating it aloud. Resident #2 was observed on 10/22/24 at 9:30 a.m. in her room lying on the floor mat covered with a blanket. Her eyes were open. She was asked if she ate breakfast and if she was comfortable. She did not respond to the questions. B. Record review and interviews revealed Resident #2, cognitively impaired and physically dependent, was sexually abused by certified nurse aide (CNA) #1 on 7/27/24. 1. A nursing progress note in the resident's record, dated 7/27/24 at 6:14 p.m., documented that the police were notified of an incident concerning an elderly female resident. CNA#1 was found in a compromising position at Resident #2's bedside by CNA #2 when she entered the resident's room. CNA #2 immediately informed the onsite registered nurse (RN) of her observation. The RN called the on-call clinical nurse manager (CNM) who collaborated with the director of nursing (DON) and nursing home administrator (NHA) for directions to address the potential abuse. The onsite RN verified the resident's immediate safety and reported to the CNM that the resident was resting in bed. 2. The NHA provided an investigation report and a timeline of the 7/27/24 incident involving Resident #2 and CNA #1 at 12:00 p.m. on 10/21/24. a. Report The facility investigation report which included interviews with CNA #1, CNA #2, CNA #3, certified nurse aide with medication aide authority (CNA-Med) #1, and all residents CNA #1 cared for, read CNA #2 walked into Resident #2's room to find CNA #1 for report and witnessed Resident #2 lying in her bed fully clothed with a blanket up to her chest and her body turned to the left side. There was a food tray behind CNA #1, out of reach. CNA #1 was positioned with his right knee on the resident's bed and his left leg on the floor. CNA #1 was facing the resident at the level of her face. When CNA #2 walked in, CNA #1 jumped off the bed, startled, shifted his pants, and pulled his shirt down. CNA #2 immediately walked away to find a nurse. CNA #3 was also looking for CNA #1. She walked into the room as CNA #1 was walking out of the room carrying a tray of food. CNA #3 said CNA #1 was more talkative and friendly. b. Timeline On 7/27/24: -CNA #2 reported to RN #1 about what she witnessed with CNA #1 and Resident #2 at approximately 6:00 p.m. -RN #1 called the on-call clinical nurse manager (CNM) after getting CNA #2's report, to inform the CNM of a staff member reporting a possible abuse. -The CNM called the NHA and the director of nursing (DON) after the incident was reported to her on the phone. -The NHA, the DON, and the CNM spoke to CNA #1 on the phone together after the incident was reported, to get a description of the incident (see investigation interviews below). -CNA #1 was removed from the facility by security immediately and suspended from his job. -Resident #2 was assessed by RN #1 and licensed practical nurse (LPN) #1 at 6:18 p.m. There were no signs of injuries present. Resident #2 was interviewed by the CNM, RN #1, and LPN #1 (see investigation interviews below). -CNA #2, CNA #3, and CNA-Med) #1 were interviewed by the CNM, the DON, and the NHA by phone (see investigation interview below). -All other residents on CNA #1's assignment were interviewed by RN #1 and LPN #1 (see summary of recorded interviews below). On 7/29/24: -Ten residents on side one (1), where CNA #1 was working on 7/27/24, which included some residents on CNA #1's assignment and others in the hallways CNA #1 could have been helping out on, were interviewed by RN #1 and LPN #1. The 10 residents denied ever being abused by any staff members or having concerns about other residents being abused. -CNA #1 was brought into the facility and interviewed by the NHA, the DON, and the CNM (see investigation interviews below). On 7/30/24: -The facility began education on neglect and abuse to the nursing care staff, including all direct care staff (see action plan and facility follow-up below). c. Investigation interviews i. RN #1, LPN #1, and the CNM interview on 7/27/24 with Resident #2 Although, in an interview after the initial facility interview, Resident #2 responded no to all abuse questions, in her interview on the day of the incident, 7/27/24 (no exact time was recorded), the resident responded uh-huh (affirmative) when asked if she had been approached by CNA #1. She responded uh-huh (affirmative) when asked if CNA #1 had exposed his privates to her. She arched her back and emphatically said yes when asked if CNA #1 had put his penis on her face or in her mouth. ii. CNM, DON, and NHA interview on 7/27/24 with CNA #2, CNA #3, and CNA-Med #1 CNA #2 and CNA #3 interviews were as documented in the investigation report above. CNA #2 walked into Resident #2's room to find CNA #1 for report and witnessed Resident #2 lying in her bed fully clothed with a blanket up to her chest and her body turned to the left side. There was a food tray behind CNA #1, out of reach. CNA #1 was positioned with his right knee on the resident's bed and his left leg on the floor. CNA #1 was facing the resident at the level of her face. When CNA #2 walked in, CNA #1 jumped off the bed, startled, shifted his pants, and pulled his shirt down. CNA #3 reported she also was looking for CNA #1. She walked into the room as CNA #1 was walking out of the room carrying a tray of food. CNA #3 said CNA #1 was more talkative and friendly. CNA-Med #1 reported that she entered the room while CNA #1 was feeding Resident #2. CNA-Med #1 reported when she entered the room, CNA #1 got up and moved the chair he was sitting on. She did not witness any inappropriate behaviors. iii. The NHA, DON, and CNM interview together with CNA #1 on the phone on 7/27/24. CNA #1 said he was feeding Resident #2 in bed with her head elevated. CNA #1 stated he was sitting in a chair beside Resident #2 with the food tray to the side of him. CNA #1 stated that CNA-Med #1 came in to give Resident #2 medication. CNA #1 said he stood up to move the chair out of the way for CNA-Med #1 to get closer to Resident #2. After CNA-Med #1 left the room, CNA #1 decided to stand up and put his left knee on the bed because he had a sore on the bottom of his left foot and it was hurting because of the pressure on it while sitting in the chair. CNA #1 denied putting his groin in Resident #2's face. CNA #1 denied exposing himself or putting his penis in or around Resident #2's face or mouth. CNA #1 stated he was startled when CNA #2 entered the room behind him and as he stood up on both feet, he readjusted his pants at the waist so the bottom of the pants was not around his feet/shoes due to being long. But see CNA #2's interview for the investigation report above. CNA #2 reported she walked into Resident #2's room to find CNA #1 for report and witnessed Resident #2 lying in her bed fully clothed with a blanket up to her chest and her body turned to the left side. There was a food tray behind CNA #1, out of reach. CNA #1 was positioned with his right knee on the resident's bed and his left leg on the floor. CNA #1 was facing the resident at the level of her face. When CNA #2 walked in, CNA #1 jumped off the bed, startled, shifted his pants, and pulled his shirt down. 4. Action plan and facility follow-up to the incident of abuse on 7/27/24 a. CNA #1 See the facility timeline above. CNA #1 was suspended on 7/27/24 immediately after the incident was reported. An interview with the NHA at 4:00 p.m. on 10/22/24 (see below) revealed CNA #1 was terminated on 8/13/24 and reported to the appropriate governing agencies, and complaints were filed on his license. b. Facility staff A review of the facility investigation documents provided by the NHA at 12:00 p.m. on 10/21/24 revealed follow-up actions specific to training on abuse and neglect by the nurse educator (NE) and included interviews, assessments, education, and reporting. The training included for staff to take measures to protect the resident and then report the allegation to a supervisor, steps that had not been taken on 7/27/24, per the facility investigation report. The facility's investigation was completed on 8/2/24 and 75 percent (%) of the direct care staff training was completed by 8/2/24. The remaining staff training was completed by 8/15/24, as staff schedules allowed. C. Staff interviews 1. CNA #4 was interviewed on 10/21/24 at 2:15 p.m. CNA #4 said she got education on abuse and neglect when she started working there and the facility's NE held an education session about abuse and neglect at the end of July 2024 where CNA #4 learned about the different kinds of abuse and how to report it. She said if she saw a resident being abused, she would make sure the resident was safe and then report it to a nurse, the DON, or social services. She said there is always a nurse on-call to call if she could not find the nurse working. 2. RN #2 was interviewed on 10/21/24 at 2:50 p.m. RN #2 said she was educated about the types of abuse and who to report abuse to and how to report it at the end of July 2024. RN #2 said she would make sure the residents involved were safe before reporting the abuse. 3. The NHA and the DON were interviewed together on 10/22/24 at 4:00 p.m. -The NHA said there was no indication that CNA #1 would have engaged in sexually abusive behavior. She said the human resource (HR) department ran his background checks before his hiring on 4/30/24 and he completed all his abuse and neglect education before beginning orientation. -The NHA said they thought he was a lazy worker because he was frequently found in the restaurant part of the community and left work early. She said he always worked the 2:00 p.m to 10:00 p.m. shift and was always on the 500 hallway (on side 1). -The NHA said she instructed security to remove him from the building immediately following the incident on 7/27/24 and placed him on suspension. She said they ended up terminating him on 8/13/24. -The NHA said they conducted education for direct care staff, which included nurses and CNAs, on abuse and neglect beginning on 7/30/24. She said they got approximately 75% of the staff educated by 8/2/24, and the remaining staff were educated by 8/15/24, due to their schedules. 4. The CNM and the DON were interviewed together on 10/22/24 at 10:07 a.m. -The CNM said she was called by RN #1 on 7/27/24 around 6:00 p.m. and was asked to talk with CNA #2. She said CNA #2 said she was coming on to her shift and looking for CNA #1 to get a report. She walked into Resident #1's room without knocking and saw CNA #1's right leg on the resident's bed and he was leaning over the resident's face. She said Resident #2's face was turned toward the left side, facing CNA #1's groin area. She said she saw him jump up and adjust his pants, grabbing them from the front and he pulled down his shirt. She said the resident's food tray was across the room on top of stacked up mats and out of reach for him to be feeding the resident, and the head of the resident's bed was flat. CNA #2 walked away to find a nurse after witnessing this, as she said it made her feel uncomfortable. -The CNM said she interviewed CNA #3 on 7/27/24 around 6:00 p.m. and she said she walked into Resident #2's room after CNA #2 left. She said she was looking for CNA #1 to get a report. She said she walked into Resident #1's room and saw the room tray was across the room, not next to the bed. She noticed the head of the bed was flat. CNA #3 said CNA #1 was acting more friendly and talkative. -The CNM said she interviewed CNA #1 with the DON and the NHA on 7/29/24 in person. The CNM said CNA #1 demonstrated how he was positioned on the bed with his left knee on the bed. The CNM said CNA #1 showed her, the DON and the NHA the sore on his left foot and said it was the size of a pinprick. The CNM said she asked CNA #1 why he pulled his pants up from the front and not the back and she said CNA #1 did not have an answer. 5. The campus director (CD), the DON, and the NHA were interviewed together on 10/22/24 at 3:10 p.m. The CD said CNA #1 did not have to be exposed for abuse to occur. III. Sexual abuse of Resident #3 A. Resident status Resident #3, age over 65, was admitted to the facility on [DATE]. According to the October 2024 CPO, pertinent diagnoses included type 2 diabetes, primary open-angle glaucoma, left eye severe stage (optic nerve damage resulting in vision loss), central retinal vein occlusion (eye condition affecting the retina and leading to vision loss), left eye with macular degeneration and need for assistance with personal care. The 7/17/24 MDS assessment revealed Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial/maximal assistance from staff for bed mobility, transfers, dressing, toileting, personal hygiene, bathing, eating, and locomotion on and off the unit. B. Record review and interviews revealed Resident #3, cognitively intact but visually impaired, reported on 10/2/24, that she, too, was sexually abused by CNA #1 before his suspension. 1. The NHA provided an investigation report and a timeline of the incident involving Resident #3 and CNA #1 at 12:00 p.m. on 10/21/24. 1. Report The facility investigation report read the NHA was informed on 10/4/24 by the local police and adult protective services that CNA #1 talked to the police (during an interview with the police on 10/3/24) about a second incident involving him before his suspension on 7/27/24. 2. Timeline On 10/4/24: -The local police department notified the NHA of CNA #1's statement (see above) and the facility determined that Resident #3 matched the description CNA #1 gave to the police. -The social services director (SSD) interviewed Resident #3 and the resident denied ever being abused at the facility. The SSD and social services assistant (SSA) #1 interviewed 50 total residents, all on the side of the unit where CNA #1 was assigned. -Facility-wide education was conducted on abuse and neglect. On 10/9/24: -The DON and SSA #1 interviewed Resident #3 and she denied ever being abused at the facility. -The HR department expanded the sample and interviewed all employees in the healthcare facility to ask if the staff had noticed any resident acting differently, if any dependent residents changed how they tolerated care, or if the behaviors of their coworkers ever made them feel uncomfortable. Staff denied this in the interviews. C. Interviews The NHA and DON were interviewed together on 10/21/24 at 4:00 p.m. The NHA said the police came back to the facility on [DATE] and told her CNA #1 had confessed to the police about sexual abuse with Resident #2. She said the police also told her CNA #1 made statements about other residents and gave identifying information. The NHA said because of this new information, they expanded their interview sample and initiated a facility-wide education on abuse and neglect on 10/4/24. The campus director (CD), the DON, and the NHA were interviewed together on 10/22/24 at 3:10 p.m. The CD said the police arrived at the building on 10/11/24 to interview Resident #3. The CD said the police told her staff were to stop conducting interviews with Resident #3. The CD reported she was told by the police that Resident #3, in an interview with the police on 10/11/24, said there was a male CNA who she did not like who worked at the facility. She said he put something in her hand. She said, What did you put in my hands and I could tell it was his penis. She said she never told anyone, not even her family until then. The NHA said that the CNM documented this statement from Resident #3 in a trauma assessment in her medical record on 10/11/24. The NHA said the facility identified the incident, investigated, reported to all agencies, and put in place a plan of correction that included healthcare staff education that was completed by 8/2/24.

Based on record review and interviews, the facility failed to ensure one (#58) of six residents reviewed for accidents out of 39 sample residents remained free from accidents. Resident #58, who was known to be a fall risk and had care planned fall interventions in place, sustained a fall on 4/20/24 which resulted in a fracture of her left femur (upper leg). During the facility's investigation of the fall, it was discovered the floor alarm, which was care planned as an effective fall intervention for the resident, had been in the off position at the time of the resident's fall and did not sound, therefore staff had not been alerted to the resident's movements in her room. Staff was aware that in order to reset the alarm after it had been triggered, it was necessary to reset the alarm by switching it to the off position and returning it to the on position. However, staff failed to ensure the alarm was in the on position at the time of the resident's fall. Due to the facility's failure to ensure staff reset the alarm appropriately after it had been triggered, Resident #58 sustained a fall on 4/20/24 which resulted in a fracture of her left femur. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/1/24 to 5/7/24, resulting in the deficiency being cited as past noncompliance with a correction date of 5/4/24. I. Incident on 4/20/24 The facility failed to ensure staff reset Resident #58's floor alarm, which had been implemented as an effective fall intervention for the resident, appropriately to the on position after the alarm triggered. Due to the facility's failure, Resident #58 sustained a fall on 4/20/24 which resulted in a fracture of the resident's left femur. Record review and interviews during the onsite investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from 5/1/24 to 5/7/24. II. Facility plan of correction A. Immediate action to correct the deficient practice for Resident #58 The corrective action plan implemented by the facility in response to Resident #58's fall on 4/20/24 was provided by the director of nursing on 5/6/2024 at 10:00 a.m. On 4/20/24, the facility conducted an investigation of Resident #58's fall. The facility interviewed all staff on duty who were involved in care for the resident on the day of fall and a few days prior to the fall. Inspection of the floor alarm device determined the alarm device was in an off position at the time of the fall and therefore did not alert the staff about the resident's movement in the room. All interviewed staff reported that the alarm was functioning well and they heard the sound of it during their shift. Staff was aware that in order to reset the alarm after it was triggered, it was necessary to switch it to the off position and return it to an on position. It was unclear when the alarm was reset for the last time and why it was in the off position at the time of the fall. The last interaction with the resident was reported around 6:30 p.m., about 30 minutes prior to the fall, when a staff member assisted the resident with care. On 4/20/24 all direct care staff who were involved in Resident #58's care and had access to the alarm device were educated on how to reset it and to make sure it was turned on. The device was to be checked at the beginning of every shift and on an as needed basis. Staff were to ensure it was in the on position after the reset. A log was initiated to ensure every shift checked the alarm. On 4/24/24 the interdisciplinary team (IDT) met to review the fall for the Resident #58. Medications, care routines, non-pharmacological interventions and resident preferences were reviewed. The IDT recommended adding the following interventions and continuing to monitor: Bariatric bed for extended sleep surface, improve lighting in the room, and add an air mattress. B. Identification of other residents The facility completed an audit and identified other residents in the building who were at risk for falls. Thirteen identified residents were reviewed for appropriate fall interventions and care plans were updated to ensure the accuracy of the interventions. The audit review was completed by 5/3/24. C. Systemic changes Nursing leadership re-educated the nursing staff in regards to reviewing the care plan and Kardex (tool utilized by staff to provide comprehensive care of the residents) as well as the importance of following and implementing interventions outlined in these documents in an effort to reduce the risk of falls for facility residents. The training of all staff was completed on 5/3/24. On 4/21/24 audits were initiated to verify fall prevention interventions outlined in the care plans for residents identified to be at risk of falls were in place accordingly via direct observations when rounding as well as via interviews with staff. D. Monitoring The director of nursing (DON) was responsible for completing the audits weekly for the next four weeks, one a month for the next two months and quarterly for the next three quarters. A monthly Report Out, summarizing the findings of the audits, was to be completed and provided to the Quality Assurance Performance Improvement (QAPI) Committee. The QAPI Report Out was to be reviewed by the QAPI Committee for compliance and trends and to make additional recommendations as needed for continued improvement. The facility would be in substantial compliance by 5/4/24. Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Facility policy The Fall Prevention And Management- Rehab/Skilled, Therapy & Rehab (rehabilitation) policy, revised on 4/2/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 2:10 p.m. It read in pertinent part, The policy's purpose is to promote resident well-being by developing and implementing a fall prevention and management program, to identify risk factors and implement interventions before a fall occurs, to give prompt treatment after a fall occurs and to provide guidance for documentation. On admission or readmission, review the applicable documents ( discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors. IV. Resident #58 A. Resident status Resident #58, age 81, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included muscle weakness, dementia with behaviors and history of falls. The 1/19/24 minimum data set (MDS) assessment revealed, resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #58 did not have any physical limitations and she used a manual wheelchair. The resident required the assistance of one person for most activities of daily living (ADL). She had at least two falls since she was admitted with no major injury. B. Record review Resident #58's fall care plan, initiated 8/25/2020 and revised 5/1/24, revealed the resident was at risk for falls and had had actual falls related to diagnosis of dementia, failure to thrive, poor safety awareness, weakness and poor balance. The resident was legally blind. Interventions included reminding the resident and encouraging her to use grab bars to prevent falls, using a padded floor alarm with the alarming device in the nurses station where the alarm alerted staff but did not sound in the resident's room to avoid scaring the resident (initiated 11/22/21), Adding anti-slip strips to the total length of the bedside area and by the sink to prevent slips leading to falls (initiated 6/28/23), adding padding to the sink to prevent injury, adding a bedside commode (without the bucket insert), with handles, over the toilet to help guide the resident to know when she had reached the toilet to sit down safely, adding a grab bar in the room to allow safety when the resident was getting out of bed and returning to bed (initiated 7/12/23) and extending the sleep surface on the opposite side of the bed to allow the resident to move and sleep sideways and help prevent falls (initiated 4/24/24). According to the fall incident report, on 4/20/24 around 7:00 p.m., Resident #58 sustained a fall. Staff found the resident sitting on the floor in no acute distress, between her bed and the sink area, scooting backwards on her bottom towards the sink wall. Resident #58 stated she was just walking toward her door and fell . Resident #58 initially denied pain or injury. The physician was notified on 4/20/24 and x-rays were ordered due to increased discomfort in the resident's left leg. On 4/21/24 the results of the x-ray revealed Resident #58 had sustained a left femur fracture and the resident was transferred to the emergency room for further evaluation. According to the hospital discharge summary, dated 4/23/24, Resident #58 was admitted to the hospital on 4/21/24 after she had a mechanical fall at the long-term care facility. She was diagnosed with a left femur fracture. The resident's family chose not to pursue surgical repair of the femur fracture and the resident returned to the facility with a palliative care consultation on 4/23/24. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/6/24 at 1:15 p.m. LPN #1 said Resident #58 was currently bed bound after she had a fall in April 2024. She said the resident had a special floor alarm that alerted the staff at the nurses station about the resident's activity in the room. She said Resident #58 had the alarm for a long time and it was very effective at preventing falls. She said she had not worked on the day when Resident #58's fall occurred. LPN #1 said she was re-educated about alarm monitoring and its functioning a few weeks ago (April 2024). She said her responsibility was to check the alarm when she started her shift, every time it was reset and as needed to ensure the alarm was on. She said she usually checked it every time she was at the nurses station or at least every 20 minutes. Certified nurse aide (CNA) #1 was interviewed on 5/6/24 at 1:35 p.m. CNA #1 said Resident #58 required extensive assistance of two people with all cares. She said the resident was a risk for falls and her responsibility was to ensure the floor mattress that had an alarm was appropriately positioned, plugged in and turned on. She said the resident currently was not able to ambulate but she was still at risk of sliding off the bed. She said the floor alarm's sounding device was at the nurses station and she was familiar with its sound and knew how to reset it after it was triggered. She said the most recent education about the alarm was a few weeks ago (April 2024). The DON and the NHA were interviewed together on 5/7/24 at 11:00 a.m. The DON said Resident #58 was the only resident in the building who was using the type of alarm she had. He said it proved to be effective in preventing falls for the resident and the resident had been using it for a while. The DON said, on 4/20/24 when Resident #58 had the fall, the alarm was found to be in the off position. He said it was inconclusive at what point the alarm was switched off and the most probable cause was that the last person who reset the alarm did not switch it all the way to the on position. He said since the incident occurred, he had completed the investigation and re-educated staff on checking the alarm prior to the shift and on an as needed basis. The DON provided copies of the audits the facility had implemented on to ensure the alarm was being monitored to make sure it was in the on position. The NHA said she believed the facility had completed a thorough investigation and ensured that all residents at risk for falls had appropriate and effective fall interventions in place. She said the facility had taken appropriate actions following Resident #58's fall and ensured the safety of all residents.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not five percent (%) or greater. Specifically, the facility's medication error rate was 7.7% or two errors out of 26 opportunities for error. Findings include: I. Professional references According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 5/06/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. According to the Food and Drug Administration (FDA) Metoprolol Succinate Extended-Release Tablets: 25 milligram (mg), 50 mg, 100 mg, and 200 mg, retrieved on 5/9/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/019962s032lbl.pdf, Metoprolol Succinate extended-release tablets are scored and can be divided, however, the whole or half tablet should be swallowed whole and not chewed or crushed. II. Facility policy and procedure The Medication Administration policy, dated 3/29/23, was provided by the director of nursing (DON) on 5/6/24 at 12:00 p.m. It read in pertinent part, Nursing assessment is a function of the registered nurse. When the location uses medication aides, the delegating nurse is accountable for assessing a situation and making the final decision to delegate. Follow the Six Rights: right medication, right dose, right resident, right route, right time, and right documentation. III. Resident #62 A. Resident status Resident #62, age greater than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease stage II (mild) and hypertension (high blood pressure). B. Record review According to the May 2024 CPO, Resident #62 was scheduled to receive the following medication: Nebivolol HCL (a medication used to treat high blood pressure) 2.5 milligrams (mg) one tablet by mouth one time a day for hypertension, and to hold the medication for a systolic blood pressure less than 100 millimeters of mercury (mmHg) or a heart rate less than 60 beats per minute (bpm), ordered 12/3/23. C. Observation On 5/6/24 at 9:30 a.m. the certified nurse aide with medication aide authority (CNA-Med) administered Nebivolol to Resident #62. The CNA-Med failed to check the resident's blood pressure or heart rate prior to administering the medication to the resident. D. Staff interview The CNA-Med was interviewed on 5/6/24 at 9:45 a.m. The CNA-Med said if vital signs were needed before giving a medication, either a heart icon was present under the medication order, or if you hovered over the order, medication parameters were listed within the further instructions section. The CNA-Med said Resident #62's order did not have a heart icon and when she hovered over the medication order, the blood pressure and heart rate parameters were not listed first under further instructions. The CNA-Med said she would take vital signs sometime that day (5/6/24). 50315 IV. Resident #49 A. Resident status Resident #49, age greater than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included fracture of the left and right femur (thigh bone), hypertension (high blood pressure) and heart failure. B. Record review According to the May 2024 CPO, Resident #49 was scheduled to receive the following medication: Metoprolol Succinate (a medication used to treat high blood pressure) extended release (ER) oral tablet 25 mg, give half a tablet by mouth in the morning related to essential (primary) hypertension. Hold for systolic blood pressure (SBP) under 110 or heart rate under 65, ordered 3/27/24. C. Observation On 5/2/24 at 9:44 a.m., registered nurse (RN) #1 was administering medications to residents. She looked at orders for Resident #49. There was an order to check vital signs before administration of medication. She took a vital signs cart into the resident's room and measured the resident's heart rate and blood pressure. They were both within normal limits to administer the medication. She walked back to her medication cart and pulled out each medication scheduled to be administered RN #1 crushed all of the medications, including the metoprolol, and mixed them with applesauce. She walked into the resident's room and administered the medications. -However, according to the manufacturer's recommendations for metoprolol succinate extended release tablets, the medication should be swallowed whole and not chewed or crushed (see professional references above). V. Additional staff interviews The DON and unit manager (UM) #1 were interviewed together on 5/6/24 at 10:49 a.m. UM #1 said when original medication admission orders were entered, they were to be signed-off by two nurses. He said when vital signs or weights were needed prior to giving medications, the heart symbol should have shown up on the medication administration record (MAR) as a visual cue to check the resident's vital signs. UM #1 said since there was no heart icon on Resident #62's MAR for the Nebivolol, it meant whoever entered the medication order into the electronic medical record (EMR) missed that step of the entry process. The DON and UM #1 said physician's orders should always be followed. They said not all medications, even blood pressure medications, required vitals signs be checked prior to administration. -However, the physician's order for Resident #62's Nebivolol had specific systolic blood pressure and heart rate parameters for when the medication should not be administered. UM #1 said it was important to follow the physician's orders in order to maintain a safe regulatory system and monitor if the medication was working correctly. He said he would review residents' physician's orders to ensure the nurses were alerted when vital signs were required prior to medication administration. The DON said he would provide education to nurses to ensure the blood pressure and heart rate were checked prior to administering medications if it was requested in the physician's order. The DON said the facility provided education to staff on 5/2/24 regarding not crushing ER medications. UM #1 said extended release medications should never be crushed. He said this was because the medication was not processed in the body like it was intended if the medication was crushed. He said crushing the medication had the potential to give the medication a stronger effect on the resident causing the resident's blood pressure to get too low.

Based on record review, and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#66 and #47) of four residents reviewed for accidents/hazards out of 24 sample residents. Resident #66 had a history of falls upon admission, was cognitively intact, used a walker and wheelchair, and needed supervision with ambulation and transfers. Between 11/29/22 and 1/12/23, Resident #66 experienced eight falls: six unwitnessed and two witnessed. After the 12/20/22 fall, the resident sustained a fractured femur (thigh bone). After the femur fracture the resident became dependent for ambulation in a wheelchair. The facility failed to conduct an interdisciplinary team (IDT) review of Resident #66's repeated falls and implement effective interventions. Additionally, the facility failed to: -Implement effective fall interventions, conduct IDT review of falls and communicate with hospice provider for Resident #47; and, -Ensure the Resident #47's feet were secured during a transfer with a mechanical lift. Findings include: I. Facility policy The Fall Prevention and Management policy, revised 3/30/22, was provided by the nursing home administrator (NHA) on 2/6/23 at 2:35 p.m. It read in pertinent part: The purpose was to promote resident well-being by developing and implementing a fall prevention and management program, identify risk factors and implement interventions before a fall occurs, give prompt treatment after a fall occurs, and prevent further injury. A fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. Upon admission the facility will review the applicable documents, discharge summary from the transferring agency, transfer record, history and physical, lab values, and any additional admit information documentation for fall risk factors. Complete the Falls Tools UDA (user defined assessment) for fall screening and identifying fall risk factors. Care plan the appropriate interventions, including personalizing all areas. Communicate fall risks and interventions to prevent a fall before it occurs per the 24 hour report, care plan, kardex, daily stand up meeting, and/or fall committee meetings. Communicate any identified environmental changes and /or referral needs (maintenance, dietary, therapy). After a fall, the facility will: a. Assess the resident. b. Notify the physician and resident representative. c. Complete the Fall Scene Huddle worksheet. d. Document the physician's comments in the medical record. e. Complete the Falls Tool UDA. f. If appropriate, contact the physician for a referral to therapy. g. Communicate that a fall has occurred during shift change and daily stand-up meeting. h. Give completed fall scene huddle worksheet to the fall committee chair. i. Report to the state regulatory agency when appropriate. j. Continue to monitor condition and the effectiveness of the interventions. k. The investigation documentation is completed in the notes tab within the Risk Management module. II. Resident #66 A. Resident status Resident #66, age 80, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included fracture of the right femur, unspecified dementia, anxiety disorder, severe protein-calorie malnutrition, depressive episode, muscle weakness, unsteadiness on feet, need for assistance with personal care, legal blindness, wedge compression fracture of T7-T8 (bones in the spine), difficulty in walking, and repeated falls. The 1/10/23 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief mental status score (BIMS) of 14 out of 15. She required limited assistance with bed mobility, transfers, and walking in the room and corridor. She used a wheelchair and had a fracture related to a fall. She had falls prior to admission. B. Record review Care plans The fall care plan, initiated 8/25/2020 and revised 1/12/23, revealed the resident was at risk for falls and had actual falls related to dementia, failure to thrive, poor safety awareness, weakness, poor balance, legally blind, and atrial flutter. The goal was for the resident to resume usual activities without further incident. The interventions included: -Monitor/document/ report pain and bruises-Initiated 2/20/22. -Provide activities that promote exercise and strength building where possible-Initiated 8/25/2020. -Contact physical therapy for strength and mobility as needed-Initiated 2/20/2022 and revised on 3/16/22. -Ensure the resident was wearing footwear when standing that has a gripping bottom and secure back such as slippers, shoes, or grip socks-Initiated 8/25/2020 and revised on 5/9/22. -Encourage the use of a wheelchair or walker when leaving the room-Initiated 8/25/2020 and revised on 5/9/22. -Frequent monitoring upon waking, before bed, before and after meals, and routinely through the night-Initiated 8/26/2020 and revised on 9/23/2020. -Monitor visual and auditory impairments-Initiated 8/25/2020. -Review as indicated for significant changes in cognition, safety, awareness, and decision making-Initiated 8/25/2020. -Review bowel and bladder continence status and establish and/or review toileting plan based on residents needs-Initiated 8/25/2020 and revised 3/16/22. -Ensure/provide a safe environment, monitor and remove tripping hazards - Initiated 9/23/2020 and revised 7/19/22. -Maintain a clear path in the corridor for ease of ambulation when the resident leaves the room-Initiated 9/23/2020 and revised 7/19/22. -Assist with maintaining a clear area around the bed to allow room to stand safely-Initiated 9/23/2020 and revised 7/19/22. -Purposeful proactive rounding every two hours for safety and assessing needs and comfort-Initiated 2/20/22 and revised on 1/10/23. The visible impairment care plan, initiated 9/14/2020 and revised 11/2/22, revealed the resident had impaired vision related to artificial left eye. She had prophylactic antibiotics for right eye health. The goal was for the resident to maintain optimal quality of life within limitations imposed by visual function left eye blindness. The interventions included: -Maintain room arrangement to promote independence. -Arrange consultation with an eye care practitioner as required. -Monitor/document/report change in ability to perform Activities of daily living (ADLS), decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, and blurred or hazy vision. -Tell resident where her items are being placed and be consistent with placement of personal items. -Approach the resident from her right side as she has a prosthetic left eye. According to the fall report, nursing progress notes and fall investigations dated 11/29/22 through 1/12/23, the resident had eight falls within three months. 1. According to the 11/29/22 risk management, at 5:30 p.m., the resident was walking down the hallway and did not see another resident in a wheelchair, causing her to lose her balance. She landed in the Indian style (crossed legs) sitting position. The nurse assessed her and walked her back to her room, where she sat on the bed. She was not injured and said she did not see the other resident and lost her balance. Predisposing factor was impaired vision. The fall was witnessed. The risk management note revealed the resident would continue working with restorative and encouraged to use her front wheeled walker when ambulating. A physician order was obtained for a PT evaluation. 2. According to the 12/9/22 risk management, at 12:35 p.m., the nurse found the resident in her room leaning with her back on her bed and her feet up against the closet and her behind up in the air. The nurse assessed the resident and assisted her to her bed. She was not injured and said she sat on the floor and was trying to get up. Predisposing factor was impaired vision. The fall was unwitnessed. The risk management note revealed the resident would continue working with restorative nursing. No new interventions were implemented since the resident was already working with restorative nursing from her previous fall (11/29/22). 3. According to the12/14/22 risk management, at 10:00 a.m., certified nurse aides witnessed the resident trip over her bedside table landing on her bottom. She was sitting on her bottom between the bed and the table. The nurse assessed the resident and assisted her to her bed. She was not injured and said she was going to the bathroom and tripped on the table. Predisposing factor was impaired vision. The risk management note revealed the resident would continue working with restorative. An electrocardiogram (EKG), labs, and urine sample was ordered related to dizziness and nausea. Staff were to ensure the room was free of clutter so the resident had a clear pathway to the bathroom and the room exit. No new interventions were implemented since the resident was already working with restorative and the room should have already been cleared of clutter from her previous two falls (11/29/22 and 12/9/22). 4. According to the 12/20/22 risk management, at 8:30 p.m., the resident was heard yelling out and was found sitting on her left buttocks with her legs to her right. She was holding onto the grab bars facing the toilet. She was wearing tennis shoes. The nurse assessed the resident as she was attempting to get up off the floor on her own. She refused to wait for the staff to use the lift to get her up. The resident was able to bear weight however she walked with a limp and complained of right outer thigh pain. She said, Ow with each movement. The resident said she tripped over her roommate who was at the sink and landed on the floor. She said she then scooted herself to the bathroom to try and stand up. A stat x-ray was ordered for the right hip pain. Predisposing factor was impaired vision and impaired memory. This was an unwitnessed fall. The resident was subsequently transferred to the emergency department for evaluation and treatment. She was found to have a right femur neck fracture which required surgical intervention. The risk management note revealed the resident had an increase of falls related to tripping over other residents. The resident appeared to be having difficulty adjusting to increasing impairment to good eye and loss of physical independence. The resident was hospitalized on [DATE] and readmitted to the facility on [DATE]. 5. According to the 1/5/23 risk management, at 3:30 p.m., the nurse was called to the resident's room by the floor certified nurse aide (CNA), and found the resident on the floor beside her bed wrapped up in her covers. The nurse assessed the resident and two CNAs used the hoyer lift to help her back into bed. She was not injured and said she was looking for her sock and slid off of the bed. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident was wearing socks. She was encouraged not to reach for items and to use the call light for assistance. The resident would continue working with restorative nursing for safe ambulation. 6. According to the 1/8/23 risk management, at 4:45 a.m., the nurse was walking down the hall, making rounds, and noticed the resident sitting on the floor in the doorway of her bathroom. She was not injured and said she rolled out of the bed and scooted to the bathroom. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident continues working with restorative nursing on safe ambulation. She will continue working with PT related to repeated falls. No new interventions were implemented since the resident was already working with restorative and PT from her previous five falls. 7. According to the 1/10/23 risk management, at 11:16 p.m., the resident was found in front of her dresser going through her clothes. She was not injured and said she put herself on the floor and was sorting her clothes. The nurse assessed her for any injuries. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident would continue working with PT related to repeated falls. The resident was reminded to use the call light and wait for assistance. No new interventions were implemented since the resident was already working with PT from her previous six falls (11/29/22 and 12/9/22), and the resident was reminded to use the call light from her previous two falls. 8. According to the 1/12/23 risk management, at 5:00 a.m., the resident's roommate went to the nurses station to report that Resident #66 was on the floor. The nurse found the resident on the toilet. She was not injured and said she was reaching for the grab bar and slid down onto the floor. Predisposing factor was impaired vision, impaired memory and gait imbalance. This was an unwitnessed fall. The risk management note revealed education was provided to the resident to use the call light and wait for assistance with transfers. No new interventions were implemented since the resident had already been educated to use her call light and wait for assistance from previous multiple falls. There were no IDT review notes for any of the above falls, the risk management notes were completed by the floor nurse. C. Staff interviews CNA #1 was interviewed on 2/7/23 at 10:08 a.m. She said the Resident #66 could not see well and was very independent. She said the facility discontinued her air mattress because it was slippery. She said the staff put her shoes at her bedside so she can put them on before ambulating. She said she was sure there were other interventions in place, but she could not think of them at the time of the interview. Licensed practical nurse (LPN) #1 was interviewed on 2/7/23 at 10:11 a.m. She said the interventions for Resident #66's repeated falls were to keep the call light within reach, frequent checks, and working with therapy. She said the resident ambulated with a front wheel walker to the bathroom. She said she was not sure if the resident was supposed to ambulate independently or not. She looked in the resident's medical record which revealed the resident was a limited assist to and from the bathroom. The restorative nurse aide (RNA) was interviewed on 2/7/23 at 2:18 p.m. She said Resident #66 was discharged from PT on 2/3/23 and she had not started working with her, however she was on her list to start a restorative nursing program. She said Resident #66 was previously on a restorative program for ambulation but was ambulating independently and discontinued the program. She said the resident was one assist with cuing. She said there had not been a fall committee since COVID-19 began. She said she had not been involved with the fall committee. The director of nursing (DON) was interviewed on 2/7/23 at 2:33 p.m. He said himself and the NHA were new to the facility. He said they were aware there was no fall committee in place and planned on starting one. He said the NHA, himself, the two new unit managers, therapy, dietary, and the facility director had morning huddles in which they discussed resident changes, occurrences, and incidents. He said a resident with repeated falls was to have a fall committee in place to look at the root cause of the falls and put a plan in place for that individual resident. He said the unit managers were responsible for updating the care plans with recent falls and new interventions. He said a fall committee would help with follow up of interventions and would include the physician. The NHA was interviewed on 2/7/23 at 3:43 p.m. She said currently the fall committee was the morning clinical stand up. She said the DON and herself were currently working on updating care plans and reviewing interventions. She said the facility recently hired two new unit managers who would be responsible for fall management investigations and care plan updates as well as the minimum data set coordinator (MDSC). She said the facility completed a fall audit in December 2022 and identified documentation missing from the neurological assessment. She said she had put together a plan to bring back the fall committee to identify residents with repeated and high fall risks and trends. She said the facility had areas that needed improvement such as neurological assessments, use of the fall huddle worksheet, interventions, and updating/revision of the care plans. She acknowledged the facility triggered high for falls. She said she would put a performance improvement plan (PIP) in place for falls. 47536 III. Resident #47 A. Professional reference Reference for safe use of the sit to stand the resident must be able to stand on his feet to ensure proper placement of the sit to stand seat halves. https://safetyucsf.edu/sites/g/files/tkssra256/f/Arjo%20Sara%20Stedy%20Instructions%20for%20Use.pdf accessed 2/6/23 read in pertinent part, the sit to stand lift is intended to transfer a resident to and from a chair, a wheelchair, a bed and a toilet. Instructions for safe use of a sit to stand are -Position resident near the sit to stand; -Ask the resident to stand up; -Pivot the two seat halves on the sit to stand upward; -Ask the resident to sit down back down on the chair while holding the sit to stand crossbar. B. Resident status Resident #47, age 88, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO) diagnoses included Parkinson's disease, Alzheimer's disease, depression, syncope (loss of consciousness) and collapse, urinary incontinence, and malaise (general discomfort). On 11/30/22 he was admitted to hospice care at the facility. The 11/28/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of four out 15. The resident required extensive assistance from two or more persons for bed mobility, transfers, toileting, and extensive assistance of one person for dressing and personal hygiene. The MDS assessment documented the resident had a fall history upon admission; with at least one fall in the previous month, and additional falls in the previous two to six months. On 11/22/22 the resident scored a 20 of 20, high risk, on the facility fall risk assessment. C. Observations On 1/1/23 at 10:30 the resident was observed sitting in the facility common area recliner and was assisted to a wheelchair by facility staff of one person using a sit-stand transfer device so that he could use the toilet in his room. The resident was able to use his arms to grasp the sit-to stand and he did not place his feet on the floor during the transfer (see professional reference). The resident's room contained an electric bed and personal items. There was a call light cord clipped to the bed linens. The cord length was too short to allow the resident to use it from the floor. D. Resident representative interview The resident's spouse was interviewed on 2/6/23 at 11:55 a.m. She stated her husband was admitted to the facility because he had several falls at home and she was unable to care for him alone. She was aware her husband had fallen since he was admitted to the facility but did not recall how many times. She was aware the resident had once crawled from his room to the common area and had sustained a skin abrasion on his foot. She said they will never know what happened with that. The resident's spouse said she thought the resident had multiple falls because his legs were weak. She did not recall facility staff speaking to her about a plan of care for occupational therapy or physical therapy, although she recalled one meeting after admission before the falls occurred. She also stated she liked to take the resident home sometimes and wished someone would help her understand how to use a transport style wheelchair so that she could do that more often. The resident's spouse was unsure if the resident would be able to consistently use his call bell light because he likely would not remember because of his anxiety. E. Record review A review of the resident's medical record revealed he had sustained 12 falls from 11/24/22 to 2/7/23. A hospice care plan was provided by the DON on 2/7/23 and identified the care area of mobility/safety/falls. The goals identified for the falls care area were for the resident to maintain a level of mobility and decreased risk of falls. Interventions for the achievement included: -Assess resident need for supportive devices; -Assess for impaired physical limitations; -Train resident/caregiver on reporting falls/safety issues to hospice; -Train resident/caregiver on safe use of equipment; -Wheelchair for transfers; -Train patient/caregiver on methods to reduce falls to use a gait belt, minimum to moderate assist of 2 people present was preferred; -Train patient/caregiver on mechanical lift; -Assess risk vs benefits for bed rails; -Hospital bed with bed rails elected by patient and primary caregiver; -Train the patient/caregiver to move and function safely within the patient's limitations; -Use an electric recliner modified 1-2 persons with supervision and use a toileting schedule; -Encourage appropriate use of durable medical equipment; -Use a sit to stand aid used in the facility with 1-2 persons; -Remove hazards and reduce injury; -Keep bed in low position/fall pad next to bed while in bed. A review of the February 2023 CPO indicated the facility failed to obtain physician orders for those fall prevention interventions recommended by the hospice provider, durable medical equipment, fall risk assessments, to notify the physician with resident changes in conditions, to complete frequent safety checks, and document transfer status. On 11/25/22 the facility and hospice physician initiated an order for an occupational therapy evaluation. Fall #1 The nurse progress note dated 11/24/22 at 7:15 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the director of nursing (DON) nursing home administrator (NHA), wife, and nurse practitioner were notified of the resident's fall. -The documentation failed to include documentation of how those notified responded and did not indicate the hospice provider was notified of the fall. Fall #2 The nurse progress note dated 11/27/22 at 2:30 p.m. documented the certified nurse aide (CNA) heard the resident's wheelchair bump into a heater. The resident was found by the CNA sitting on the floor between his wheelchair and bed. -The nurse did not document that a post-fall assessment was completed. The nurse note failed to reveal notification to the family, physician, hospice provider, DON, or NHA. Fall #3 A nurse progress note dated 11/29/22 at 5:30 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his wheelchair. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the resident's call light was in his reach and frequent safety checks were in place. -There was no documentation that indicated the resident had the ability to understand and use a call light system. Results of the results of the safety checks were not found in the record. The note revealed the DON, NHA, wife, and nurse practitioner were notified of the fall. The documentation failed to include how those notified responded or any if any recommendations were made. The documentation failed to reveal the hospice provider was notified. The facility's residents care plan was updated on 11/30/22 and initiated a focus for fall prevention. The facility care plan added the following and interventions: -Monitor/document/report as needed x 72 hours (after a fall) to health care provider for signs and symptoms, pain, bruises, changes in mental status, new onset, confusion, sleepiness, inability to maintain posture, agitation; -Ensure the resident wears appropriate non-slip footwear when mobilizing in wheelchair; -Monitor resident for significant changes in gait, mobility, positioning devices, standing/sitting balance and lower extremity joint function. Fall #4 A nurse progress note dated 12/5/22 at 11:38 a.m. documented the resident was found on the floor, on his back. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented responsible parties notified; the DON, NHA, wife, and physician. -The documentation failed to include responses or recommendations from those notified. There was no documentation the hospice provider was notified of the resident's fall. On 12/8/22 the facility updated the resident's care plan with the following intervention: -Cognitive: encourage participation and plan diversional activities that are of resident interest. There was no documentation of assessment or interdisciplinary team review for consideration of effectiveness or failure of previous interventions and why and how the resident's cognition contributed to his falls prevention. Fall #5 A nurse progress note dated 12/9/22 at 6:49 p.m. documented a fall that was reported by another resident who noticed the resident was on the floor by his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. After the fall the nurse placed a fall mat next to the resident's bed and put the resident's bed in the lowest position. The nurse documented the DON, NHA, wife, and after-hours provider were notified about the fall. -The documentation failed to include responses or recommendations from those notified. After the two new interventions were initiated, the facility did not update the residents care plan and did not document that communication with the hospice provider occurred. The hospice nurse completed a nurse visit on 12/22/22. It documented on the Missouri Alliance for Home Care (MAHC) 10-Fall Risk Assessment the resident had a score of 10 with a score of four or more was considered a risk for falling. -The hospice nurse did not include documentation of an awareness of the resident's falls. Falls #6 and #7 The nurse progress note dated 12/20/22 at 4:16 a.m. documented the resident had two falls during the shift. The nurse note revealed the resident was found on the floor next to his bed on the fall mat. -The documentation failed to include a post-fall nursing assessment for each fall and did not document whether or not injuries were present. The nurse determined the resident required anti-anxiety medication. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. Fall #8 A nurse progress note dated 1/2/23 at 4:15 p.m. documented the resident was found on the floor in his room between the recliner and bed. The nurse documented the resident said he was getting up and out of his recliner. The nurse documented the resident's vital signs and neurological assessment was all normal and did not indicate whether or not any injuries occurred. -The nurse documented all notifications were made, but did not include who was notified of the fall, or whether or not those notified had responses or recommendations. There was no note the hospice provider was notified of the resident's fall. On 1/4/23 the facility edited the resident's care plan and listed some of the dates the resident had falls: 11/24/22, 11/17/22, 11/29/22, 12/5/22, 12/9/22, 1/2/23. The care plan edits failed to include changes to the fall prevention interventions and there was no documentation the facility or hospice provider interdisciplinary teams had reviewed the residents fall status. Fall #9, #10 and #11 The nurse progress note dated 1/17/23 at 6:48 a.m. was a nurse summary note for three separate falls during the shift. The nurse documented the resident was found out of bed on the fall mat next to his bed after each fall. -The nurses documentation failed to include a post-fall nursing assessment after each fall and did not document whether or not the resident was injured. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. On 1/19/23 the facility physician discontinued the order for occupational therapy evaluation and treatment. On 2/7/23 the facility produced a copy of a handwritten sticky note which indicated the resident had refused the occupational therapy evaluation. There was no documentation why the resident refused or if therapy benefits were reviewed with the resident and family. Fall #12 The facility physician documented on 1/25/23 the resident was found on the floor on a previous day. The physician documented the resident had crawled out of his room, across a common area to where he was found by the facility staff. The physician documented as a result of crawling on the floor, the resident sustained an abrasion to his right foot which required wound care evaluations and physician orders for treatment. The facility physician documented the resident had a problem with falls and all interventions were in place. The nurse progress notes dated 1/21/23 documented the resident had a new wound on his right foot. The nurse progress note failed to document if the family or hospice physician was notified of the resident's change in condition. F. Staff interviews Registered nurse (RN) #1 was interviewed on 2/6/23 at 11:30 a.m She stated the staff keep a close eye on the resident to prevent falls. She said the resident sits in a recliner in the common area and his wife visits him to help calm his anxiety. She stated the resident has impulsive behaviors and did not use his call light for staff assistance when he was in his room. The RN was unable to locate a hospice care or communication binder. She stated at times communication with the hospice nurse occurred when the hospice nurse visited the resident. The RN was unable to identify when the hospice nurse visited the resident and could not locate documentation that revealed the hospice had been notified of the resident's falls. The RN stated she was unaware how the hospice and facility reviewed and collaborated with the resident's care and believed it was up to the hospice company to complete nurse assessments and communicate with the providers regarding resident status. She was unaware of fall prevention interventions recommended by the hospice provider. The restorative nurse aide (RNA) was interviewed on 2/7/22 at 2:15 p.m. She stated she was unaware the resident had fallen numerous times. She stated she could evaluate the resident and spouse's request for assistance with wheelchair use and training. The director of nursing (DON) was interviewed on 2/7/22 at 2:33 p.m. The DON stated when a resident had a fall the nurse was to complete an assessment form and a facility incident report form. He stated he was unaware of the numerous falls the resident had and that the facility staff had not been communicating with the hospice provider. The DON provided several printed hospice nurse visit notes but was unable to locate documentation the facility had communicated the resident's problem with falls with the hospice provider. The DON stated the facility did not currently have an interdisciplinary team that reviewed resident falls or a fall prevention team. The DON stated the facility was aware improvement was necessary and planned to start a quality improvement project for falls prevention in February 2023. <[TRUNCATED]

Based on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for two of three medication storage rooms. Specifically, the facility failed to discard expired medications. Findings include: I. Facility policy The Medication Storage, dated January 2021, was requested and received on 2/6/23. The policy stated in pertinent part: -Medications and biologicals are stored properly, in containers that meet requirements. The pharmacy dispenses medications that meet labeling requirements which may include medication carts, medication rooms, or other suitable containers; -Outdated medications and containers are immediately removed from stock, disposed of according to medication disposal procedures; -Medication storage conditions are monitored on a regular basis as a random quality assurance check. II. Observations and interviews A. Medication room [ROOM NUMBER] On 2/6/23 at 10:25 a.m., the Heritage Square medication room and medication cart were observed with registered nurse (RN) #1. RN #1 verified the medication cart had a bottle of open multi-dose floor stock guaifenesin cough syrup and the label indicated the medication expired in June 2022. The RN stated staff involved in administering medications was responsible for verifying expiration dates and removing expired items from supply. RN #1 stated using expired medications could expose the resident to a risk for infection and/or receiving ineffective medications. She immediately removed the bottle of medication for proper disposal. A review of February 2023 computerized physician orders for residents on the Heritage Square hallway revealed four of 16 residents had an active order for liquid guaifenesin cough medication. One of the residents was administered a dose of guaifenesin on 2/2/23. RN #1 stated when the medication was prepared, the nurse selected the medication from the medication cart. There was one bottle on the medication cart. B. Medication room [ROOM NUMBER] On 2/6/23 at 10:55 a.m., the Mountain Lodge medication room and medication cart was observed with licensed practical nurse (LPN) #2. LPN #2 verified the emergency medications kit had expired in January 2023. There was a sticky note on the outside of the kit that read a new kit was ordered from the pharmacy on 1/29/23. The LPN stated she did not know who was responsible to follow-up and ensure a replacement medication kit was received. On 2/7/23 at 10:25 a.m., RN #2 verified the expired emergency medication kit had not been removed from stock and replacement emergency medications had not been received. LPN #2 verified the medication room supply cabinet contained blue top vacutainers, BD - 81 each had expired on 1/31/23 and had not been removed from supply. LPN #2 stated the blue top vacutainers were used by nurses when immediate laboratory orders were received from the physician. She stated using expired blood collection tubes could contribute to inaccurate lab results. A blue top collection tube used for blood coagulation testing and other plasma or whole blood determination laboratory testing. The blue top collection tube contained a measured amount of citrate, a reversible anticoagulate, which preserved the blood until processed in the laboratory. III. Interviews The infection preventionist was interviewed on 2/6/23 at 11:00 a.m. He stated expired items should be removed from supply and the removal of expired items was assigned to the night shift nurses. He said that staff were not comfortable with disposing of glass items and were unsure when items could be thrown in the trash or if specific disposal containers were required. He stated the emergency medication kits were prepared and sealed at the pharmacy. When a used or expired medication kit was used, the pharmacy would replace the kit on a one-to-one exchange basis and expired items should be removed from stock. The director of nursing (DON) was interviewed on 2/6/23 at 11:15 a.m. He stated he was unaware of the expired items in the medication rooms. He said it was the responsibility of the night shift nursing staff to identify and remove expired medications from the medication rooms and carts. The DON was unsure if the pharmacy tracked and replaced the kits automatically or if the facility was required to order a new kit with each expiration. The DON stated he would contact the pharmacy on 2/6/23 and request a replacement for the expired emergency medication kit.

Based on observation, record review, and staff interviews, the facility failed to ensure two (#2 and #32) of four out of 28 sample residents received care consistent with professional standards of practice to promote prevention and healing of pressure injuries. The facility failed to ensure Resident #2 who was severely cognitively impaired with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failures to implement timely person centered interventions, follow up on the initial observation of the wounds and implement new interventions created a delay in care indicated the facility did not do everything to promote prevention of pressure ulcers. The facility's failures to implement an air mattress for Resident #2 who was dependent on staff for off loading, prevented Resident #2 the ability to retain healthy skin integrity and Resident #2 sustained a Stage 3 pressure ulcer. Resident #2 had the ability to heal, therefore the pressure ulcer was avoidable. Additionally, the facility failed to timely implement treatment orders for Resident #32's pressure injury. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org (11/22/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). II. Facility policy The Wound Care Pressure Ulcer policy, revised on 5/25/21, was provided by the nursing home administrator (NHA) on 11/17/21 at 2:36 p.m. It documented in pertinent part, to include mobility support and positioning, documentation, and pressure ulcer prevention and treatment. The policy noted the facility must ensure a resident who enters the facility without pressure sores does 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. III. Resident #2 A. Resident status Resident #2, age 83, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/27/21 minimum data set (MDS) assessment revealed Resident #2 was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. He required extensive one person assistance with all activities of daily (ADLs) and was always incontinent of bowel and bladder. Resident #2 had one stage 3 pressure injury. He had a pressure reducing device on his bed and on his chair. He was receiving pressure ulcer/injury care, he was on a hydration and nutrition program as well as a turning/repositioning program. He was a fall risk and was using a wheelchair for mobility. B. Record review The 7/28/21 MDS revealed Resident #2 did not have any pressure ulcers identified. The resident's pressure ulcer care plan, revised on 11/10/21, identified a pressure ulcer on his left ischium. The goal was to have the pressure ulcer healthed by the review date. The interventions included: -Monitor location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Report abnormalities, failure to heal, infection, and maceration to the health care provider; -Identify potential causative factors and eliminate/resolve where possible; and, -Turn and reposition in bed and wheelchair as needed for maximum comfort and to minimize skin breakdown. The November 2021 CPO included: -Protein modular 30 milliliters (ml) liquacel mixed with 240 ml beverage of choice one time a day for wound healing with a start date of 11/16/21. (added during survey) -Protein modular 1 ounce (oz) liquacel mixed with 4 ounces beverage of choice one time a day for 14 days for wound healing with a start date of 10/25/21. -Vitamin C tablet ([MEDICATION(S)]) 500 milligrams (mg) two times a day for wound healing with a start date of 8/26/21. -Left ischium wound treatment cleanse, apply [MEDICATION(S)] dressing, may secure with transparent film three times a week every day shift on tuesday, thursday and saturday and as needed with a start date of 8/28/21. (This was not ordered for nine days after the first observation see, rehabilitation note below 8/19/21) -Offload buttocks turn resident on his side when he was in bed. Resident should not sit up for longer than 1 hour at a time every day and night shift for wound with a start date of 8/26/21. -Air mattress for wound care with a start date of 10/1/21. The quarterly care conference note dated 8/3/21 revealed the resident's skin was intact with no noted concerns. His weight was stable and he ate 80 percent of his meals. The rehabilitation note dated on 8/19/21 noted the resident had a quarter sized spot on his left buttock that was open and bleeding from bowel movement (BM) irritation. The wound was cleaned with wound cleaner, applied skin prep to edges and applied a foam dressing to protect the remainder of the night and offloaded buttocks. Documented reported to day staff to have physician determine the course of action. There was no follow-up documentation that indicated the day staff were notified after the observation on 8/19/21 until the nurses note on 8/23/21. This created a delay in care to address the residents' pressure related skin areas. The 8/22/21 Braden scale assessed Resident #2 was at mild risk for skin breakdown with a score of 16 out of 23. The intervention guide suggested frequent turning, manage nutrition, manage moisture and provide pressure reduction support surfaces if bed or chair bound. The nurses note dated 8/23/21 documented the registered nurse (RN) was called to the residents room while he was being cleaned. The resident had a moisture associated skin damage (MASD) open area on his left buttock. It was noted he had a pressure wound on his left ischium and a wound on his right ischium. The RN asked for orders for the resident to be seen by the wound doctor. The RN wound rounds note dated 8/26/21 noted the open area on the right ischium was resolved and the left ischium wound was debrided and orders given for wound treatment. The nurses note dated 8/26/21 noted new orders for occupational therapy (OT) to evaluate and treat for proper positioning in a wheelchair. The physician wound evaluation dated 9/2/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 1.0 x 2.4 x 0.15 centimeters. The treatment plan was ordered to apply dressing three times a week for 23 days with offloading and repositioning per facility protocol. The RN wound rounds note dated 9/2/21 documented the wound on his left ischium was 80 percent better than it was last week. The physician wound evaluation dated 9/16/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 0.7 x 2.2 x 0.15 centimeters. The treatment plan was ordered to apply dressing three times a week for 30 days with offloading and repositioning per facility protocol. Dietitian to review his protein intake. The physician wound evaluation dated 9/23/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 0.9 x 2.0 x 0.15 centimeters (cm). The treatment plan was ordered to apply dressing three times a week for 23 days with offloading and repositioning per facility protocol as well as limiting his sitting to 60 minutes. The physician wound evaluation dated 9/30/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 0.9 x 2.4 x 0.15 centimeters (cm). The treatment plan was ordered to apply dressing three times a week for 23 days with offloading and repositioning per facility protocol. Limit his sitting to 60 minutes. Gel cushion to his wheelchair. The RN wound rounds note dated 9/30/21 noted the wound on his left ischium was a little bigger than it was last week. The nurses note dated 10/3/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the skin breakdown was first discovered by the rehabilitation department on 8/19/21 and the resident was assessed by an RN on 8/23/21 for skin concerns with MASD and open area to left buttock (see rehabilitation note 8/19/21 and nurse note 8/23/21 above). The physician wound evaluation measurements read weekly: -10/7/21, 0.5 x 1.4 x not measurable; -10/14/21, 0.4 x 2.0 x not measurable; -10/21/21, 0.7 x 1.7 x 0.1 cm; and, -11/4/21 0.5 x 0.9 x 0.1 cm. The RN wound rounds note dated 11/4/21 noted the wound on the left ischium was smaller probably due to the air mattress he was using on his bed. -This indicated the resident had the ability to heal given proper person centered interventions and care. This also indicated the wound was avoidable. The physician wound evaluation dated 11/11/21 noted the resident had a stage 3 pressure wound of the left ischium for at least 81 days duration. The wound size was 0.7 x 2.2 x 0.15 centimeters. The treatment plan was ordered to apply dressing three times a week per 30 days with offloading and repositioning per facility protocol as well as limit sitting to 60 minutes. C. Observations and wound care observation On 11/15/21 at 11:25 a.m. a continuous observation was conducted. Resident #2 was observed in his wheelchair in the dining room. He was observed exiting the dining room and propelling himself down the hall. The resident was observed in his wheelchair for the duration of the observation period from 11:25 a.m. until 3:44 p.m. During the observation, he propelled up and down the hallway and staff would redirect him back towards his room. He did have a cushion on his wheelchair during observation. -Staff were observed redirecting him but did not offer for him to lay down or offload during the four hour observation. On 11/17/21 at 4:45 p.m. licensed practical nurse (LPN) #2 was observed providing wound care to Resident #2. LPN #2 performed hand hygiene and donned cleaned gloves before she provided wound care treatment. The wound on the left ischium was not measured at time of treatment but was approximately 1.5 inches long, 1 centimeter wide and 0.1 centimeters deep. There was serosanguinous drainage, no odor and no signs of infection. LPN #2 said the wound was facility acquired due to the resident sitting in his wheelchair for too long. She said he did not like to lay down and stayed in his wheelchair for long periods of time. D. Staff interview LPN #2 was interviewed on 11/17/21 at 12:45 p.m. She said there was a wound care nurse and a physician who completed a weekly wound care round for the residents with wounds. She said when a resident was admitted to the facility a registered nurse would assess residents for wounds and for skin integrity. She said Resident #2 did not have wounds when he was first admitted . She said he used to walk with a walker and was more independent. She said he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said he was incontinent of bowel and bladder which contributed to his skin breakdown. She said he did not like to lay down in bed and will yell to get back into his wheelchair. The director of nursing (DON) was interviewed on 11/18/21 at 9:49 a.m. She said the wound for Resident #2 was a facility acquired pressure ulcer. She said he was noncompliant with offloading and preferred to be in his chair. She said the staff encouraged repositioning and the care plan was updated. However the pressure ulcer care plan revised 11/10/21 did not indicate the resident was non-compliant with offloading and preffered to be in his chair. IV. Resident #32 A. Resident status Resident #32, age 92, was admitted [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/15/21 minimum data set (MDS) assessment indicated Resident #32 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. She was totally dependent on two persons for transfers, and required extensive two person assistance with bed mobility, toileting, dressing, and personal hygiene. She had no pressure ulcers, but was at risk for pressure ulcers. She was incontinent of bowel and bladder. B. Record review The November 2021 CPO was reviewed and revealed Resident #32 had an order to apply moisture barrier cream to buttocks every shift start date 4/6/21, and pressure reducing mattress start date 3/30/21. The skin integrity care plan, dated 6/25/21, documented the resident has actual and potential for impairment to skin integrity related to Braden score of 13 and need for ADL assistance with bed mobility and transfers. Keep skin clean and dry. Use lotion on dry skin. Turn and reposition in bed as needed to maximize comfort and minimize skin breakdown. Resident uses incontinence products: brief. Check before and after meals and as needed. The skin observation tool written on 11/3/21 at 10:39 a.m. revealed redness to left and right buttock. The nurses notes, on 11/7/21 at 4:09 p.m., documented, CNA (certified nurse aide) reported to writer that resident has two small open areas on her tailbone/coccyx. Writer looked at area and applied barrier cream. Will notify nurse practitioner (NP) and see if there are any new orders. -There were no further orders or documentation regarding the wound or follow-up from the nurse practitioner (NP) until 11/15/21. The wound data toll collection sheet, on 11/7/21 at 4:13 p.m., documented there was an open ulcer, slightly red. The resident had a hard time repositioning, but it documented she had an air mattress. The data collection sheet documented the wound was not present on admission and the section for measurements was blank. The wound data collection sheet further documented will write note to the NP about open area and see if they would like to order anything. The nurses note, dated 11/9/21 at 4:50 p.m., documented communication with NP, resident open areas on buttocks/sacrum. Orders to consult wound care RN and to assist with weight shifting. -However, no orders were written until 11/15/21. The nursing skilled note, dated n 11/13/21 at 2:02 p.m., documented Resident #32 had wounds/ulcers, shallow open areas to coccyx and sacrum. -There was no measurement. An order was written on 11/15/21, during the survey, for the wound care MD to eval and treat the wounds. -However, this was seven days after the order was initially given on 11/9/21. The nurses notes, on 11/15/21 at 4:54 p.m., seven days later, documented Communication with NP related to resident open areas on buttocks/sacrum. Orders to consult wound care RN and to assist with weight shifting. The facility failed to follow up on the open wounds for seven days. -The NP ordered a wound care consult on 11/9/21. The nurses notes, on 11/16/21 at 1:52 p.m., documented, Resident has two open areas one on each side of her sacrum. They are both superficial and look like blisters that may have opened. The nursing skilled note, on 11/16/21 at 7:35 p.m., documented two superficial open areas to both sides of the sacrum. Area cleaned, barrier cream applied, Order to see wound care MD. It further documented, the resident was sent to the hospital at 3:45 p.m. with critical labs. The residents wounds could not be observed during the survey due to being transferred to the hospital, and she had not returned by the completion of the survey on 11/18/21. C. Interviews Registered nurse (RN) #1 was interviewed on 11/17/21 at 10:30 a.m. She said if a new or worsening skin condition occurred, the nurse should document a description of the wound, notify the MD for orders, and then notify the DON for further follow up. The DON was interviewed on 11/18/21 at 10:15 a.m. She said when a nurse finds a new wound or worsening wound, they should call the MD for orders and leave the facility wound care nurse (WCN) a message for follow-up. The wounds should be assessed and documented including the size, color, drainage and odor. The DON said the nurse notified the NP on 11/7/21 and the NP responded to the message sent to her on 11/9/21. The DON said the messages sent were not part of the medical record, but she could see them on her laptop. The DON said the NP gave instructions to get a wound care consult, and assist the resident with weight shifting. The DON said the wound care physician was at the facility on 11/11/21, but did not see the resident because no order was written until 11/15/21. The DON looked at the medical record on her laptop, and said she did not see an assessment from the wound care MD, or any follow up documented from the nurses. The DON said she reviewed the facilities WCN's wound log and did not see anything documented on her wound care log for Resident #32. She said the wounds should have been on the wound care log to be tracked and ensure follow up. The DON said the wound care log was used to track all wounds. The DON was interviewed again on 11/18/21 at 12:42 p.m. She said the WCN was not available at the facility for an interview. The DON said she had spoken to the WCN and the WCN said she had not seen any order until 11/15/21. The DON said Resident #32 had gone to the hospital on 11/16/21, and they would assess her wounds there. The DON said there was no further documentation regarding the wounds, or follow up, until the order was written on 11/15/21. The WCN was interviewed by phone on 11/22/21 at 4:45 p.m. She said Resident #32 was not seen by the wound care physician because the order was not written until 11/15/21. She said she did not know why there was a delay. The WCN nurse said she did not know if the wound was from pressure. -However, the wounds were over a bony prominence. The WCN said she had not seen the wounds because she had been pulled to work the floor frequently, and had not had a chance.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in three out of five medication carts and two out of two medication rooms. Specifically, the facility failed to: -Date medications when opened; -Dispose of expired medications; and, -Ensure the temperature of the medication refrigerators were monitored daily to ensure they maintained temperature. Findings include: I. Facility policy and procedure The Medication Acquisition, Receiving, Dispensing and Storage policy, dated 12/28/2020, was received from the director of nursing (DON) on 11/18/21, at 10:08 a.m. The policy documented in pertinent part, the location will routinely check for expired medications and necessary disposal will be done .refrigerators holding medications (such as insulin, etc.) will be kept between 36 degrees and 46 degrees fahrenheit .Check refrigerator temperatures daily. II. Facility pharmacy guidelines A document with the facilities pharmacy name, titled, Insulin Drug chart, dated 2018, was received from the DON on 11/18/21, at 12:30 p.m. The form documented in pertinent part; -[MEDICATION(S)] insulin, [MEDICATION(S)] injection expires 28 days after first use; -[MEDICATION(S)] insulin, expires 28 days after first use; -[MEDICATION(S)] insulin, expires 42 days after first use; -[MEDICATION(S)], discard vials in use after 30 days; -Multidose injectable vials, the beyond the use date after initially opening multi dose containers is 28 days. -[MEDICATION(S)], discard when the counter reaches 000 or 12 months after removal from protective pouch III. Failures A. Medication cart 800 West observations and interview The medication cart was reviewed with registered nurse (RN) #2 on 11/17/21, at 9:25 a.m. during medication pass. A multidose vial for [MEDICATION(S)] (used to treat overproduction of growth hormone) solution 500 mcg (micrograms) per ml was observed in the top drawer. RN #2 pulled out the vial to draw up the medication in a syringe and administered the medication to Resident #23. She said the vial, which was half full, was not dated and therefore should not have be used. She said she would dispose of the vial. She obtained a new vial to administer the medication and dated the vial. RN #2 said she did not know how long the vial was good after it had been opened. She said she thought maybe 28 days. B. Medication cart 800 East observation and interview The medication cart was reviewed with RN #1 on 11/17/21, at 10:22 a.m. The following was observed: -[MEDICATION(S)] insulin pen for Resident #37, open, no date; -Humolohg Kwik insulin pen for Resident #37, open, no date (cross reference F-761-significant medication errors); -[MEDICATION(S)] multidose inhaler, open, but not dated when opened. The inhaler had no counter for the number of doses administered. RN #1 said the insulin was good for 28 days after opening, but she did not know how long the eye drops and inhalers were good after opening. She said she did not have that information, but they needed to be dated when opened. C. Medication cart 700 Hall The medication cart was observed with licensed practical nurse (LPN) #1 on 11/17/21, at 10:54 a.m., the following was observed; -[MEDICATION(S)] insulin pen, open, no date; -[MEDICATION(S)] insulin multidose vial, open no date, and no name on the vial, the label had been partially peeled off and the name and order were not visible; -[MEDICATION(S)] insulin pen, open, no date: D. Medication room-Mountain Lodge The medication room was reviewed with RN #1 on 11/17/21, at 10:30 a.m. The mediation refrigerator was observed. In the refrigerator was a multidose vial of [MEDICATION(S)]. The vial was one fourth full. It had no date on it to indicate when it was opened. RN #1 said it was used to perform two step [CONDITION(S)] skin tests on residents. She said it should have been dated when it was opened. RN #1 took the vial to dispose of it. The medication refrigerator temperature log was observed. The log on the refrigerator was dated October 2021, the log indicated it was checked seven times in October, and was 42 degrees each time. There was no log for November. RN #1 said the refrigerator should be checked each day, (see DON interview below) but she did not know what the temperature should be. She provided a copy of the October log from the front of the refrigerator. No other documentation was provided for the month of November. E. Medication room-Meadows The medication room as observed with RN #1 on 11/17/21, at 12:00 p.m. The medication refrigerator had a log on the front door. The log was dated November 2021. The log indicated the refrigerator temperature was checked on three days, 11/11/21, 11/12/21, 11/13/21 and was 40-42 degrees. There were no other temperature checks of the medication refrigerator on the log. RN #1 provided a copy of the log at that time. F. DON interview The DON was interviewed on 11/17/21, at 1:34 p.m. She said the licensed nurse should date insulin, multidose vials, eye drops and inhalers when opened. She said she thought insulin was good for only 28 days after it was opened. She was unsure of how long other multidose vials or eye and inhalers were good after opening. She was unsure if she had a list from the pharmacy regarding how long these medications were good after opening but she would investigate further. The DON said the night nurse should have checked the refrigerator temperatures every night. She said she did not know what temperature the medications needed to be kept at. The DON said the nurse should move the medications to another refrigerator if the temperature was not correct. However, she did not know what that temperature should be. It was not listed on the refrigerator log. The DON said it did not matter how long the refrigerator temperature had been outside the correct range for medications. The nurse should move them to another refrigerator. The DON was interviewed again aon 11/18/21, at 10:07 a.m. She said the refrigerator temperature should be 36 to 46 degrees. The DON said the nurse should move the medications to another refrigerator if the temperature was not correct. However, she did not know what that temperature should be. It was not listed on the refrigerator log. The DON provided another copy of the temperature log for the Mountain Lodge medication refrigerator. This time the log was dated November 2021. The DON said the nurses accidently labeled it October instead of November and she had changed the month on it. The log was still missing temperature checks for 11/9/21, 11/10/21, 11/11/21, 11/14/21, and 11/15/21. IV. Facility follow-up On 11/18/21, at 10:06 a.m. the DON provided inservice education, dated 11/17/21, titled, Medication Acquisition, Receiving, Dispensing, Storage. The inservice had six signatures. It documented in pertinent part, refrigerators holding meds will be kept between 36 and 46 degrees fahrenheit. Check refrigerator temperatures daily. Log on log sheet. There was no instruction for what to do with the medications if the temperature was outside the recommended range. Additionally, the inservice documented that eye drops, creams, over the counter medications and vials must be dated when opened and expiration dates circled.

Based on observations, interviews and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being of two (#2 and #12) of two residents reviewed for activities out of 28 sample residents, and failed to provide evening activities for the residents who resided in the facility. Specifically, the facility failed to ensure: -Activities were provided for Resident #2 and #12 to prevent loneliness and boredom, and improve their well being; -Residents were not spending most of their time alone in the common areas unengaged with activity staff; and, -Evening activities were offered and provided to residents. Findings include: I. Facility policy The Activities policy, dated 8/25/21, was provided by the nursing home administrator (NHA) on 11/17/21 at 5:25 p.m. The policy included the following: Activities refer to any endeavor, other than routine activities of daily living (ADLs) in which a resident participates that is intended to enhance their sense of well-being and promote or enhance physical, cognitive, and emotional health. Activities will be a combination of large and small groups, one to one and self-directed activities. The program of activities will be a system that supports the development, implementation and evaluation of the activities provided to the residents. Activities will be designed with the intent to reflect residents' interests and age, reflect choices of the resident and promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. II. Resident #2 A. Resident status Resident #2, age 83, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/27/21 minimum data set (MDS) assessment revealed Resident #2 was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. He required extensive one person assistance with all activities of daily (ADLs) and was always incontinent of bowel and bladder. He was a fall risk and was using a wheelchair for mobility. B. Observations Resident #2 was observed on 11/15/21 multiple times throughout the day sitting in his chair in the hallway with little to no interaction from staff. During the observation, Resident #2 was not engaged in group activities or in one to one activities. -At 10:20 a.m he was sitting in his wheelchair propelling himself down the hallway. He would stop and tap his fingers together and roll his hands in a circular motion before he would continue to propel his wheelchair. -At 11:25 a.m. he was in his wheelchair exiting the dining room. He propelled himself down the hall. Staff redirected him back to the dining room. -At 11:40 a.m. he was in his wheelchair exiting the dining room. -At 11:59 a.m. he was leaving the dining and staff brought him back to the dining room. -At 12:31 p.m. he was propelling himself down the hallway. Staff walked by him with no interaction. -At 1:00 p.m. he was seated in his wheelchair in the hallway. Staff again walked by him with no interaction. -At 1:35 p.m. he was propelling himself down the hallway. He stopped and would tap his fingers together and roll his hands in a circular motion before he would continue to propel his wheelchair. -At 2:46 p.m he was in his wheelchair at the end of the 600 hall. He pushed the exit door at the end of the hall and his wander guard alarm was set off and the door did not open. Staff turned his wheelchair around and redirected him to go towards his room. He continued to propel himself down the hallway. Staff did not offer, encourage Resident #2 to participate in an activity or visit with him. -At 3:04 p.m. he propelled himself down the 600 hallway. Staff asked him what he was doing and he said, I don't know. Staff did not offer an activity or provide any leisure of interest to him. Resident #2 was observed during the survey, conducted from 11/15/21 to 11/18/21, spending most of his time in his wheelchair propelling himself down the hallway. He was not observed in an organized activity and was not observed in a one to one visit. He wandered around the facility in his wheelchair fidgeting with his hands, tapping his fingertips together and was not observed engaging in an organized leisure activity. C. Record review The annual activities initial assessment, completed 1/29/21, revealed the resident's activity preferences included books, magazines, music and outside time. This was the last assessment completed to reflect his leisure interests. There was not an updated assessment to reflect a change in condition or change in leisure interests. The activities care plan, initiated on 1/20/2020 and revised on 11/4/21, did not reflect any of the residents past or current leisure interests. The care plan did reveal a goal that he would express satisfaction with own level of interest and involvement during leisure time based on own interests and preferences. The care plan did reveal a list of interventions to include: -one to one visits 2 x a week and/or as available. Staff to offer a cup of coffee, warm blanket, reminisce, speak in spanish, offer hand massage/aromatherapy, offer to play cards or listen to music. -invite and remind of scheduled activities, assist to and from locations as needed; -offer to look at magazines; -encourage and monitor independent interests, assist with television in room, offer supplies in room, books and reading materials as needed; -offer outside time weather permitting; -offer men's group; -invite and assist to group activities; -offer visits with the chaplain when available; and, -offer animal visits when available. The November 2021 activity participation documentation reviewed on 11/16/21 at 2:24 p.m., revealed the resident participated five times in one to one activities in November. The documentation also revealed the resident participated in either a group or self directed activity 12 times in the month of November. The documentation does not specify the type of activity, the length of time or if it was staff lead or resident lead. D. Staff interviews The activity assistant (AA) #1 was interviewed on 11/17/21 at 8:59 a.m. She said she worked full time during the day Tuesday through Saturday and there is another AA who worked full time during the day Sunday through Thursday. She said all of the activities are documented on the electronic program point click care (PCC). She said the activity department offered group activities and one to one activities. She said they were not offering evening activities currently because there was not enough staff to work in the evening. She said the one to one program was posted in the activity office and listed the residents who were on the program and how many times a week the resident was visited. She provided the list of residents on the program. She said Resident #2 was on the one to one program to be seen two times a week. She said there were not any residents who were offered three times a week visits, only two times a week. She said the AD was the one who decided which residents were on the program. The AD was interviewed on 11/17/21 at 9:54 a.m She said there was a one to one program for specific residents identified by the staff who need more support. She said there are 14 residents on the one to one program currently. She said the activity staff met regularly to review which residents would benefit from one to one visits. She said the residents were seen one to two times a week depending on their need. She said they did not have any residents on three times a week for visits. She said Resident # 2 was recently added to the one to one program and was scheduled for two times a week. She said she did not identify him as needing three times a week. She said he preferred to be in his wheelchair and propel himself around the facility. She said he does not stay in one spot for very long. She said she would need to look at his assessment to see what he enjoyed. She agreed three times a week or more would benefit resident #2 and all residents would benefit from more engagement and interaction. III. Resident #12 A. Resident status Resident #12, age 90, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/5/21 annual minimum data set (MDS) assessment revealed Resident #12's activity preferences included books, magazines, pets, music and outside time and documented the resident was involved in the assessment. The 8/4/21 minimum data set (MDS) assessment revealed Resident #12 was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive one person assistance with all activities of daily (ADLs) and was frequently incontinent of bowel and always incontinent of bladder. B.Observations Resident #12 was observed on 11/15/21 multiple times throughout the day sitting in the television (tv) room with little to no interaction from staff. During observation, resident #12 was not engaged in group activities or in one to one activities. She would either be awake or sleeping in the reclining chair. -At 10:20 a.m she was seated in the recliner in the tv room. The television was on. -At 10:40 a.m. she was seated in the reclining chair in the tv room. -At 11:15 a.m. she was seated in the reclining chair in the tv room. -At 1:00 p.m. she was sleeping in the reclining chair in the tv room. -At 1:35 p.m. she was sleeping in the reclining chair in the tv room. Staff did not engage or offer organized visits with the resident during the observation. Resident #12 was observed on 11/16/21 multiple times throughout the day sitting by herself in the tv room with little to no interaction from staff. During the observation, she did not engage in group or one to one activities. -At 9:50 a.m. she was observed sleeping in the reclining chair in the tv room. She was leaning on her right hand with her head on the arm of the chair. -At 10:30 a.m. she was observed sleeping in the reclining chair in the tv room. -At 1:40 p.m. she was observed sleeping in the reclining chair in the tv room. She had her baby doll on her lap. -At 3:07 p.m. she was observed sleeping in the reclining chair in the tv room. She was in the same chair she was observed sleeping in this morning. -At 3:50 p.m. she was observed sitting in the reclining chair in the tv room. She was awake holding her baby doll. Staff were observed walking by her throughout the observation and did not offer a one to one visit or engage with the resident. Resident #12 was observed during the survey, conducted from 11/15/21 to 11/18/21, spending most of her time in the common area television (tv) room. She was observed sitting or sleeping in a recliner in the tv room for hours at a time. She would have her walker placed in front of her and would sleep in the recliner. She would have a baby doll sitting on her walker or in her lap at times during the observation. Staff would approach her when she would cry or raise her voice and offer her a warm blanket. The interaction was not an organized activity and was not long [MEDICATION(S)]. The observed staff interactions were one to two minutes at a time and were a result of the resident crying or a displayed behavior. C. Record review The annual activities initial assessment, completed 6/3/21, revealed the resident's activity preferences included books, magazines, pets, television, spiritual, walking, music and outside time. This was the last assessment completed to reflect her leisure interests. There was not an updated assessment to reflect a change in condition or change of leisure interests. The activities care plan, initiated on 5/2/19 and revised on 11/8/21, did not reflect any of the residents past or current leisure interests. The care plan did reveal a goal that she would express satisfaction with own level of interest and involvement during leisure time based on own interests and preferences. The care plan did reveal a list of interventions to include: -invite and remind of scheduled activities, assist to and from locations as needed. -offer to look at magazines; -offer animal visits when available; -promote independence through offering diversionary activities such as folding towels and household tasks; -encourage and facilitate opportunities to visit with other residents; -provide dementia friendly techniques, and; -offer warm blanket, compassionate listening, favorite soda and animatronic animal. The November 2021 activity participation documentation reviewed on 11/16/21 at 1:57 p.m., revealed the resident participated one time in one to one activities in November. The documentation also revealed the resident participated in either a group or self directed activity 10 times in the month of November. The documentation does not specify the type of activity, the length of time or if it was staff lead or resident lead. The activities care plan reviewed on 11/16/21 did not reveal the resident had received weekly visits from a private caregiver. The care plan did not reflect one to one visits from the facility staff or from a private caregiver. The activities care plan was updated by the AD on 11/17/21 to reflect the resident was receiving one to one visits from a private caregiver. The care plan revealed she was receiving support from a private caregiver and will monitor the need for supplemental one to one interventions outside of the caregiver presence. D. Staff interviews The activity assistant (AA) #1 was interviewed on 11/17/21 at 8:59 a.m. She said Resident #12 was not on the one to one program. She said she preferred to sit in the television (tv) room in the recliner chair. She said she did not join many group activities and preferred to observe others. She said she was social at times but would also raise her voice towards staff and not want to be bothered. She said she thought the resident received visits from an outside caregiver company. She did not know how many times a week she received the visits, but thought she was not on the one to one program because she received visits from another company. She said she would benefit from the one to one program and more companion visits would be good for her. The AD was interviewed on 11/17/21 at 9:54 a.m. She said Resident #12 was not on the activity one to one program. She said she preferred to spend time in the tv room observing others. She said she had a private caregiver from an outside company located on the campus. She said she was not on the program because of her private caregiver. The AD did not know how often the caregiver visited or on what days. She said she did not know if it was once a week or more. She agreed it was not in her current care plan. She said she would contact the company to find out how often she has a caregiver visit her weekly. She said she would update the resident's care plan. She said Resident #12 would benefit from more one to one visits and she could have been on their program in addition to the private caregiver. She said the resident did enjoy social visits and would reminisce about family when staff sat with her. She said all the residents would benefit from more engagement and interaction. IV. Evening activities A. Record review The facility activity calendar for September, October and November 2021 were provided by the activity director (AD) on 11/16/21 at 11:30 a.m. The activity calendars revealed there was one evening activity scheduled in September and October for 5:00 p.m. dinner and a movie program. The November calendar revealed there were no evening activities offered. The calendars revealed group activities were offered during the three month period. The average number of group activities offered daily for the three month period were three a day with the latest program offered at 3:00 p.m. on average. The facility resident council minutes for September, October and 2021 were provided by the AD on 11/16/21 at 11:30 a.m. The resident council minutes revealed that the September 2021 group activities were limited due to the COVID 19 status in the building and due to staffing issues. There were not as many programs offered including evening activities and outings. The resident council minutes revealed that the October 2021 group activities were canceled due to the COVID 19 status in the building. The November activities were adjusted due to open positions in the activity department. B. Resident interviews The resident council group interview was conducted on 11/17/21 at 9:57 a.m. Two residents participated in the interview due to the COVID status in the building. The resident council president stated that the activity department is short staffed and not able to provide evening activities. She said the AD schedules the programs for the two activity assistants to run, but she does not run the programs herself. She said the activity staff are in the building from 8:00 a.m. to 5:00 p.m. She said the department has an evening position open, but can not fill the position because of the low census in the building. She said there were not enough group activities during the day offered to the residents because there are not enough staff. The group interview revealed that the evening movie night that was scheduled one time a month has not been going on for the past couple of months. It is currently not on the November 2021 schedule. The group said they enjoy the movie night and miss it. They said they would enjoy weekly evening activities but understand there is not the staff to run evening activities. They said the activity room was left open after the activity staff left for the day and the residents were able to use the space for resident run activities or individual activities. C.Staff interviews The AD was interviewed on 11/17/21 at 12:29 p.m. She said the activity program had two full time activity assistants who covered seven days a week. She said she had an open position for part time evening shift. She said the program currently offered one evening activity a month, but it was not offered last month or this month. She said the number of activities offered is [NAME] because of the low census and open positions. She said there are three full time activity staff including herself but they work during the day and not at night. She said the activity room is left open for residents to lead individual activities and independent activities in the evening.

Based on observations, record review and interviews, the facility failed to ensure two (#2 and #61) of three residents out of 28 sample residents were free from restraints and accident hazards as possible and received adequate supervision and assistive devices to prevent accidents. Specifically, the facility failed to: -Ensure an assessment, obtain consent, physician order, and care plan were in place for Resident #2 for the use of a wander guard; -Obtain consent prior to the use of a wander guard for Resident #61; and, -Ensure Residents #2 and #61 were being monitored for elopement behavior to warrant the continued use of wander guards. Findings include: I. Facility policy and procedure The Bed, Chair and Door alarm policy, last revised August 2021, was provided by the nursing home administrator (NHA) on 11/17/21 at 3:25 p.m., it revealed in pertinent part, the facility will ensure that a system is in place for all bed, chair and door alarms and these alarms are in proper working order. The facility is to: -ensure that use of alarms is dignified and appropriate based on the resident's condition; -ensure nursing staff will be responsible for visually checking placement of alarms daily; -ensure the charge nurse will notify the family of the use of the alarm and educate staff regarding the alarm system; and, -ensue the use of the alarms will be reviewed on a regular basis but not less than quarterly by the interdisciplinary team. This can be done by the reduction or behavior committee or the care plan team. II. Resident #2 A. Resident status Resident #2, age 83, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included [CONDITION(S)], type 2 diabetes mellitus with diabetic polyneuropathy, [CONDITION(S)], unspecified dementia without behavioral disturbance, unsteadiness on feet and muscle weakness. The 10/27/21 minimum data set (MDS) assessment revealed Resident #2 was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. He required extensive one person assistance with all activities of daily (ADLs) and was always incontinent of bowel and bladder. He was a fall risk and was using a wheelchair for mobility. Resident #2 was code as not having e an alarm or restraint during the observation period. B. Observations On 11/15/21 at 2:46 p.m. the resident was propelling his wheelchair down the 600 hallway towards the exit door at the end of the hall. The resident attempted to push open the door and his wanderguard alarm was set off. The exit door did not open and the staff reacted to the alarm and redirected the resident to turn around and head towards his room. C. Record review On 11/16/21 at 2:06 p.m the computerized physician orders (CPO) revealed there were no orders for the wander guard to be in place, to be monitored daily or to be re-assessed quarterly. The care plan, last revised on 11/10/21, revealed the wander guard and risk for elopement were not identified. Care plan did not reflect the use of an alarm or risk for elopement. No assessment or consent with risks and benefits for the use of a wander guard were found in the resident's record. D. Staff interviews The licensed practical nurse (LPN) #2 was interviewed on 11/17/21 at 12:45 p.m. She said the resident does have a wander guard because he was a wander risk and he frequently went to the exit doors at the end of the hallway and would try to get out. She said he frequently leaves the dining room during meals and will try to exit the doors to the assisted living side of the building. She said he spends most of his time in his wheelchair wandering up and down the hallway. She said she did not see an order in his physician's orders for the wanderguard but he does currently have a wander guard placed on his chair. The director of nursing (DON) was interviewed on 11/17/21 at 1:55 p.m. She reviewed Resident #2's current physician orders and confirmed that he did not have an order in place for his wander guard. She said he did not have an assessment completed prior to placement and the wander guard was not care planned in his current care plan. She said she would update his care plan and his orders. The social services director (SSD) was interviewed on 11/17/21 at 4:00 p.m. She said their policy for wander guards is to have an assessment for the alarm and to update the resident care plan. She said the facility does not have a consent for the wander guard as they did not consider it a restraint. She said Resident #2 did not have an assessment completed for the wander guard and she did not find it in his care plan. III. Resident #61 A. Resident status Resident #61, age below 80, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), the diagnoses included [CONDITION(S)], anxiety disorder, Alzheimer's disease with early onset, hallucinations, altered mental status, muscle weakness, difficulty walking, unsteadiness on feet, delusional disorders and cognitive communication deficit. The 10/27/21 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a BIMS of three out of 15. She required limited assistance with bed mobility, transfers, dressing, and personal hygiene. She used a walker. The wanderguard was not indicated in the MDS. B. Record review The November 2021 CPO documented: -Check function of wander guard every night shift. -Check placement of wander guard every day and night shift. There was no order for the actual use of the wanderguard. The cognitive function care plan, initiated 7/14/21, revealed the resident had dementia as evidence by short and long term memory deficits, periods of increased confusion and altered perceptions, impaired comprehension and decisions, poor safety awareness, gets lost easily, and a history of wandering. The goal was for the resident to be safe in her own environment as evidenced by not leaving the facility without supervision. Interventions included: -Provide the resident with necessary cues-stop and return if agitated. -Wanderguard in place to alert resident of healthcare boundaries. -Present just one thought, idea, question or command at a time. The 4/24/21 elopement assessment documented the resident had started a new medication and had wandered in the past 60 days. The resident had no behaviors but had a diagnosis of dementia and was at risk for elopement. Resident/family education documented not applicable. There were no further elopement assessments completed in the most recent past two quarters of the year 2021. C. Interviews Resident #61's was not interviewable according to the current BIMS. The resident's legal representative was interviewed on 11/16/21 at 9:53 a.m. The representative said he was not aware that the resident had a wander guard in place and wanted it removed immediately. He said the facility never informed him or educated him nor did he give consent to place a wanderguard on the resident. The director of nursing was interviewed on 11/17/21 at 1:50 p.m. She said the facility did not consider a wanderguard as a restraint and did not need family consent to place. She said an order was given by the provider and they would make the family aware. She said a resident with a wanderguard should be assessed quarterly for appropriateness of continued use. D. Follow-up Additional documentation after facility was informed On 11/18/21 at 10:06 a.m. the DON provided additional information and documentation to support the use of the wander guard for Resident #2. The DON provided: -An order for the wanderguard dated 11/18/21 at 8:38 a.m.; -A physical device and restraint assessment effective date 11/18/21 at 8:38 a.m.; -An updated care plan initiated on 11/18/21 revealed the resident has potential for elopement and exhibits wandering behavior. The goal documented the resident will not leave the facility unattended and the interventions revealed the wander guard used to alert staff to resident movements, check wander guard functionality every shift to ensure wander guard is in working order and educate families to use the sign in/sign out sheet at nurses station. On 11/18/21 at 10:06 a.m. the DON provided documentation for a nursing inservice and education on the wanderguard monitoring system. The inservice included: -Resident must have a physician order in place for placement and monitoring; -Wanderguard must be careplanned; and, -Resident must be assessed for placement and re-assessed per regulation

Based on record review and interviews, the facility failed to provide adequate nutritional and hydration care and services, consistent with the comprehensive assessment for one (#1) of three residents reviewed out of three sample residents. The facility failure to closely monitor for Resident #1 with a [DIAGNOSES REDACTED].#1 sustaining a 10.6 pound weight loss or 7.69% in 14 days. Subsequently, she had critical laboratory levels requiring immediate interventions and the need to be sent out to the hospital emergently. Resident #1 was admitted to the hospital with [REDACTED]. Cross-reference: F580 Failed to timely notify physician and family. Findings include: I. Policy and procedure A. Nutrition Interventions Policy revised The Nutrition Interventions Policy and Procedure, last revised 1/19, received from Registered Dietitian (RD) on 7/7/2020 at 9:45 a.m., revealed in pertinent part, The dietitian identifies residents who are at risk and/or potential risk for nutrition-related problems due to insufficient/inappropriate intake of food. The dietitian recommends interventions to improve the resident's intake, based on resident preferences and tolerance. The dietician should determine appropriate interventions based on the identified etiology/cause of the risk factor, monitor the residents' acceptance/outcomes on a regular basis, recommend changes to foods served based on nutritional assessment and seek approval from the Medical Director for methods to increase calorie and protein intake. B. Hydration Policy and Procedure The Hydration Policy and Procedure, last revised 1/19, received from the RD on 7/7/2020 at 9:45 a.m., revealed in pertinent part, Residents will be provided with sufficient fluid to maintain proper hydration and health, including fluids served at mealtimes and between meals, offered consistent with care plan, preference and choice. Risk factors for dehydration will be identified. Risk factors may include cognition/dementia, fluid loss or restriction, functional impairments, refusal to consume food/beverages, or other factors. If hydration status is poor on thickened liquids, consult with family/SLP (speech/language therapist)/physician on balancing the risks for aspiration against the potential benefits of better hydration. The dietitian will be notified of all significant changes in hydration status for accurate assessment of fluid needs and recommended interventions. Additional fluids are offered between meals throughout the day. Resident's identified at risk for dehydration include those with conditions such as weight loss, poor meal intakes and pressure injuries. These residents may have their fluid intake monitored by nursing, have interventions documented on the care plan, be added to Nutrition Alert, and offer additional fluids during medication pass or between meals. II. Resident #1 A. Resident status Resident #1, age 79, admitted [DATE] and discharged [DATE] to the hospital. According to the May 2020 computerized physician orders [REDACTED]. The 3/17/2020 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and unable to complete the brief interview for mental status (BIMS). Staff assessment revealed the resident had both short and long term memory problems. She required extensive assistance with all activities of daily living. The resident received a mechanically altered diet. No rejection of care documented. III. Record review The nutrition care plan, initiated 6/13/18 and last revised 3/20/2020 (new interventions were not added until after the resident was sent out to the hospital-see May 2020 CPO), revealed the resident had a potential for nutritional problems and had a significant weight loss. Interventions included: -Follow resident by nutritionally at risk (NAR) committee related to weight loss, initiated 12/17/19; -Weekly weight as ordered, initiate 6/13/18; -Adaptive equipment of plate guard and cups with straws needed, initiated 6/17/19; -Requires regular diet with pureed textures with mildly thickened liquids and extra gravies and sauces. Provide room water pitcher, initiated 6/13/18; and, -Provide puree snacks daily related to reduced intakes, initiated 3/20/2020. The May 2020 CPO revealed the orders for a regular diet with pureed texture, mildly thick consistency fluids with extra sauces and gravies, ordered 3/16/2020. The 3/18/2020 quarterly dietitian assessment revealed the resident had a significant weight loss of greater than 10% in 180 days, however, the resident weight trends had stabilized in the past 30 days with improved intakes. It indicated the resident estimated calorie needs were 1,294-1,582 kilocalorie (kcal)/day with 63-79 grams (g) of protein/day and 1,701-1,890 milliliters (ml)/day of fluid. The assessment revealed the resident's labs were within normal limits based on labs completed on 1/7/2020. The 3/24/2020 care conference progress note revealed the resident's diet was changed to puree with mildly thickened liquids and the resident was self-initiating eating well with the puree. The daughter attended the care conference telephonically. It indicated the resident's current weight was 137.6 pounds and she was eating 70-80% of her meals. According to the weight summary, the resident's weight on 3/29/2020 was 141.6 pounds then decreased to 135.6 pounds on 4/19/2020 and decreased again to 129 pounds on 4/26/2020 (a 12.6 pound weight loss in 28 days). -There was no documentation the family, dietitian or physician were notified of the significant weight loss. The May 2020 treatment administration record (TAR) revealed the resident was to have a weekly weight done every Thursday on night shift. On 5/7/2020 the TAR was coded (8), indicating to refer to the progress notes, which was blank. On 5/14/2020 the TAR was blank, indicating the weight was not obtained (no documentation was found in the progress). On 5/21/2020 the TAR was coded (8) and the progress note indicated the weight was not obtained because the resident was already in bed. The 5/14/2020 physician progress notes [REDACTED]. -It did not indicate any further work-up would be completed and no new interventions were recommended. The 5/22/2020 nutritional status progress note revealed the resident was being followed by the nutritionally at risk (NAR) committee related to insidious (gradual but harmful) weight loss. The resident's weight on 5/11/2020 was 130.8 pounds, down 4.8 pounds or 3.5 % in 30 days, 9.4 pounds or 6.7% in 90 days and down 24.2 pounds or 15.6% in 180 days. It indicated the resident had good intake, consuming 69% of meals on average in the past 30 days and accepted snacks occasionally between meals. It indicated the registered dietitian (RD) was going to trial interventions for weight stabilization-the trial interventions were not documented. According to the weight summary, the resident's weight on 5/24/2020 was 121.2 pounds. A re-weigh was done on 5/25/2020 at 120.2 pounds. (This was a 10.6 pound weight loss in 13 days). A 5/24/2020 progress note revealed the resident was difficult to arouse and stimulate to wake up and eat meals for the last two days. A 5/25/2020 progress note revealed the resident was noted with weight loss with poor appetite, taking only bites of each meal and drinking 1-2 cups of fluid with meals. It indicated the RD and nurse practitioner (NP) were notified. -There was no documentation to indicate the resident's family had been notified of the weight loss. A 5/25/2020 progress note revealed to continue pushing fluid, skin no longer flushed since early morning. The night nurse was notified to monitor the resident and push fluids when awake and report the next day, to the nurse practitioner, on how she was doing. A 5/26/2020 at 11:25 a.m. progress note revealed the resident continued to not eat or drink and appeared to be flushed. The nurse documented attempting to notify the daughter but she was unavailable. She contacted the nurse practitioner who requested emergent lab work and urinalysis. (A review of the progress notes revealed this had been the first contact with the daughter since 4/9/2020). A 5/26/2020 at 6:00 p.m. progress note revealed the resident had a change in condition and revealed signs of [MEDICAL CONDITION] and dehydration. A 5/26/2020 at 6:11 p.m. progress note revealed new orders were received to push fluids and the resident required IV fluids due to her poor intake. According to the May 2020 CPO, an order for [REDACTED]. -On 5/27/2020, this intervention was added to the resident's care plan, after she was discharged to the hospital. The May 2020 food and fluid intake report documented the following: -5/1/2020-5/26/2020: Resident #1 received less than 1700 ml of fluid a day except on 5/2/2020 when she received 2310 ml. -5/1/2020-5/26/2020: Resident #1 received less than 1294 kcal/day except on 5/2/2020 when she received 2310 kcal and on 5/18/2020 when she received 1400 kcal. For the month of May 2020, Resident #1 received less than the recommended amount of fluid and calories per day that was estimated by the RD on 3/18/2020 (see quarterly dietitian assessment above). A 5/26/2020 health status progress noted revealed the resident was not wanting to eat or drink, so the NP was notified and stat labs were ordered. The 5/26/2020 laboratory results revealed the following: -BUN (blood-urea-nitrogen) - 42mg/dL (milligrams/deciliter), normal range 5-28; -BUN/creatinine ratio - 49, normal range 10-28; -Sodium - 153 mmol/L (millimole/liter), normal range 136-145; and -Chloride 113 mmol/L, normal range 100/110. The 5/26/2020 verbal physician's orders [REDACTED]. Another 5/26/2020 health status progress note revealed the NP was notified of the laboratory results and ordered intravenous (IV) fluids for the resident, however, the facility did not have any sodium free fluids available, so the resident was sent to the emergency department for IV fluids and management of her high sodium. The 5/26/2020 emergency department report revealed the resident was being seen for critical high sodium of 153 mmol/L. The report indicated her admitting [DIAGNOSES REDACTED]. Her physical exam revealed her oral mucosa was dry and her weight at the hospital was 110 pounds (10 pounds less than the weight obtained at the facility on 5/25/2020). The 5/27/2020 hospital physician progress notes [REDACTED]. She had not been on hospice or palliative care while residing at the facility. IV. Family interview Resident #1's family member was interviewed on 7/7/2020 at 9:00 a.m. She said her biggest regret was lack of communication. She said she had called the nursing home administrator (NHA) and had left a message wanting them to consider having her father come in to assist her mother with meals. She said she had seen her mother through the window on 5/15/2020 and her mother was covered with a blanket. She said her mother seemed very confused. She said she saw her mother again through the window on 5/22/2020 and her mother only had on pants and a shirt and was not covered by a blanket. She said at this time she was very concerned and wanted the facility to reconsider letting her father into the facility to assist her with meals. She said she had attended a care conference telephonically in March 2020 and they had discussed weight loss would be an issue for Resident #1. She said that staff were also aware, as it was discussed in the care conference that her father would go to the facility twice per day to assist Resident #1 with meals until all visitors could no longer come to the facility as a result of COVID-19. She said she worked in nursing homes and trusted they would get a hold of me. She said how could a facility let that go (a big weight loss) and not contact the family? She confirmed on 5/26/2020 the nurse called her and said she had to immediately go to the hospital because they needed to start intravenous (IV) fluids to correct Resident #1's sodium levels. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/2/2020 at 10:18 a.m. She said that Resident #1 had started declining in the last few weeks and had gone from regular texture to pureed food. She said Resident #1's spouse would come in every day to help assist her with meals and when the resident started declining her spouse would stay longer to help her with eating until visitors were no longer allowed because of COVID-19. CNA #2 was interviewed on 7/2/2020 at 10:26 p.m. She said that Resident #1's spouse came in daily to assist with two or three meals until visitors were no longer allowed. She said she remembered the day she went to the hospital because the resident was so lethargic. Resident #1's medical doctor (MD) was interviewed on 7/2/2020 at 10:44 p.m. He confirmed that the resident had a decline and prior to visitor restrictions the resident's family would come every day and provide assistance. The social worker (SW), registered dietician (RD), director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 7/7/2020 at 9:30 a.m. The RD said on 3/16/2020 the resident was ordered nectar thick liquids (NTL) and she added pureed snacks to the care plan which included pudding, jello and pureed fruit. She confirmed this was the first intervention she had added when the resident started losing weight. Both the DON and the RD confirmed offering pureed snacks was not on the kardex (CNA communication about the resident from the care plan). She said if snacks would have been a physician's orders [REDACTED]. The RD said she always reviewed the meal intake and would have started other interventions if the meal intakes had been significantly low. She said since the weight loss was insidious she only started the puree snack. She said she wanted staff to offer the snack at least one time per day. She said there had been no other labs completed for the resident since January 2020 (see 3/18/2020 dietitian assessment above). The RD said the resident's last dietary assessment was completed in March 2020. She and the DON indicated that fluid intake was documented based on fluid intake at meals and nursing staff were encouraged to chart fluid intake between meals. The RD said she looked at fluid intake regularly; primarily when completing a resident's quarterly MDS assessment. The RD said it was standard for the dietary staff, during meals, to offer two fluids, usually one was water and then something else. She said although the amount of fluid the resident consumed was low, both she and the DON agreed that they would also rely on nursing staff to provide fluids throughout the day and this was not being documented. The RD said that she would take the average of what a resident was eating to determine whether an intervention should be implemented. She said from 5/6/2020 until 5/21/2020 the average for Resident #1 was 69% which was close to 70%. She said if it had been less than 70% she would have implemented other interventions. The RD said since September 2019 the resident's spouse would come to the facility for one or two meals daily to assist her with eating . She said when her spouse was helping Resident #1 she responded very well and when he was able to come in she was more engaged. She said her normal practice was to reach out to families about the residents status if nursing had not, however she assumed nursing had contacted the family in this case. The RD said, moving forward she would be making a point to ask families how frequently they would like to be contacted because making sure we have double communication is always better than not having communication. The RD confirmed there was a significant decrease in meal intake from 5/21/2020 until 5/24/2020 and the Mighty Shake (dietary supplement) was started 5/25/2020. The RD said the May 2020 NAR meeting had been the first time Resident #1's weight loss had been discussed; although the care plan indicated she should have been reviewed in NAR as of 12/17/19. The NHA said based on the guidelines they had they would not have considered Resident #1 nearing end of life therefore they did not consider the spouse to be an essential visitor. Licensed practical nurse (LPN) #1 was interviewed on 7/16/2020 at 1:36 p.m. She said Resident #1 had a decline during the time they had worked together in the last year and had become less active. She said Resident #1's spouse would come in and assist with both lunch and dinner until visitors were not allowed in the facility. She said the resident ate very well when her husband was assisting her with meals. LPN #1 said on 5/25/2020 Resident #1 was not eating or drinking and the NP was notified, towards the end of the day Resident #1 began to drink so the NP told the nurse to continue to monitor the resident and push fluids. She said on 5/26/2020 the resident did not accept any fluids and the NP and the family were notified. The NP ordered labs and once the results were obtained the NP ordered Resident #1 be sent to the hospital for fluids.

Based on record review and interview, the facility failed to ensure two (#109, and #140) of four, of 37 sample residents were provided a safe environment free from accidents and hazards. Specifically: -Resident #109 was a victim of physical abuse from another resident (#63) and the facility failed to provide oversight and interventions to protect resident #109 from a second attack, and -The facility failed to identify the risk of accidents for resident #140's use of a recliner. The findings include: 1. Facility Policy Abuse and Neglect (revised 9/13) documented the following: "The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, center staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility will provide education and training to staff and volunteers in regards to abuse, neglect, mistreatment and misappropriation of property. Residents and families will be informed upon admission that they may file a complaint with the state survey and certification agency concerning resident abuse, neglect and misappropriation of property. Residents, staff and others are encouraged to share any concerns regarding allegations of abuse/neglect without fear of retribution. In addition the center will report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as nurse aide or other center staff to the state nurse aide registry or other licensing authorities. The center will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigations are in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certifications agency within five working days of the incident, or sooner as designated by state law. If the alleged or suspected violation is verified, appropriate corrective action will be taken" 2. Resident # 109 a. Resident Status Resident #109, according to the face sheet, was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly minimum data set (MDS) assessment dated [DATE] the resident was severely impaired in her cognition. She required limited assistance for her bed mobility and personal hygiene. She required extensive assistance for transfers, dressing and toilet use. A review of the care plan dated 11/10/14 showed the resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, evidenced by impaired ability to understand or be understood, refusing cares, and striking out at staff. b. Family Interview On 3/6/15 at 9:00 a.m., the resident's niece was interviewed. The niece stated an incident occurred a couple of months ago. There was a resident who came into her aunt's room agitated and confused and started to choke her. The staff came in and intervened, they called the police, they did everything they were supposed to do, and the staff called the niece that day. They took the other resident to a different facility; her aunt (#109) had red marks on her neck that (eventually) went away. The facility offered to call the police and send her aunt for a psychiatric evaluation, but the niece did not want to have the resident relive the incident and declined. The other resident did come back; he was away for three to four weeks. The niece stated, "It happened again I think he came into the room and tried to assault her again. Staff called the police, gave me the information, and they took him away and told me he was not going to be able to come back. My aunt is fine, she has dementia and was on guard and shaken for awhile but she is fine. I think she might have escalated his agitation by kicking, and screaming and I think that was when he came at her: he entered her room. But this was the second time; she did not do this the first time." The niece stated her aunt was doing well these days. The facility informed her that after the first incident the assailant was taken to a behavior medication unit and if they felt he was safe to come back then they would allow him back. She was informed when he came back and the facility they put a large stop sign in front of her aunt's door. The assailant ignored the sign and went under it. They did not inform her of any other intervention to prohibit a repeat of the resident to resident abuse. c. Incident Reports 1. A review of resident #109's incident report for the first incident noted above, dated 1/2/15 at 2:30 p.m., documented in pertinent part: Saw resident (#63) enter resident (#109's) room; the certified nurse aide (CNA)went to remove resident (#63) from the room; CNA came walking out with resident (#63) who presented agitated; CNA reported that resident (#63) grabbed resident (#109) around the neck and shook her; CNA stated that she intervened by trying to place herself between the two residents, that's when resident (#63) took a swing at the CNA's face with a closed fist - no contact made with CNA; after resident swung at CNA he then turned and that is when he grabbed resident (#109) around the neck and shook her. Resident (#109) stated to CNA that resident (#63) entered her room and grabbed her wrist and he then said "your (sic) going to be my woman." Resident stated she then kicked him. Immediate action taken: resident (#63) was removed from resident (#109's) room immediately; vital signs stable, redness noted to anterior neck area - resident denies pain to her neck; no other areas of redness noted at this time. 2. A review of resident #109's incident report for the second issue noted above, dated 2/9/15 at 10:40 a.m., documented in pertinent part: Heard resident screaming from her room; upon entering, found resident (#63) in resident (#109's) room; resident (#109) was slouched in her wheel chair and breathing heavy; resident (#63) was standing facing resident (#109) - no contact seen between the two at this time; called for CNA to assist in separating the residents. Resident (#109) states she was in her room when resident (#63) entered; resident (#109) stated she told him to leave her room and he didn't say anything; resident (#109) said she said it again and waved her foot in resident (#63's) direction when he grabbed her foot and began to pull her out of her wheelchair; resident stated she began to yell and he told her "be quiet" and grabbed her around the neck. Immediate action taken; resident (#63) was removed to his room immediately, resident (#109's) neck was assessed - redness noted on right side; resident states some neck pain, and headache, resident denies pain with swallowing, resident (#109) vital signs stable, resident (#63) was escorted to the dining room and resident (#63) was taken to nurses desk for monitoring. d. Witness Statements A hand written note by CNA #6 dated 1/2/15 documented at 4:40 p.m. this CNA went to help resident #109 into her pajamas and to explain a stop sign had been placed on her entrance door to detour a male resident #63 from entering her room. The door handle to resident #109's room began to jiggle. This CNA opened the door as resident #63 was ducking under the stop sign and attempting to enter the room of resident #109. The resident #63 was redirected to the dining room with a snack and a drink. The Licensed Practical Nurse (LPN) was notified. A hand written note by CNA #5 dated 1/2/15 documented at 2:30 p.m., a nurse asked CNA #5 to go to resident #109's room due to seeing resident #63 was in resident #109's room. The CNA #5 entered the room and found resident #109 yelling at resident #63 to get out of her room. When CNA #5 tried to walk up to resident #63 he turned around quickly, took his fist and tried to punch this CNA in the face. The CNA #5 moved away to miss the punch and when this CNA turned back; resident #63 grabbed resident #109 around the neck and was shaking her. CNA #5 tried to remove the hands of resident #63 from the neck of resident #109. The CNA #5 walked resident #63 out of resident #109's room and reported this to the charge nurse. At 3:45 p.m., CNA #5 walked out of another resident's room and did not see resident #63 but heard a loud scream from resident #109. The CNA #5 ran to resident's #109's room. Resident #63 was yelling at resident #109. Resident #109 was yelling back to resident #63 to get out of her room. Resident #109 was very upset due to being half dressed and getting ready for bed. The CNA reported this to the charge nurse. e. Timeline of Abuse by Facility A review of the timeline submitted by the Nursing Home Administrator (NHA) documented: "January 2, 2015; Resident (#63) was found in female resident (#109's) room, direct aggression to staff when intervention took place. Resident (#63) grabs female resident around the neck and begins to choke female resident. Staff intercept event. Emergency medical staff (EMS) and police are called to facility. EMS transports resident (#63) to emergency department for evaluation and treatment. Police investigate the event. Investigation, incident and state reports completed. January 3, 2015; Resident (#63) is transferred from Emergency Department to a Behavior Health Psychiatric facility for evaluation and medical management/treatment. Behavior Health Facility evaluates resident (#63) medications and they are decreased upon his arrival. Baseline hospitalization justification is established for hallucination, delusions, agitation, depression, danger to self and others. Through the course of his treatment medications are again started and dosages were adjusted. Daily psychiatric evaluations were considered achieved by the evaluators, plan to transfer back to facility was arranged with facility. January 12, 2015; Facility begins communication with resident (#63's) spouse regarding facility requirements for continuation of cares for resident (#63) upon return. Requiring 24/7 sitter care. January 17, 2015; Resident (#63) returns to Secured Unit from Behavior Health Facility. One to One care is arranged with family for 24/7 coverage as required by the facility until January 25, 2015. January 23, 2015; One to One sitter care is decreased as resident (#63's) behaviors begin to return to baseline. February 9, 2015; Resident (#63) is found in female resident (#109's) room as staff respond to the resident calling out. Female resident (#109) reported to staff that resident (#63) had his hands around her neck. EMS and police are called. Resident (#63) is transferred from the facility to the Emergency Department. Police investigate the event. Investigation, incident and state reports completed." 3. Resident #63 a. Resident Status Resident #63, according to the face sheet, was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the resident was severely impaired in his cognition. He required supervision for bed mobility, limited assistance for transfers, extensive assistance for dressing and extensive assistance for toileting and personal hygiene. A review of the care plan dated 1/13/14 showed the resident had a mood problem related to dementia, depression, anxiety, and life losses as evidenced by periods of agitation, verbal aggression, restlessness, pacing, preservation on worried/delusional thoughts, seeking wife or feeling he needed to be elsewhere. Interventions included: Assist resident in developing a program of activities that is meaningful and of interest: music, reminiscing, and socializing. Encourage and provide opportunities for exercise and physical activity. Provide encouragement/assistance/support to maintain as much independence and control as possible. Incident Report A review of resident #63's incident report dated 1/2/15 at 2:30 p.m., documented in pertinent part: Saw resident (#63) enter resident #109 room; the certified nurse aide (CNA) went to remove him from resident (#109's) room; CNA came walking out of resident (#109's) room with resident (#63) who presented agitated; CNA reported that resident (#63) grabbed resident (#109) around the neck and shook her; CNA stated that she intervened by trying to place herself between the two resident's when resident (#63) took a swing at her face with a closed fist - no contact was made with CNA; after resident swung at CNA he then turned and that is when he grabbed resident (#109) around the neck and shook her. Immediate action taken; resident removed from resident (#109's) room ; resident allowed to pace try and calm himself down; spoke with resident about trying to calm down. A review of resident #63's incident report dated 2/9/15 at 10:40 a.m., documented in pertinent part: Heard yelling coming from resident (#109's) room, upon entering the room saw resident standing facing resident (#109); called for immediate CNA assistance - resident escorted from resident room (#109) back to the dining room by CNA. Immediate action taken; unable to assess due to increased agitation; resident sat at dining room table with staff. Nurse Progress Notes A review of the nurse progress notes from 1/18/15 though 2/9/15 showed the resident was aggressive and unpredictable. --On 1/20/15 (five days prior to the facility determining a decreased need for, and discontinuing one to one supervision) at 3:39 p.m., the nurse documented "The resident began to yell at three residents, this nurse intervened due to the nature of his aggressiveness; resident then stepped into this nurses face to threaten and began yelling "NO, NO", pointing and swinging his arms; this nurse stated to the resident that she was going to step back and the resident stated "you better, or I'm going to put you in a basket ..." --On 1/21/15 (four days prior to the facility determining a decreased need for, and discontinuing one to one supervision) at 8:11 p.m., the nurse documented "Resident with sitter this shift; resident with episode of increased anxiety and agitation, resident began to yell and shake his fists stating "I don't know." --On 1/22/15 (three days prior to the facility determining a decreased need for, and discontinuing one to one supervision) at 12:18 p.m., the nurse documented "agitated, restless, not able to sit or redirect at this time." --On 1/29/15 at 1:53 p.m., the nurse documented "The resident attempted to enter resident (#109's) room; staff intervened and resident redirected without further incident ..." --On 1/29/15 at 3:25 p.m., the nurse documented "Resident found in resident (#109's) room, resident (#109) upset he was in there; resident redirected by staff and became upset and angry." --On 1/30/15 at 8:12 p.m., the nurse documented "Resident quiet this shift; resident with some aggression towards another resident where he began yelling and shaking his fists; resident found wondering into resident (#109's) room again this shift." --On 1/31/15 at 2:45 p.m., the nurse documented "Resident with heavy exit seeking; resident yelling at staff and other residents; resident wandering the unit; resident disrobing his pants in the dining room and getting upset with staff when they are trying to help and assist; resident chewing on fingernails." --On 1/31/15 at 7:16 p.m., the nurse documented, "Resident very angry and aggressive this shift, consult with nurse manager and social services regarding resident's behaviors; resident seen yelling at staff and other residents - no apparent reason for the aggression; resident wandered the unit and seen coming out of resident (#109's) room; resident disrobing this shift in the dining room, pulling his pants down in front of residents and visitors and getting angry when staff attempted to help by pulling them up." --On 2/1/15 at 4:54 p.m., the nurse documented "Resident very busy this shift; resident presented very angry, pointing and begin aggressive towards others; resident intrusive with other residents' and staff conversations; resident wondering (sic) this shift in room (multiple rooms identified) resident hovering over staff and other residents; resident (#109's) family upset they had to argue with resident to get him out of her room." --On 2/5/15 at 6:18 p.m., the nurse documented "Resident very busy this shift; resident wondered (sic) the unit in and out of rooms; resident redirected out of resident (#109's) room multiple times, resident found in resident (#109's) room while she was sleeping standing over her; resident collecting other residents' items and staff found lipstick in his room." --On 2/5/15 at 7:15 p.m., the nurse documented "Resident with aggressive episode towards CNA and resident in room (room number identified); resident approached them saying "STOP, STOP, or I'm going to let you have it." --On 2/9/15 at 10:40 a.m., the nurse documented "Resident has been very busy this morning; resident very intrusive with other resident's; resident kept untying another resident's shoes while he was sitting in the recliner; resident kept trying to get him to stand and move; resident redirected multiple times; resident found standing in front of resident (#109) in her room, resident redirected out of resident (#109's) room back to dining room." Nursing notes documented the resident as being aggressive and seeking out resident #109 nine times after his one on ones were discontinued. One to One Schedule A review of the one to one schedule for resident # 63 showed there was one to one care for resident #63 from his return date of 1/17/15 through 1/25/15. Psychiatrist Notes A review of a psychiatrist note 2/6/15, documented "unpredictable and unprovoked behaviors and yells at other and follows the staff and other residents: increased his Depakote (used as a mood stabilizer) to 250 mg three times a day." Review of the resident record revealed there were no additional interventions added to the plan of care when the residents's one on ones were discontinued to prevent the resident from contact with resident #109. c. Interviews --On 3/6/15 at 4:08 p.m., the Licensed Practical Nurse (LPN) # 1 stated she was the nurse who was working when both incidents happened on 1/2/15 and 2/9/15. She stated resident #63 was very unpredictable: he would change his moods and behaviors very quickly. It was possible that resident #63 was provoked by the other resident's screaming. He was on 1:1 cares for about eight days when he came back on 1/17/15, he felt he was invaded upon and this was making him angry. They had television monitors so the LPN would watch them a lot. If the resident was pacing the staff would walk with him and provide one on one attention themselves, attempting to redirect him, read to him and provide some kind of activity with him. He was worse when he came back and he was a lot more unpredictable. The LPN stated CNAs would say they did not feel comfortable with him. They had male CNAs help with the resident at times. The resident became angry with most cares. --On 3/6/15 at 3:06 p.m., the Director of Nursing (DON), stated that after resident #63 was sent to the emergency roiagnom on [DATE] he did not return. --On 3/9/15 at 10:12 a.m., the Nursing Home Administrator (NHA) stated the facility had taken resident #63 off of 1:1 sitter care when they felt he was re-directable, and he had also been seen by the psychiatrist. (See note on 1/22/15 of resident not being re-directable.) --On 3/6/15 at 12:37 p.m., when the NHA was asked about the psychiatrist note (2/6/15) identifying the resident as "unpredictable, unprovoked, and following residents," the NHA stated the nurse that noted the Psychiatrist notes on 2/6/15 did not alert management regarding the Psychiatrist notes. 4. Resident #140: Facility failed to identify the risk of accidents for the resident's use of a recliner. a. Resident Status: Resident #140, age 83 was admitted into the facility on [DATE]. According to the face sheet, the resident [DIAGNOSES REDACTED]. According to the quarterly review MDS assessment dated [DATE] the resident was admitted from an acute hospital. The resident was alert. He had a clear speech and was able to express himself if given time. His vision was adequate with corrective lenses. The BIMS score was 5, indicating severe cognitive impairment. The resident required one to two person physical assistance with toileting, bathing, transfers, and eating. b. Record Review Review of the CPO for March 2015 revealed: -Resident may be in recliner every two (2) hours PRN (as needed) to elevate feet for edema, related to unspecified cerebral artery occlusion and atrial fibrillation. -Pressure alarms in wheelchair and bed at all times for safety related to poor safety awareness and a recent fall. Review of a care plan revised 12/11/14 revealed: -The resident is at risk for falls R/T (related to) weakness E/B (evidence by) confusion, Fall Risk 30 (a rating indicating a fall risk). The goal was the resident will be free of falls through the review date. The interventions included: Encourage participation and plan diversional activities that are of resident's interest. Educate resident/family about safety reminders and what to do if a fall occurs. A Nursing Note (NN) dated 3/4/15 revealed: "Resident in recliner and continued to try and slide forward slouching in the chair; resident asked multiple times by staff to sit up and move his bottom back so he was sitting properly in the chair; resident continued to slide his bottom forward and off the chair." c. Observations On 3/5/15 at 2:10 p.m., the resident was observed with his legs over the foot rest on the recliner. The nurse observed the resident attempting to get out of the recliner and said, "Give me a minute and I will be right there." On 3/6/15 at 10:25 a.m., the resident was observed attempting to get out of the recliner; the wife was observed lowering the foot rest of the recliner. d. Staff Interviews On 3/6/15 at 10:22 a.m., the licensed practical nurse (LPN) #1 was interviewed. She stated that there was a physician's orders [REDACTED]. On 3/9/15 at 1:30 p.m., the director of nursing (DON) was interviewed. She confirmed that no assessment was done to rule out the risk of accident for the recliner use. On 3/9/15 at 1:58 p.m., the MDS coordinator was interviewed. She confirmed that she had seen the resident attempting to get in and out of the recliner by putting his leg over the foot rest which could be a hazard.

Based on record review and interview, the facility failed to ensure the resident environment remained as free from accident hazards as is possible for three (#132, #155, #142) of 34 sample residents. Specifically: --Resident #132 was assessed to be at high risk for falls upon admission; despite this, fall interventions were not implemented or care planned and she suffered a fall resulted in a humerus fracture and pain associated with the fracture; --Resident #155 did not receive adequate supervision resulting in a fall during toileting; and --Fall interventions were not implemented after resident #142's falls. The findings include: A. Facility Policy The facility's Fallen or Injured Resident procedure directed, in pertinent part: "Purpose ...to prevent further injury ... Update the comprehensive care plan and documentation record with any changes/new interventions ..." B. Resident Failures 1. Resident #132 a. Resident Status According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE], discharged [DATE], readmitted [DATE], discharged again 3/11/14 and readmitted [DATE]. Her diagnoses, per the 1/30/14 face sheet, included congestive heart failure, atrial fibrillation, congenital mitral insufficiency, chronic kidney disease, aortic valve disorders, and generalized pain. According to the 1/30/14 self-care performance deficit care plan, the resident required assistance with bed mobility, bathing, transferring, toilet use, and personal hygiene related to a hip fracture and congestive heart failure. The 1/31/14 admission Fall Risk Data Collection tool was reviewed and identified the resident as being at high risk for falls. The tool revealed the resident had fallen in the last month and had a fracture related to fall in the previous six months. The resident was unable to independently come to a standing position, required hands-on assistance to move from place to place, and used an assistive device. The discharge/return anticipated MDS dated [DATE] showed the resident was cognitively intact. She required extensive assistance with bed mobility and limited assistance from one staff member with transfers, walking, dressing, and toilet use. She was occasionally incontinent of urine. She had one fall since admission or prior assessment with a major injury including a bone fracture. On 4/8/14 at 11:49 a.m., a registered nurse (RN) who worked with the resident was asked if the resident had a fall or sustained a fracture within the last 30 days. He said, "Yes, she fell on [DATE] and broke her humerus." b. Record Review The nursing progress notes were reviewed back to March 2014 and revealed, in pertinent part: --3/7/14: "Resident was extremely lethargic today, having vomited several times on day shift. (A laboratory) called at 3:00 p.m. with a critical lab value of 2.3 potassium..(Physician) was notified and the resident was taken to (the hospital) by ambulance for IV therapy ..." --3/9/14: "Resident returned from the hospital at 12:45. She arrived via facility transport ...She was admitted to the hospital (due to) critical (potassium) level. She had IVs and labs while in the hospital. She continues to be ambulated using (a walker) and assist x 1 ..." --3/9/14: "Resident very tired this shift. No complaints of pain." --3/10/14: Resident alert and cheerful. Stated she was feeling much better. Edema (lower extremities bilateral). She stated that both legs are hurting today ..." --3/11/14: "At 7:45 a.m., resident tried to go to the bathroom unassisted and fell on her L (left) side. She had skin tears on both elbows and was (complaining of) severe pain in L upper arm. Resident was removed from the floor using a lift. STAT X-ray of L humerus and elbow was ordered. Portable X-ray arrived shortly after that. X-ray revealed a L humerus neck displaced (fracture). (Nurse Practitioner) ordered that resident be sent to (the emergency room ) ..." The fall investigation was requested on 4/9/14 and revealed, in pertinent part: -"Date: 3/11/14 -Nursing Description: Staff called RN (registered nurse) to (resident's) room. Resident was lying on her L side on the floor by the bathroom. The call light was not on. -Resident Description: Resident stated she was going to the bathroom and fell . -Description: Resident was turned to her back. ROM (Range of motion) of legs was fine. ROM of L (left) arm caused a great deal of pain ...resident removed from the floor using mechanical lift and put into bed. STAT X-ray of L humerus and elbow ordered. -Predisposing Physiological Factors: drowsy, impaired hearing." No interventions to prevent further falls were listed on the fall investigation. Further, the resident's assistance needs and the time the resident had last gone to the toilet previous to her fall were not identified in the fall investigation. The resident's hospital encounter notes were reviewed for her 3/11/14 - 3/18/14 hospitalization following her fall and revealed, in pertinent part: "Left humerus fracture. Will likely require ORIF (open reduction and internal fixation) for pain control and basic quality of life. Will have great difficulty with ADLs as she will be unable to use a walker ...Mod to high risk surgical candidate but benefits of surgery likely outweigh the risks ... The patient is a [AGE] year old female who had presented with a left humerus fracture after a fall. She is known to our service from a previous right proximal femur fracture. She had been improving at the nursing facility but unfortunately fell again and injured her right shoulder ...She will likely require ORIF but we are waiting for her family to arrive.." On 3/18/14, the resident was readmitted to the facility following her hospitalization . The 3/18/14 nursing progress note revealed, in pertinent part: "Resident alert and oriented only to self. Is a full lift with transfers. Continues to receive (antibiotic treatment for [REDACTED]. Obtained evening dose from the e-kit. had room tray for evening meal. Took meds without difficulty. Left arm elevated on pillow. (Dressing) to left shoulder (clean/dry/intact). Currently in bed with call light in reach of resident." Further nursing progress notes following her hospitalization revealed, in pertinent part: --3/19/14: "Resident sleepy today. Did not want to get out of bed. Didn't want to do therapy. Stated that she was too tired and "It won't do any good." Was only up for therapy ...Full lift is being used for all transfers. (Wheelchair) is used for mobility and she is not able to propel it herself." --3/20/14: " ...Resident had bladder incontinence this shift, which is unlike her. She attributed it to the fact that getting up to the toilet is too painful ...Sling in place to L arm ..." --3/23/14: "Resident alert and calm. Denies pain today. Demonstrating some confusion. Resident told RN "Both of my legs are broken. I don't know how I get in these messes." Resident refused to get out of bed today. She stated that she doesn't know why she has the sling on the L arm. When RN told her that it is broken, she said "When did that happen?" Resident had meals in bed ..." c. Fall Interventions The resident's comprehensive care plan was reviewed and showed there was not a care plan in place or interventions to address the resident's high fall risk at the time of her fall on 3/11/14. Further, even though the resident was identified by the facility as a high fall risk and having a fall resulting in a fracture on 3/11/14, there was no evidence a fall care plan was implemented until 3/24/14, six days after her return from the hospital. The fall care plan, initiated on 3/24/14, showed the resident had an actual fall with a fracture of shoulder related to poor balance. Approaches included: --Provide activities that promote exercise and strength building where possible. --Educate resident and family on safety of assistive devices resident uses. --Educate resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. --Ensure that resident is wearing appropriate non-skin footwear when ambulating or mobilizing in (wheelchair). --Review bowel and bladder continence status and establish and/or review toileting plan based on resident needs. Despite the intervention to review the resident's bowel/bladder continence status and establish or review a toileting plan based on her needs, there was no evidence this was done. The resident's assessments were reviewed back to her admitted and there was no evidence showing the resident's bowel/bladder continence status had ever been assessed. Moreover, a care plan addressing the resident's bowel/bladder continence status was not implemented. d. Resident Observations --On 4/8/14 at approximately 3:00 p.m., the resident was observed in her room. She was wearing a sling on her arm and was seated in a wheelchair. The resident was pleasant, alert, and oriented. She said she did not recall the fall which led to her arm being fractured. --On 4/14/14 at approximately 9:15 a.m., the resident was observed in her room. She was seated in her wheelchair. She was lethargic and had an emesis basin in front of her. The resident said she wanted to lie down and a certified nurse aide (CNA) was notified. e. Staff Interviews --On 4/9/14, the interim director of nursing (IDON) was asked if a fall care plan or interventions were implemented for the resident prior to the fall, given her fall history and fall assessment on 1/31/14. She said she would check. She was also asked where interventions to prevent further falls would be found. She said, following a fall, the interventions would be listed on either the fall care plan on in the progress notes. However, no interventions to prevent falls were found in the resident's progress notes reviewed from 3/18/14 - 4/10/14. --On 4/10/14 at approximately 5:30 p.m., the nursing home administrator (NHA) and IDON acknowledged there was not a fall care plan or fall interventions in place prior to the resident's 3/11/14 fall. --On 4/14/14 at 9:25 a.m., a CNA who was working the morning the resident fell was interviewed. She said, "I was just in there and had walked away for two minutes. I don't think she was quite awake yet. I got her breakfast order and then the nurse heard a bang and she had fallen." The CNA was asked if she had offered or assisted the resident to the bathroom that morning. She said the resident would usually ask for help to go to the bathroom. --On 4/14/14 at 9:29 a.m., the unit manager registered nurse (UM) who worked with the resident was asked the procedure when a resident is identified to be at moderate or high risk for falls. She said, "Usually they set something in place like an alarm, frequent checks, or keeping the door open and it's care planned." The UM was asked if a toileting assessment had been completed for the resident. She said it was the responsibility of the MDS coordinator to complete toileting assessments. --On 4/14/14 at approximately 9:45 a.m., the MDS coordinator was interviewed. She checked in the system and agreed a toileting assessment had not been completed for the resident since her admission to the facility. She said these were completed upon admission and with any changes. --On 4/14/14 at 12:10 p.m., the UM stated pervious to her fall, the resident required assistance with using the toilet. --On 4/14/14 at 12:30 p.m., the NHA was informed of the findings above. She said she expected fall interventions to be implemented and followed when residents were identified to be at risk for falls. She said she would check to see if something was done. --On 4/14/14 at 2:55 p.m., the NHA confirmed the facility was unable to find evidence of a bowel or bladder assessment for the resident. She stated a bowel and bladder assessment would be completed for the resident. --On 4/14/14 at 4:07 p.m., the IDON said a fall care plan should have been implemented directly after the resident's return to the facility following her hospitalization . She also expected fall interventions to be followed. f. Facility Failures 1. Although prior to her admission, the resident had a fall with a fracture and was assessed to be at high risk for repeat falls, fall interventions and a fall care plan were not implemented for the resident. The resident then fell and suffered a humerus fracture. 2. The resident's bowel/bladder status was not assessed at anytime during her tenure at the facility. She fell while attempting to use the toilet. 3. The resident was lethargic, weak, and complained of leg pain in the days prior to her fall with injury. A fall care plan and interventions were again not implemented and the resident's bowel/bladder assessment were not assessed or care planned. A CNA saw the resident minutes prior to her fall and did not offer toileting assistance to her at that time. 4. Following her readmission to the facility after her fall with fracture and subsequent hospitalization , there was a further delay in implementing fall interventions and a care plan. On 3/24/14, six days after her readmission, a fall care plan was implemented. An intervention of, "Review bowel and bladder continence status and establish and/or review toileting plan based on resident needs," was added. However, there was no evidence this was done for the resident as of 4/14/14. 2. Resident #155 Resident #155, age 89, was admitted to the facility on [DATE]. The Face Sheet documented the resident had [DIAGNOSES REDACTED]. a. Resident status The admission Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) of 03, indicating severe impairment. The resident required extensive assistance from staff for bed mobility, transfers, dressing, eating, personal hygiene and toileting. The resident required two + people assist for toileting. The resident's movement on and off the toilet was not steady; the resident was only able to stabilize with staff assistance. The MDS further documented the resident had functional limitation in range of motion to her lower extremities (hip, knee, ankle, foot). Review of the resident's Care Plans (CP) revealed: -Resident had an Activity of Daily Living (ADL) self care performance deficit related to weakness (imitated 11/5/13). One intervention for this plan of care for toileting the resident was limited assist of one staff member participation to use the toilet. -Resident had Parkinson's disease (initiated 11/5/13). One intervention for this plan of care was to monitor and observe for risk of falls. The CP did not contain a comprehensive plan of care for falls (cross reference F279 - comprehensive care plan). b. Record Review - Documentation of Resident Fall Risks Initial Interdisciplinary Data Collection Tool GSS #472 dated 10/24/13 documented the resident had fallen in the past 2-6 months. Falls Data Collection Tool GSS #194 dated 10/24/13 documented the resident had a score of 13, indicating high risk. Mobilization Support Data Collection Tool GSS #185 (not signed or dated) documented the following pertinent information: -4. Requires weight bearing support to transfer from one surface to the other, able to weight bear on at least one leg; follows simple commands; able to sit upright. Lift type was circled sit- to -stand with a medium sling size. Comments - the resident does not ambulate at this time. Daily Skilled Note GSS #183 dated 10/24/13 at 2200 (10:00 p.m.) documented the resident would require a sit-to-stand lift until assessed by physical therapy. Daily Skilled Note GSS #183 dated 10/25/13 at 10:30 a.m., documented sit-to-stand lift used for transfers. Physical Therapy Evaluation and Plan of Treatment signed 10/25/13 at 3:50 p.m., documented the resident scored a 1/28 (high risk for falls) on the Tinetti Assessment (measurement of a resident's gait and balance: resident receives a score based on their ability to perform specific tasks). The Assessment Summary for Risk Factors documented the resident had physical impairments and assisted functional deficits; the resident was at risk for compromised general health, decreased ability to return to prior living environment and falls. Daily Skilled Note GSS #183 dated 10/25/13 at 16:00 (4:00 p.m.) documented resident was slow to understand the routine of the facility and what to expect with her care. Resident somewhat disoriented at times. Interdisciplinary Rehabilitation Rounds GSS #923 dated 10/29/13 documented Occupational Therapy note for toileting was dependent maximum. Resident confused: lift for staff. Daily Skilled Note GSS #183 dated 10/30/13 at 2:30 a.m., documented resident calls out and does not use call light. At 1320 (1:20 p.m.) documented resident yelling when day staff arrived: resident calls out rather than using call light. Occupational Therapy Evaluation and Plan of Treatment signed 10/31/13 at 4:36 p.m., documented in Background Assessment / Patient Preferences as precautions; confusion, hypertension, hard of hearing and fall risk. Daily Skilled Note GSS #183 dated 10/31/13 at 2:00 a.m., documented resident resting comfortably in bed with eyes open: exhibits confusion. At 1505 (3:05 p.m.) documentation noted resident calls out for help rather than using the call light. c. Documentation of Fall Daily Skilled Note GSS #183 dated 11/1/13 at 1650 (4:50 p.m.) documented the resident was found on the floor of the bathroom approximately five minutes after being transferred to toilet by a Certified Nurse Aide (CNA). The resident was found in the sitting position. The resident stated she "held on to the bar as long as I could and then lowered myself to the floor." No apparent injury. Sacral skin and buttocks checked with no skin tears. Incident report filed. Incident Details GSS #401 dated 11/1/13 (no time) documented time occurred 4:35 p.m., resident found on the floor sitting with knees bent. Comments Section documented the resident was found on the bathroom floor after she attempted to stand, unassisted. Resident reported to staff she grabbed the wall bar, stood up, could not stand any longer; lowered herself eventually falling to the ground and landed on her buttocks. Immediate interventions were teaching resident of importance of using call light to notify staff and staff informed of need to stand by resident during toileting. Further documentation noted approximately one hour after the incident the resident complained of mild right flank pain with Tylenol 650 mg (milligrams) administered. d. Interviews On 4/14/14 at 2:30 p.m., the Nursing Home Administrator (NHA) reviewed and agreed there was a discrepancy in the MDS (two + people assist) and the care plan (limited assist of one staff member) for toileting. The NHA stated it was her expectation the information in the MDS and Care Plans was complete and accurate. The NHA stated she was unable to find any documentation regarding the specific staff member who had initially began the resident's toileting process was informed of the need to stand by the resident during toileting as noted in the Incident Details GSS #401 dated 11/1/13 (no time). The NHA stated she was unable to find any documentation of staff in-services (after the resident's fall 11/1/13) educating staff on the necessity to stand by residents who require additional assistance during toileting. 3. Resident #142 Resident #142, according to the face sheet, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. a. Resident status The resident's Minimum (MDS) data set [DATE] revealed he was understood and could understand, his cognition (decision making ability) was moderately impaired. He had no behaviors and needed extensive assist for most activities of daily living. On 4/8/14 at 4:47 p.m. the licensed nurse was asked if the resident had a fall in the last 30 days. She did not have the exact date but knew he was found on his knees in the past 30 days. b. Record Review - Falls after admission Review of the medical records revealed the resident had three falls since admission; falls occurred on 2/7/14, 2/25/14 and 3/23/14. (1) The fall investigation dated 2/7/14 and revised on 2/21/14 revealed the resident was found on the floor in his room just a few minutes after the nurse had been there to give him his meds. The resident had wet his pants. The resident was alert without complaints of pain. No bleeding/red marks on the resident's body. The resident was oriented to person. Predisposing physiological factors was a recent illness. Predisposing situation factors was psychopharmacological medication. There were no other notes found. There were no interventions put into place to prevent future falls. There was no care plan in place for falls. (2) The fall investigation dated 2/25/14 and revised on 3/4/14 revealed under nursing description that the resident was found on knees on fall mat with hands on the bed, alarm sounding and bed in lowest position. The resident stated, 'I rolled out of bed. I was sleeping.' The resident was oriented to person, place, time and situation. Predisposing situation factors were alarm sounding and fall mat in place. There were no other notes or safety interventions put into place to prevent further falls. There was no care plan in place for falls. (3) The fall investigation for the fall on 3/23/14 revealed the following: Reason for documentation was a recent fall occurred. History of falls noted the resident had a fall within the month and had falls prior to that date, two or more since admission. The resident was unable to independently come to a standing position. He required hands on assistance to move from place to place. There were medications listed that may be a factor in the fall; these were listed as antidiabetics, antihypertensive, and psychopharmacological drugs. There was no description of how and where the fall occurred or what the resident was doing at the time he fell . No new safety interventions were put into place. A care plan for falls was developed on 3/24/14 after the resident's third fall. The problem was a history of falls. The goal was no falls through 4/29/14. The approaches were to ensure the resident was wearing the appropriate footwear, rubber soled shoes and non-skid socks when ambulating. There was no plan to increase resident supervision given his assistance needs (see above). On 4/14/14 at 12:30 p.m., the NHA stated she expected fall interventions to be identified, implemented, and followed when residents were identified to be at risk for falls or had fallen.

Based on record review, observation and interviews, the facility failed to ensure two (#114 and #144) of 34 sample residents received the care and services necessary to promote the healing of existing and/or acquired pressure ulcers. Specifically: -Resident #114, who had multiple risk factors for skin breakdown (incontinence, [MEDICAL CONDITION]/dependence, extensive assistance needs and diabetes) was identified 7/14/13 with three open areas on her left buttock which measured 1- 2 cm. The facility failed to provide the resident consistent care as expected per facility protocol, including daily monitoring of the open areas, weekly monitoring/tracking of the open areas, pressure redistribution, care plan modifications, and repeated resident/family education regarding the consequences of treatment refusals. In addition, staff failed to timely communicate to and ensure timely response from the resident's primary care provider (PCP) and the facility medical director when the open areas failed to improve and worsened in order to obtain timely treatment changes. These failures contributed to decline in the status of the open areas to development of a stage IV wound measuring "greater than 100 centimeters squared" with osteo[DIAGNOSES REDACTED] (bone involvement) "nearly a given." The wound required several wound debridements as well as continuous [DEVICE] treatment. -Resident #144, who had a healing stage III heel ulcer, failed to receive ordered treatments The findings include: A. Facility Protocol The facility's skin assessment and pressure ulcer prevention procedure directed, in pertinent part: " ...to systematically assess residents with regard to risk of skin breakdown, to accurately document observations and assessments of residents, to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers ... Risk factors are factors that increase a resident ' s susceptibility to develop or impact healing times of pressure ulcers. They include, but are not limited to: impaired/decreased mobility and decreased functional ability, resident refusal of or level of compliance with their plan of care and treatment, exposure of skin to urinary and fecal incontinence. Residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is recommended based on observation of the resident ' s skin over a period of time. If a pressure ulcer is identified ... the registered nurse should record the type of wound and the degree of tissue damage (i.e., for a pressure ulcer, record the stage). The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics. Document the information on the wound care sheet. Notify the physician/practitioner of the ulcer and resident ' s condition to obtain orders for a treatment. Notify resident and/or family of the pressure ulcer, orders and planned interventions. The interdisciplinary teams should determine any modifications that are necessary to the resident ' s care plan. Interventions should focus physical, mental, and psychosocial aspects that may be impacted. Treatments and interventions should be consistent with the resident ' s goals. Education should be provided to the resident and/or family. When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication or change is identified) should include the following: an evaluation of the ulcer, if no dressing is present, an evaluation of the status of the dressing; if present (whether it is intact and whether draining, if present, is or is not leaking), the status of the area surrounding the ulcer (that can be observed without removing the dressing), the presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example, increased redness or swelling around the wound or increased drainage from the wound) and whether pain, if present, is being adequately controlled. If the pressure ulcer is not determined to be clinically unavoidable, the ulcer should show signs of improvement within two to four weeks. Signs of improvement might include decreased in size of wound (length x width), decreased in amount of exudate and improvement in the tissue type (i.e., improvement from necrotic to slough to granulation to [MEDICATION NAME] to healed). The pressure ulcer should be assessed/evaluated at least weekly and documented on the wound flow sheet. Observations of the ulcer ' s characteristics may be documented by a licensed nurse and should include at least the following: measurements - length, width, depth, characteristics of the ulcer - including wound bed, undermining and tunneling, exudate, surrounding skin, etc, presence of pain, current treatments. Progress towards healing and any modifications to the plan of care/treatments should be assessed and evaluated by the registered nurse. If a resident makes an informed choice to refuse treatment, then education of what a pressure ulcer is, what the risk of the refusal is and what the potential outcome may be should be provided to the resident and/or family. This information should be provided initially and reviewed periodically, but at least quarterly. This education should be documented on Interdisciplinary Teaching Record. If the resident ' s ulcer is clinically " avoidable, " not showing signs of healing and the interdisciplinary team and/or the physician have made modifications to the treatments and interventions; consider a referral to a wound care specialist and a discussion with the center ' s medical director. B. Resident #114 According to the resident's face sheet, the resident was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. 1. Resident Status 4/13 According to the Minimum (MDS) data set [DATE], the resident was cognitively intact. She needed extensive assist for bed mobility, transfers and toilet use. She was frequently incontinent of urine, was at risk for developing pressure ulcers, and had one or more unhealed pressure ulcer at stage I or higher. A stage II ulcer acquired 11/29/12. 2. Discovery of open areas 7/14/13 - Facility response - Facility failure Discovery of open areas: The nurses' notes, reviewed back to 7/14/13, revealed, in pertinent part: --7/14/13 at 10:00 p.m., the registered nurse (RN) charted " ...CNA (certified nurse aide) reported that resident has three open areas on her left buttock. This RN assessed areas this afternoon, however resident didn ' t want to remain in full lift long enough for areas to be measured and a dressing to be applied. Resident provided with a pressure relieving cushion for her wheelchair and RN manager notified that resident will need a pressure relieving mattress as well... " --7/14/13 at 10:35 p.m., the RN charted " ...Three open areas noted on left side of upper posterior thigh on measures 2 x 0.5 centimeters on her fold between her buttock and thigh, 1 x 1 centimeter on her upper thigh and 1 x 0.5 centimeter on her labia. RN manager notified to assess and recommend treatment. Resident positioned on her side with [MEDICATION NAME] applied ... " --7/15/13 at 11:30 a.m., the RN charted " ...Checked three open areas on left perineum, left vulva/labia wound is 1.5 x 1.0 centimeters, left vulva is 3.5 x 2.0 centimeters and 1.0 x 1.4 centimeters on left buttock near ischial. All are full thickness, none on bony prominences. All appear caused from skin exposure to urine. Zinc oxide applied. Will ask for order to change brief every two hours during a.m. to p.m. and every three hours at night. If I understand correctly, this resident has not been changed at night although totally incontinent related to her request to sleep thru the night. No known history of these type of wounds. Urine is strongly smelling, unable to cover wounds with a dressing because their location on the labia and perineal folds ... " A physician progress notes [REDACTED]. Facility response: A skin integrity care plan originally dated 5/7/13 and revised on 11/5/13 showed the resident had an actual alteration in skin integrity related to incontinence manifested by three open areas on the perineum. Approaches included --Repositioning plan: every 2 hours with cares. Reposition feet every 2 hours during the night --Resident education to be careful with power wheelchair mobility to avoid injury to bilateral lower extremities --When bathing make sure to put shower chair height up enough to prevent her feet from touching floor or wheels --To wear soft Prevalon blue boots when in bed --Provide pad between her knees and pants to help prevent skin injury related to involuntary leg movements. DO not use knee protectors with back as could cause pressure and she would not be able to feel it --Observe skin daily with cares. Report any changes, concerns to nurse Failures in response: -While the nurses' notes indicated a pressure relieving mattress would be obtained, on 2/11/14 note that read" "message left for staff to order a pressure relieving mattress tomorrow," indicated a pressure relieving mattress was not obtained until mid-February. -While 7/14 - 7/15/13 nurses' notes above indicated the resident had a ROHO cushion as of 7/14/13, review of nurses' notes 7/19/13 revealed the cushion was removed after the resident slid from the wheelchair. A 2/3/14 nurses' nurse that read "wound doctor would like resident to be evaluated for a pressure relieving ROHO cushion for her wheelchair," indicated a cushion was not obtained subsequent on 9/5/13 (see below) when the open area was classified by the physician as pressure. The 2/3/14 note indicated, rather, that the resident did not have a cushion in place consistently after 7/14/13 until sometime in 2/14. -Although the facility developed a care plan (see above) that identified the resident's altered skin integrity, this care plan was not updated with identified barriers to healing, including the resident's refusals in relation to the orders and plans of care subsequently developed. See below nurses' notes, orders, and physician notes. 3. Deterioration of open areas, classified by the physician on 9/5/13 as pressure ulcer, following discovery - Facility response - Facility failures Review of nurses' notes 7/13 - 2/14, physician progress notes [REDACTED]. Review of the nurses' notes (NN), the physician notes (PN) and the WNP notes, revealed the resident refused repositioning and off loading of the open areas, as well as incontinence checks and changes as ordered. Staff conducted weekly skin assessments but the assessments did not include wound measurements until 12/20/13. Moreover, record review revealed that from the time the open areas were discovered and until 2/14, staff failed to provide the resident consistent care as expected per protocol, including daily assessments of the open areas, weekly monitoring/tracking of the open area (per a pressure or non-pressure wound tracking form), pressure redistribution, care plan modifications, and repeated resident/family education regarding the consequences of treatment refusals. In addition, staff failed to timely communicate to and ensure timely response from the resident's primary care provider (PCP) and the facility medical director when the open areas failed to improve and worsened in order to obtain timely treatment changes. Review of nurses' notes (NN), physician notes (PN), WNP notes and orders after discovery of the open areas revealed: -NN: 7/15/13 at 11:30 a.m., the RN charted " ...Checked three open areas on left perineum, left vulva/labia wound is 1.5 x 1.0 centimeters, left vulva is 3.5 x 2.0 centimeters and 1.0 x 1.4 centimeters on left buttock near ischial. All are full thickness, none on bony prominences. All appear caused from skin exposure to urine. Zinc oxide applied. Will ask for order to change brief every two hours during a.m. to p.m. and every three hours at night. If I understand correctly, this resident has not been changed at night although totally incontinent related to her request to sleep thru the night. No known history of these type of wounds. Urine is strongly smelling, unable to cover wounds with a dressing because their location on the labia and perineal folds ... " There were no further NN regarding the resident's open areas after 7/21/13 until 10/3/13. There was no evidence a weekly wound tracking form (either pressure or non-pressure tracking forms) was developed to monitor the open area areas in 7/13 - 8/13. -PN: 9/5/13, a physician progress notes [REDACTED]. This was diagnosed two days ago. The course has been episodic. It is of moderate intensity. Associated symptoms include patient has pressure sore which is open to left ischium per nursing staff. Positive for pressure sore to left ischium. Plan: pressure ulcer stage one continue care per wound care team. Cleanse daily, apply TAO and cover with [MEDICATION NAME] until healed, follow up if not improving in one week ... " See: Ruth A Bryant, RN, MS, CWOCN and Denise P. Nix, RN, MS, CWOCN, "Acute and Chronic Wounds, Current Management Concepts," third edition, Mosby (2007). page 144: "Patients at risk for skin breakdown should have a daily skin inspection (Bergstrom and Braden, 1992; WOCN society, 2003). " There was no evidence daily monitoring or weekly wound tracking form (either pressure or non-pressure tracking forms) was developed to monitor the open area areas in 9/13. -NN: 10/2/13 at 10:25 p.m., the RN charted " ...resident has a 3 x 2 centimeter open area located on the posterior aspect of resident ' s right thigh on her gluteal fold most likely the result of irritation from urinary incontinence. Resident is being toileting frequently throughout the day with Zinc Oxide being applied frequently as well with area not improving. This RN applied replicare dressing for additional protection this evening with RN manager and (nurse practitioner) notified requesting any further recommendations for treatment ... " -NN: 10/3/14 at 10:44 p.m., the RN charted " ...Resident requesting that open area on the posterior aspect of her thigh be cultured for infection prior to initiating treatment with Anifungal ointment or agreeing to insertion of Foley catheter. Fax communication completed to NP requesting an order to culture wound. Resident continues to be toileted frequently with barrier cream being applied for protection. Resident ' s husband requested that resident be seen by urologist related to urinary incontinence ...RN manager notified of husband ' s request ... " Review of physician orders [REDACTED]. -PN: 10/4/13 " ...resident is being seen today at facility for a wound to the buttocks, seen at the request of the nurse. Positive for red irritated area to the left buttocks, spreading to the right buttocks ... Plan: yeast rash patient has been on antibiotics and I believe this to be a candidiasis ... Patient requests a culture as well. We will get a culture and then treat the candidiasis with suppositories and cream topically while waiting for results of culture. Continue to monitor. Keep area clean and dry ... " Physician orders [REDACTED]. -PN: 10/9/13 " ...She is wheelchair bound. She is chronically incontinent of urine. She has had small areas of skin breakdown on her right upper leg on the posterior aspect. It is near the crease of the buttocks. Staff has been treating it with antifungal cream. She recently had a culture of the area but anyone of these could be a skin contaminant. On her right posterior upper leg there is a six centimeter round indurated [DIAGNOSES REDACTED]tous warm area. It does not feel like a discrete abscess. There is surrounding [DIAGNOSES REDACTED] ... Assessment: patient has skin breakdown with subsequent [MEDICAL CONDITION]. The cause of the skin breakdown is multifactorial including her being (immobile) and sitting in a wheelchair much of the day, urine incontinence and diabetes. We will need to get the diabetes under better control ... I would treat this as a poly microbial diabetic wound. We will add [MEDICATION NAME] sofa and [MEDICATION NAME]. Okay to continue the [MEDICATION NAME]. Continue the wound care. Use a [MEDICATION NAME] powder on it. I believe she would benefit from something to prevent urine contamination (in) the area and perhaps a Foley catheter or suprapubic catheter would be helpful ... " -NN: 10/9/13 at 6:09 p.m., the RN charted " ...Dr. (name) visited with resident this afternoon and assessed wound on the back of resident ' s right upper thigh with new orders to change antibiotic, [MEDICATION NAME] powder, and referral to Urologist related to urinary incontinence ... " -NN: 10/10/13 at 2:49 p.m., " ...weekly skin assessment completed, resident skin warm dry intact with exception to right shin scratch that has been healing. Peri/coccyx area with skin breakdown and redden area. Physician notified of this at an earlier date and current treatment is ointment and [MEDICATION NAME] powder. Area is blanchable." Baza antifungal cream re-ordered 10/17/13 and per 10/13 MAR applied. -NN: 10/19/13 at 5:20 p.m., the RN charted " ...Resident continues on antibiotic for right thigh [MEDICAL CONDITION] ... " There was no evidence a weekly wound tracking form (either pressure or non-pressure tracking forms) was developed to monitor the open area areas in 10/13. -NN: 11/1/13 at 4:54 p.m., the nurse manager charted " ...MDS quarterly note: resident has open wound on thigh (non-pressure) and excoriated areas on labia that are being treated topically ... -NN: 11/4/13 at 4:23 p.m., the nurse manager charted " ...Talked with resident if she wanted an appointment with wound care to evaluate and treat wound to thigh. She stated she would like to wait until after she has talked to the urologist related to catheter ... " -PN: 11/05/13 " ...Asked to evaluate wound and possible referral for wound care eval, for a non-healing wound that has been present since July, and now has progressively become worse. Developed on her right posterior upper leg, just in the crease of her coccyx ... It is hard to get her to lie down. She can be up for periods of 8 to 10 hours and is somewhat difficult with her incontinence due to the transfer device that they use to change her causes her soreness and pain and discomfort, so she is one to refuse this. She has not gone to an increase in lying down since this has developed due to her active social life, per what she tells me. Assessment: skin breakdown due to exposure to urine and stool and this is going to be difficult to heal until we can diminish this exposure to urine. At this time, I think we should wait before we send her to the wound clinic ... See what happens after she sees the urologist, possibly for an indwelling foley catheter or possibly for a suprapubic ... I also instructed her that she needs to lie down and if she can ... I would recommend that we increase her incontinence changes and get her to lie down in the afternoon until further intervention can be done to urology to prevent this wound from getting any worse and she seems to be agreeable to this today ... " -NN: 11/5/13 at 3:00 p.m., " ...care conference note: the unit manager reported that resident ' s wounds are being treated with a combination of medications and then allowed to breath for an hour each day. The resident ' s husband reported that he has scheduled an appointment with the urologist for 11/19 so she can have a catheter ... " (Catheter placed 11/20/13) -NN: 11/6/13 at 9:41 a.m., the RN charted " ...resident is requesting to wear attends when she is in bed and resident is refusing to leave attends unfastened and open to air with resident stating " what is the difference between me laying in a wet diaper or a wet attends? " . Resident also refused to lay down this afternoon ... " Orders were written 11/6/13 for " ...return to bed in the afternoon for two hours - no attends every shift for open area, no attends when in bed every shift for open area" and an order 11/7/13 for [MEDICATION NAME] cream mixed with destin to open area with each incontinent episode. Review of the resident's skin integrity care plan (see above) revealed no updates with the above orders and no documentation regarding education and/or interventions to address the resident's refusals. -NN: 11/11/13 at 12:40 p.m., the LPN charted " ... left buttock wound improving ... " -NN: 11/28/13 at 12:00 midnight, the RN charted " ...fax communication completed to PCP ' s NP regarding no improvement noted to wound on posterior, upper right thigh with this RN requesting new order for treatment of [REDACTED]. There was no evidence a weekly wound tracking form (either pressure or non-pressure tracking forms) was developed to monitor the open area areas in 11/13. -NN: 12/1/13 at 9:43 p.m., the RN charted " ... this RN encouraged resident to leave wound open to air tonight since she has a catheter and is no longer incontinent of urine. This RN educated resident that leaving her skin open to air may promote healing of wound. Resident stated " but what about when I roll over. " The RN educated resident that ointment will rub off on attends or soaker pad and resident would have a soaker pad underneath her instead of a brief. Resident stated, " I want to wear a brief. " This RN suggested resident leave brief unfastened with resident instructing CNA to fasten brief " loosely " ... " Review of the resident's care plan revealed no care plan update on resident education, resident refusal, interventions to promote compliance. -NN: 12/9/13 at 10:45 a.m., the LPN charted " ...skin check: warm dry intact. Dark bruise right lower abdomen from insulin injection ... " -NN-12/20/13 at 10:57 p.m., the RN charted " ...open area to posterior right upper thigh measures 2.5 x 3.0 centimeters this evening. Resident informed of new order to apply a [MEDICATION NAME] dressing in the morning starting 12/21/13 and change the dressing every three days since there is no improvement in healing noted using [MEDICATION NAME] and [MEDICATION NAME] ointments with resident in agreement to use of dressing instead of ointments ... " Orders revealed an order 12/21/13 for [MEDICATION NAME] dressing, change every 3 days, one time a day every 3 days. -NN: 12/27/13 at 12:47 p.m., the RN charted " ...dressing to the right buttocks change, wound noted flat with white wound bed, no noted drainage to site, no offered complaints of pain with palpation to site ... " A white wound bed can suggest devitalized tissue which needs to be debrided. However, there was no indication the physician was notified of the change in status of the resident's wound. See: Ruth A Bryant, RN, MS, CWOCN and Denise P. Nix, RN, MS, CWOCN, Acute and Chronic Wounds, Current Management Concepts, "Debridement," third edition, Mosby (2007) page 177 and 461: - "Debridement is indicated for any wound, acute or chronic, when necrotic tissue (which may be slough (soft, moist avascular (necrotic/devitalized) tissue; it may be white, yellow, tan or green; it may be loose, stringy, or firmly adherent) or eschar (thick, leathery necrotic tissue, devitalized tissue) ) or foreign bodies are present. It is also indicated when the wound is infected. Once the wound bed is clean and viable tissue is present, debridement is no longer indicated. " - " Delaying debridement can lead to progressive necrosis from desiccation of the surface of the wound and continued multiplications of bacteria in the necrotic (avascular) portion of the wound bed. " -NN: 12/29/13 at 9:27 p.m., the RN charted " ...this RN was informed by CNA on 12/28/13 at approximately 10:00 p.m. that dressing on resident ' s right upper thigh needed to be changed. This RN was unable to locate a [MEDICATION NAME] dressing on nursing cart or wound care cart with this RN informing night RN during end of shift report that dressing would need to be changed and [MEDICATION NAME] dressings would be obtained from central supply. This RN entered resident ' s room this evening (12/29/13) to administer medication with resident stating. " I just wanted to tell you that I did not get a dressing put on until 5 o ' clock this morning. " -NN: 12/30/13 at 12:39 p.m., the RN charted " ... weekly skin check - open area to right buttock fold has yellowish minimal drainage wound bed is beefy red, treatment applied as ordered. All other skin is intact ... " There was no evidence a weekly wound tracking form (either pressure or non-pressure tracking forms) was developed to monitor the wound in 12/13. -NN: 1/4/14 at 10:54 a.m., the RN charted " [MEDICATION NAME] falling off of left thigh wound. Wound cleansed and new [MEDICATION NAME] applied. Minimum amount of drainage noted dark area in center of wound. No verbal complaints or signs of pain. Dressing replaced ..." Although a dark area can suggest devitalized tissue that needs to be removed, there was no indication the physician was notified about this change in the status of the resident's wound. See above reference, "Debribement." On 1/6/14, over five months since discovery of the open areas and their failure to heal, the resident was seen by a physician at a wound clinic who ordered 'diaper at all times, butt paste 2-3 x a day and with Bowel Movement, return in two weeks.' -NN: 1/7/14 at 11:29 a.m., the nurse manager charted " ...returned from appointment with wound care clinic with order for butt paste two times daily and as needed with each bowel movement. Leave brief on at all times, clean wound with soap and water and apply paste per doctor from wound clinic ... " -NN: 1/7/14 at 11:43 a.m., the LPN charted " ...this nurse applied the first dose of new treatment to buttock wound. Center of wound with yellowish skin. Small amount of black noted. Edges of wound thick, red in color on posterior edges. Anterior edges thin pink/red in color. Resident states " glad can ' t feel it. " The order, per treatment record, read, 1/8/14 - "Butt Paste two times a day, clean wound with soap and water and then apply paste." There was no evidence the resident's care plan was updated, new interventions added and/or existing interventions revised. -NN: 1/8/14 at 10:41 p.m., the LPN charted " ...resident wound has black center and has red chafing area around that is peeling. Resident states there is no pain. Strong odor coming from wound noted ... " Although a new findings of "strong odor," but no evidence PCP or wound clinic physician notified. -NN: 1/13/14 at 4:03 a.m., the RN charted " ...wound measures 3.5 x 2.0 centimeters. The surface of the wound is dark in color. The wound is oozing blood. Resident has temperature of 99.2. Resident had taken scheduled Tylenol 15 minutes before temperature taken ... " -NN: 1/15/14 at 11:17 p.m., the RN charted " ...buttock wound cleaned and butt paste applied with resident tolerating procedure well. Wound outer measurements remain 5.5 centimeters at widest point and four centimeters at narrowest in oblong shape. Area of necrotic tissue has increased to four centimeters in circular diameter ... " The documentation above revealed the wound had grown two centimeters both in length and width and necrotic tissue continued to also grow. There was no indication in the NN that the physician or wound clinic was notified; the resident did not visit the wound clinic again until 1/20/14. -NN: 1/20/14 10:05 p.m., the RN charted " ... the resident returned from appointment at wound clinic. This RN applied butt paste to wound on her left posterior superior thigh with majority of wound yellow/black in appearance from the center to the edges with outer edges pink with skin peeling ... " Review of the wound clinic note 1/20/14 revealed in pertinent part, to check for soiling every 2 hours while awake , twice over night and to continue butt paste. -NN: 1/22/14 at 6:20 p.m., the RN charted " ...resident was seen by PCP this afternoon with resident assisted into bed so PCP could evaluate wound on posterior aspect of her left upper thigh ... " There was no documentation in the record of physician's assessment. No new orders were written per MAR and TAR review. -NN: 1/24/14 at 3:59 a.m., the LPN charted " ...left posterior gluteal fold wound appears larger in size since this nurse last saw wound. No active bleeding noted, moderate amount of yellowish drainage on brief. Wound with eschar and moderate amount of slough throughout bed, skin around peri wound continues to peel. Open area has grown and now extends up into labia fold, continues to be malodorous ... " -NN: 1/25/14 at 12:44 a.m., the LPN charted " ...wound to left gluteal fold remains full of slough and eschar to wound bed, minimal bleeding noted to periwound edges. Skin continues to peel around wound. Open area extends up through labial fold and continues to grow in size ... " There was no indication in the record that staff communicated with wound clinic or PCP to report lack of progress and the presence of a larger, foul smelling wound with necrotic center, changes documented after 1/20/14 wound clinic visit. -NN: 1/26/14 at 7:01 a.m., the RN charted " ...wound has necrotic center with a border of slough. There is a foul odor. There was a moderate amount of drainage this shift. Butt paste applied per orders. -NN: 1/26/12 at 9:50 p.m., the RN charted " ...wound on left posterior upper thigh measures 6.5 centimeters by 7.5 centimeters. The majority of the wound is black from the center to the edges with the edges of the wound macerated. Scant amount of serosanguineous drainage noted of insert when it was changed this afternoon and this evening. Butt paste ([MEDICATION NAME]/[MEDICATION NAME]/Questran) was applied twice after wound was cleansed with warm water and soap. This RN notified night RN at end of shift report that resident does not want to be awoken at 4:00 a.m. for application of Butt paste. The RN also left message for RN manager requesting resident follow up with the doctor at the wound clinic since no improvement is noted with healing of her wound ... " There was no documentation in NN or elsewhere in record if or when the wound clinic was contacted. However, see below; review of wound clinic notes revealed 2/3/14, the wound clinic physician referred the resident to the WNP. -NN: 1/27/14 at 5:01 a.m., the RN charted " ...Temp 97.6 resident continues on two antibiotics for wound infection without adverse effect ... " -NN: 1/30/14 at 3:34 a.m., the LPN charted " ...left gluteal fold ulcer continues to grow near labial fold, wound appears to be tunneling in this area. Large amounts of slough and eschar noted throughout wound, continuous to be malodorous. Resident even commented on how the wound " stinks " . Increased redness and peeling to periwound area. Cleansed with warm soapy water and thick layer of butt paste applied. There was no evidence a weekly wound tracking form (either pressure or non-pressure tracking forms) was developed to monitor the wound in 1/14. -NN: 2/3/14 at 5:31 p.m., the nurse manager charted " ...the wound clinic called and stated that the wound doctor would like resident to be evaluated for a pressure relieving ROHO cushion for her wheel

Based on observation, record review, resident and staff interview, the facility failed to ensure three of 29 sample residents (#63, #32, and #74) received adequate supervision and assistance to prevent accidents. Specifically, the facility: -Failed to prevent repeat injuries to resident #63 during transfers. The resident was totally dependent on two or more staff for bed mobility and transfers. He sustained repeated skin tears, primarily attributed to transfers. On 6/17/12, following a transfer, he was discovered to have a painful left ankle. Subsequent x-rays revealed a fracture. -Failed to implement adequate interventions to prevent falls for residents #32 and #74 and -Failed to properly store oxygen tanks. The findings include: I. Falls A. Resident #63 According to the face sheet, the resident was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], showed the resident required total assistance from two or more staff members with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The resident had a functional limitation in range of motion in both of his lower extremities. His short and long term memories were impaired. The resident's comprehensive care plan, dated 5/8/12, showed the resident had a self care deficit related to Parkinson's and aphasia with late effect, CVA, depression, advanced [DIAGNOSES REDACTED], and anemia manifested by immobility, increased weakness, and communication deficits. Approaches included: -AM, PM Cares: Full assist -Teeth: Total Assistance -Dressing: Full assist -Day Schedule: Arise 6 - 7:30 a.m., put in recliner until breakfast ...Foot pedals, elevate at all times except with meals. The resident's comprehensive care plan, dated 5/8/12, showed the resident had a mobility deficit related to Parkinson's manifested by decreased ability to stand, bear weight or self transfer. He required a full mechanical lift for all transfers. a. Resident Observation On 6/26/12, at approximately 2:00 p.m., the resident was observed in the living room watching television. The resident was seated in a wheelchair. His ankles and feet were elevated by a foot board attached to the wheelchair's footrests. A certified nurse aide (CNA) approached the resident and brought him back to his room. She asked for the assistance of another CNA. A sling was placed behind the resident and he was transferred from his wheelchair to his bed with a mechanical lift. The resident was unable to physically participate with the transfer. He was also unable to lift his feet or arms and his extremities were manipulated by the CNAs during the transfer. b. Resident Injuries According to nurses' notes, corresponding incident reports and investigations, the resident sustained [REDACTED]. The resident was injured while the mechanical lift was in use on 2/6/12 and 6/4/12. It was also suspected the resident's use of the mechanical lift caused his injuries on 3/18/12 and 6/17/12. Implemented interventions to prevent injuries using the mechanical lift and sling were ineffective. More specifically: 1. 2/4/12 Bruise A 2/4/12 nurse's note documented, "Res(ident) found to have appox. 9 cm x 5 cm bruising top of R(ight) hand of unknown occurrence." A related incident report, dated 2/4/12, showed this was an injury of unknown source. An immediate intervention implemented by facility staff to prevent this from happening again was to keep the resident away from sharp objects. The related investigation, dated 2/6/12, asked if the incident was witnessed. If the incident was not witnessed, all caregivers for the past 72 hours were to be listed. However, only two staff members were listed to have worked with the resident for the past 72 hours. A summary of factors contributing to the incident documented, "Appears res may have bumped his hand against an object." The corrective actions taken to prevent recurrence of this incident were to continue to keep the resident in a safe environment. The results of the investigation were, "Res may have bumped his hand against an object. No sharp objected noted. Resident on Coumadin." 2. 2/6/12 Skin Tear A 2/6/12 nurse's note documented, "Res obtained skin tear to LFA (left forearm) during transfer with lift. Cleaned applied steri strips. Family and MD notified. Res with no c/o (complaint) at this time." A related incident report, dated 2/6/12, showed the resident obtained the skin tear to his LFA during a transfer with the lift. An immediate intervention implemented by facility staff to prevent this from happening again was to check the placement of the lift and sling when doing transfers. The related investigation, dated 2/7/12, showed the incident was witnessed by two staff members. A summary of factors contributing to the incident documented the use of the lift was the apparent cause of the incident. The corrective actions taken to prevent recurrence of this incident included employee education. The results of the investigation were, "Check placement of lift and positioning of arms in sling." 3. 3/18/12 Skin Tear A 3/18/12 nurse's note documented, "Skin tear to L(eft) elbow measuring 3 cm. Appears to not be new as ST (skin tear) is already scabbed over ..." A related incident report, dated 3/18/12, showed the resident had a skin tear to his left elbow measuring 3 cm. This appeared to be an old ST because it was scabbed over. No blood was noted to the resident's bed linens or clothes. Bruising was noted to the surrounding areas. No immediate interventions were implemented because it was, "Unknown how resident obtained ST. Unable to initiate any interventions. Possible from sling/lift. Staff to check placement prior to transfers." The related investigation, dated 3/18/12, listed seven staff members who had worked with the resident in the past 72 hours. A summary of factors contributing to the incident documented, "St to L elbow. Possibly from sling/lift. Staff to check placement of sling prior to transferring resident." The corrective actions taken to prevent recurrence of this incident were employee education. The results of the investigation were, "Reopen of old skin tear - wear long sleeves. Staff to be aware of arm placement with sling transfers." 4. 5/12/12 Skin Tear A 5/12/12 nurse's note documented, "Skin tear of unknown origin noted to R elbow ..." A related incident report, dated 5/12/12, showed, "CNAs state they transferred resident to bed. Moved 02 (oxygen) tubing from R arm and noted a bleeding skin tear. Skin tear triangle shaped and measured 10 cm." An immediate intervention implemented by facility staff to prevent this from happening again was, "Moisture barrier applied to skin. Larger pajama to be required from daughter as CNA report currently supply is too tight. Resident was wearing a short sleeved shirt at time of incident." The related investigation, dated 5/15/12, showed 15 staff members had worked with the resident in the past 72 hours. A summary of factors contributing to the incident documented, "Resident has very fragile, thin skin that tears easily with friction, shearing, or injury. Unknown origin." The corrective actions taken to prevent recurrence of this incident were to apply a moisture barrier to the resident's skin. The results of the investigation were, "Skin tear of unknown origin. Resident confused and unable to verbalize cause. No abuse or neglect suspected." 5. 6/4/12 Skin Tear A 6/4/12 nurse's note documented, "Res has ST to R top of hand. Please see (incident report) for details." A related incident report, dated 6/4/12, showed the lift and sling were involved in the incident. "When transferring into w/c (wheelchair), CNAs stated when lowering res, res hand got caught on sling and resulted in ST to top of R hand." No immediate interventions to prevent the incident from happening again were listed. The related investigation, dated 6/7/12, showed the incident was witnessed by two staff members. A summary of factors contributing to the incident documented the use of the lift listed, "Res was being transferred into w/c via mec. lift when res hand got stuck in sling when being pulled up. CNAs got hand out but ST already occurred, hand was outside sling per protocol." The corrective actions taken to prevent recurrence of this incident were employee education. "Nursing spoke with staff about making sure environment is safe before moving res. Ensure hands are on straps of hygiene sling or crossed over chest in regular sling. Signs posted." 6. 6/17/12 Ankle Fracture A 6/17/12 nurse's notes documented, "Come look at (resident's) ankle. When I move his foot, he cried out in pain. Resident's daughter asking nurse to check L ankle. Resident sitting in w/c visiting with daughter. Shoe and sock removed from L foot. It was noted that L ankle was swollen and painful to touch. Measurement of L ankle was 29 cm. R ankle is 26 cm. Ankle iced and elevated. Stat x-ray ordered. Resident given Tylenol for pain." A related incident report, dated 6/17/12, showed, "Resident's daughter observed resident's reaction. When she repositioned his left leg on the w/c, resident expressed pain. Shoe and sock removed revealed swollen L ankle (29 cm) R ankle (26 cm). Immediate interventions implemented were, "Careful transfers with mechanical lift. The swollen ankle is unknown why it occurred." The related investigation, dated 6/18/12, did not list staff who had worked with the resident in the past 72 hours. A summary of factors contributing to the incident documented, "Cause of the incident is unknown." The corrective actions taken to prevent recurrence of this incident were employee education. "Nursing will educate CNAs to transfer carefully and gently" A further injury of unknown origin investigation, dated 6/17/12 documented, "Possible cause is during transfers with the mechanical lift into w/c. Possible other resident ran into (resident) while in w/c. Possible past fx (fracture), non-weight bearing for 1+ yrs. CNAs thought the only possibility could be with transfers with the mechanical lift since resident does not attempt to transfer himself. It is unknown if this is the cause or when it happened." Conclusion: "From the x-ray of the ankle, it was not conclusive whether the swelling was from an old fracture or subacute fracture. Careful transferring is a must with the resident." Two staff interviews were conducted with the CNAs working the evening on 6/17/12. CNA #1 stated she had put the resident's shoes on and she transferred the resident from his bed to his wheelchair at approximately 4:30 p.m. CNA #1 did not recall the resident complaining of pain and stated the resident's ankles were usually swollen and dark in color. CNA #2 stated the resident's ankle looked swollen, but stated it usually was. She did not remember if the ankle was bruised or reddened. She said the resident did not complain of pain. These CNAs were educated to transfer the resident gently. No other staff interviews were recorded as part of the investigation. X-ray Results: The resident's initial X-ray conducted by a portable machine on 6/17/12 showed, "Soft issues swelling is present. Avlusion fractures of the inferior aspects of the medical and lateral malleolus are present. Fracture lines are indistinct suggesting a subacute process or old process. The resident was sent for an additional X-ray on 6/18/12. This x-ray showed, "Alignment is normal. There is a subtle potential cortical discontinuity of the lateral cortex of the lateral malleolus well below the plafond suggesting a probably nondisplaced oblique fracture. Impression: Nondisplaced oblique fracture through the distal fibular shaft below the level of the plafond. Equivocal mild loss of Boehler's angle which may indicate prior calcaneal injury. If there is concern for an acute calcaneal injury, suggest additional calcaneal views." On 6/19/12, the resident's physician documented the resident had, "A fracture of the left ankle of unknown age and from an unknown cause. He has been referred to orthopedic surgery." On 6/20/12, the resident's orthopedic physician documented the resident had an avulsion fracture of the left malleolus, possible from twisting motion of ankle. An avulsion fracture is occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma. c. Facility Failures Physician Orders: According to the June 2012 computerized physician orders, the resident had the following pertinent orders: -Lotion to both lower legs and feet BID (twice daily) -Nurse to monitor all bilateral toes daily for s/s (signs and symptoms) of skin breakdown at HS (bed time) Even though these orders were in place, there was no evidence nursing staff, who had applied the lotion or assessed the resident's feet prior to the discovery of the fracture, were interviewed about the resident's injury 6/17/12. Care Plan: Notwithstanding repeated injuries during transfers, follow up education for staff, and recommendations from post-injury investigations(see above), there was no evidence the resident's care plan was updated to include post-injury recommendations. Likewise, there were no directives included regarding staff education in order to ensure the resident was safely transferred. (Signs regarding transfer safety were not posted until the 6/4/12, after the resident had sustained several skin tears.) Facility Training: There was no documentation provided by the Director of Nursing (DON) to show the staff education referenced in the post-injury investigation and no documentation that all staff working with the resident were educated on how to ensure the resident was safely transferred. d. Staff Interviews On 7/09/12 at 9:29 a.m., a CNA who worked on the morning shift on 6/16/12 was interviewed. She said the resident required total assistance with care. She said when she worked on 6/16/12, she did not notice anything unusual about the resident's ankle. The CNA said the facility obtained new lifts and slings in February 2012. She said the slings were rough textured and had scratched several residents. On 7/9/12 at 9:35 a.m., the LPN (licensed practical nurse), who worked the morning shift on 6/17/12 was interviewed. She said the resident had a fracture and she did not know how he got it. She said she did put lotion on the resident's ankles and feet on the morning of 6/17/12, but claimed she did not notice anything unusual about the resident's ankle. The LPN said the resident was very quiet and was not vocal about expressing pain. On 7/9/12 at 9:42 a.m., the CNA who worked the morning shift on 6/15/12, said the resident was very dependent on care. She said the only thing the resident was able to do for himself was pick up a cup. She said when she worked on 6/15/12, the resident's ankle looked normal. She said when she transferred the resident with the lift, she was careful because she was concerned the resident's foot could get stuck on the middle piece of the lift. On 7/9/12 at 12:06 p.m., a CNA who worked the morning shift on 6/17/12 said, "I typically get him up in the mornings. We have to change his brief, get his socks on, his shoes, and pants and shirt. We have to use a lift to get him up. That shift, he didn't seem to be in any more pain. I was really surprised when I heard that he had a fracture because we transfer him so I'm not even sure how that could even happen." She said she did not notice swelling or bruising of the resident's ankle when she dressed him that morning. On 7/9/12 at 4:36 p.m., the CNA, who had worked the morning shift on 6/16/12, said she knew about the resident's fracture but said, "I don't know how it could have happened because he's a full lift. I've worked with him. You have to be careful so that you have both of his feet on one side of the lift bar. There could be skin tears if you didn't." She said the resident's ankle looked normal on 6/16/12. On 7/9/12 at 4:41 p.m., the CNA who worked the evening shift on 6/17/12 was interviewed. She said, "I had got him up that night with the nurse and she had helped me transfer him to his chair. His shoes were off and I put his shoes on, got the sling on him, and put his oxygen on. I did not know anything about his foot until the daughter had come and was in the front solarium and said that his foot was swollen and that he was in pain. Usually (the resident) doesn't tell you he's in pain." She said the resident's feet and ankles were normally swollen and had a "purplish color" to them. The CNA said when she put the resident's shoes on, she did not notice the resident was in pain. On 7/9/12 at 4:48 p.m., the registered nurse (RN) who worked the evening shift on 6/17/12 was interviewed. She said, "His daughter comes every Sunday at 4:30 p.m. One of the aides was on break and I went to assist a CNA to move him from the bed to the chair. We got him up and moved him. I didn't notice any pain or anything different. The daughter was visiting with him and wanted to line his legs up in the chair. She moved his left ankle and he grimaced with pain. She told me he had pain in his ankle. I noticed the right ankle was more swollen and I measured it. You could tell that he was in pain." The RN said she estimated 45 minutes had passed from when she and the CNA had transferred the resident and his daughter reported the pain. The RN said, "He doesn't move, so the fracture had to be with a transfer or with care." She stated she was sure it did not happen when she and the CNA had transferred the resident. On 7/10/12 at 1:09 p.m., the DON was asked if there was evidence of education provided to staff members related to the resident's injuries, she said, "Nothing is formally documented on that." The DON acknowledged the resident had several injuries involving the mechanical lift and sling. She said the resident had very fragile skin and had a general decline. She said he had a significant history of skin tears and was on Coumadin. When asked about the resident's fracture, she said, "The nurses observed there was no bruising and no red marks. He had edema in both ankles. He was having noticeable pain where it had not been before and the nurse asked for an x-ray. It was inconclusive and we sent him out the next day for a better x-ray. That one came back that there was absolutely a fracture but there was no apparent trauma to the limb. He doesn't talk much and is unable to say if anyone had mishandled him or anything like that." She said the corrective action of educating the two CNAs to transfer the resident carefully was appropriate because of the resident's fragility. She said she was not sure if the fracture happened during a transfer and said it could have been spontaneous. The DON said she was not aware the resident had the two orders for a daily assessment of his toes and twice daily lotioning of his ankles and feet. Therefore, she acknowledged she specifically did not ask the nurses if they had noticed swelling or something unusual while carrying out the orders. e. Additional Information Following the survey exit, on 7/11/12, the facility sent additional information for review. The resident's history and physical dated 4/10/06, showed the resident had a fractured foot in the past. A physical therapy assessment dated [DATE], documented the resident was unable to participate in therapy due to pain in his left foot. B. Resident #32 Resident #32, [AGE] years old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], revealed unclear speech but usually understood. She had impaired vision, no behaviors, needed extensive assist for bed mobility, transfers, dressing, locomotion off the unit, personal hygiene and toileting. She also had a potential for choking. The care plan for falls, dated 3/27/12 and updated on 4/25, 5/3 and 5/19/12 revealed the goal was to be free of falls the next 90 days. The approaches, in pertinent part, were: -Resident to have bed controls so she can readjust the bed as desired. -Keep call light with in reach and encourage the resident to call for assist with transfers. -Frequent visual checks. -Anticipate needs and follow the toileting plan. -To have a transfer pole to assist her with transfers. -Will not use alarms due to anxiety and to maintain independence. -Resident refuses to follow physical therapy recommendations. -Keep the bed in low position. review of the resident's medical record revealed [REDACTED]. -4/22/12 The resident was self transferring. According to the investigation report, this was a pattern and trend. The recommendations were, "informed choice - refusing to ask for assistance." -5/3/12 The resident slid to the floor using the transfer pole. This was a pattern and trend. The recommendation was, "On going." -5/18/12 The resident was found on the floor. "The resident is very impulsive and will self transfer. An alarm may be helpful." The resident sustained [REDACTED]. -5/20/12 The resident was found on the floor in her room. No incident report or investigation was found in the medical record. -5/22/12 The resident was found on the floor. "Resident was confused due to low blood sugar of 38." The recommendation was to continue the care plan and interventions. -5/24/12 The resident was found on the floor holding the transfer pole. "Trying to get to the bathroom. Staff will toilet at 5-6 a.m. to help prevent falls." -6/9/12 The resident was found on floor between the bed and the transfer pole. The resident's blood sugar was 32. The results of the investigation was "look at the amount of insulin." This was a second fall with low blood sugar. (Cross Reference F309) -7/8/12 The resident slid to the floor. There was no investigation done on this fall The incident report read, "Re-educate the resident to use the call light for assistance." C. Resident #74 Resident #74, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His MDS dated [DATE], revealed he was usually understood and usually understands. He had impaired vision and hearing. He needed total assist with bathing and personal hygiene and extensive assist with transfers, bed mobility and toileting. He was frequently incontinent of urine. His care plan for falls dated 6/19/12, had a goal to have fewer falls over the next 90 days. The problem of falls was related to Parkinson's disease, decline in physical mobility, and inability to make needs known. The approaches were: Make sure the alarm is turned back on when his wife leaves. Pressure alarm in wheel chair. Do not leave resident alone in the room while he is up. Anticipate needs and follow the toileting plan. Frequent visual checks. Keep wheel chair out of sight so he will not try to transfer himself. Answer alarm promptly. Review of the medical chart revealed: -5/13/12 The resident was found wedged between the roommate's bed and the resident's wheel chair. The resident attempted to stand via the foot board and slipped under the bed. The alarm had been removed by resident and was found next to the resident not sounding. There was no investigation for this fall and no interventions. -5/27/12 There were no notes in the medical chart and no incident report. There was an investigation. The resident fell out of bed, the resident's legs slid over the sides of the bed. According to the incident report, the interventions were to change the mattress. -6/17/12 According to the incident report, the resident was found face down on the fall mat. Stated he rolled out of bed. The investigation recommendation was poor safety awareness and remind to use the call light. -7/7/12 The resident was found sitting next to the bed with fall mat under the resident. There was no investigation and therefore no recommendations. The director of nursing (DON) was interviewed on 7/9/12 at 10:30 a.m. The DON stated the resident was non-compliant with calling for assistance. when he wanted to get out of bed. She stated the resident could not remember he was unable to walk or remember to use the call light. II. OXYGEN STORAGE REQUIREMENTS NFPA 99 - 1999 EDITION (LESS THAN 3000 CUBIC FEET) Division of Quality Assurance - Bureau of Regulatory Compliance (revised 3/04) 4-3.5.2.1(b) 27 freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. Facility Policy On 7/5/12 at 1:53 p.m., the Nursing Home Administrator (NHA) provided the facility policy on Guidelines Oxygen Use Safety #II.O.4a dated 3/11 (revised). The policy documented the following pertinent information: "13. All oxygen cylinders should be chained in place, racked or stored in stable carts at all times." On 7/5/12 at 11:33 a.m., observations in the Oxygen Storage Room (OSR) on the Rose Garden Hall, included one 6 cubic feet oxygen tank (cylinder) inside a blue canvas carrying case (bag). The carrying bag was leaning up against a wall and was sitting on top of a wheel connected to a metal portable oxygen rack. The portable oxygen rack was sitting on two edges of a plastic milk crate. The milk crate sat on the concrete floor. A Licensed Practical Nurse (LPN) was immediately notified. The LPN observed/agreed the oxygen tank was inside the blue canvas carrying bag sitting (positioned) on top of the wheel connected to a metal portable oxygen rack. The LPN stated the oxygen tank should have been properly stored in a rack. The LPN stated oxygen transfers did occur in the OSR. At 11:45 a.m., the NHA stated it was his expectation staff store oxygen tanks (cylinders) according to the facility's oxygen storage policy.

Based on observation, record review, resident and staff interview the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for five of 29 sample residents (#34, #32, #143, #119 and #74). Specifically, the facility: -Failed to adequately treat severe pain for resident #34. -Failed to ensure appropriate interventions were taken for low blood sugars for resident #32 and resident #119. -Failed to ensure a resident's skin was assessed and monitored after an unwitnessed injury for resident #74. -Failed to ensure neurological checks were implemented after unwitnessed falls for resident #119. -Failed to ensure adequate monitoring and follow up after a status change for resident #143. The findings include: 1. Failure to Treat Pain Resident #34, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. His most recent minimum data set (MDS), dated [DATE], revealed no memory loss, he needed extensive assist with bed mobility and dressing, he had a pain level of four out of 10 (10 being the worst pain) and was on scheduled pain medication. The resident's care plan for pain, dated 4/17/12, identified back pain and frequent right ankle pain. The goal was lessening or absence of pain, post nursing interventions. The approaches were: -Administer medications as ordered. -Observe for signs/symptoms of pain and report to the charge nurse. -Monitor pain each shift. The care plan had not been updated after his readmission on 7/2/12. The resident had a fall on 6/28/12. Per the nurse manager, at 12:00 p.m., the resident was outside by the ponds got up to transfer himself and fell . He was sent to emergency room from outside and therefore was not assessed by nursing. He returned to facility on 7/2/12. He sustained a fracture, however, there was no surgery and he currently required a full lift for transfers. The resident was interviewed, at 1:40 p.m. on 7/5/12. The resident stated that his pain was at an eight out of ten. He stated he asked for pain medication about noon while in the dining room and was told he needed to wait an hour. He received the pain medication at 1:00 p.m. According to the resident, more than 40 minutes later the resident's pain was still at an eight. The licensed practical nurse (LPN) on duty was interviewed at approximately 1:50 p.m. The LPN stated he did give the medication at 1:00 p.m. Regarding the resident's level of pain, the LPN stated the resident asked for pain medication at lunch and he told him he would have to wait until 1:00 p.m. The LPN stated he did not think the resident was in pain. He stated the resident, "Doesn't complain and when told he had to wait in the dining room he just left." The LPN added the resident did not grimace or complain. He further stated that he had been observing the resident that day and felt the resident was not acting like he was in pain. After the LPN was informed of the findings, he went to the resident's room, on 7/5/12 about 2:00 p.m. He asked the resident if he was in pain. The resident stated he had a "whole bunch of pain." He first rated it at a 7 and then stated, "No, 8 out of 10." The resident further stated he needed something stronger. The LPN stated that he was going off duty and would tell this to another nurse. At 3:00 p.m. on 7/5/12, the other LPN was interviewed. She stated the resident was scheduled to receive Tylenol shortly. She said the resident did not exhibit pain but he definitely had pain. She stated the resident's physician was currently at the facility and would be seeing the resident. Approximately 10 minutes, the LPN said the resident's pain medication dose was increased. The resident's pain record was reviewed on 7/12/12. The pain scale was done twice during the day, morning and evening. The pain scale was 1-3 mild pain, 4-6- moderate pain and 7 or higher was severe pain. On 7/5/12, no pain level was recorded in the MAR. From 7/6/12 the resident's pain was coded as a 9 for all evenings even though the medication ([MEDICATION NAME]) dose was increased from 10 mg to 15 mg. The morning shift rated the pain at 7-9 out of 10. However, even after the order was changed the licensed nurses continued to administer the 10 mg dose. On 7/6/12, the resident received 10 mg at 7:30 a.m., even though he rated his pain 9.75 out of 10. The result was somewhat effective. On 7/6/12, the resident received 10 mg of [MEDICATION NAME] at 7:40 p.m. with his pain at 9 out of 10. No effectiveness/results were documented. On the 7/8/12, he received [MEDICATION NAME] 10 mg twice. The result was recorded as helpful, however, there was no pain scale noted. He received 10 mg of [MEDICATION NAME] on 7/9/12 at 12:45 a.m., after he complained of hip pain at a 9 out of 10. The medication was given with 650 mg Tylenol and the results were "helpful." On 7/9/12 at 4:45 a.m., the resident received 10 mg of [MEDICATION NAME] and 650 mg of Tylenol. The pain was not rated, though the results were documented as helpful. There were no further 10 mg doses of [MEDICATION NAME] administered to the resident after 7/9/12, more than four days after the medication dose was changed, even though the resident was rating his pain at a 9 out of 10. Although the resident received doses of the 15 mg of [MEDICATION NAME] on 7/6/12 at various times during the day evening and night, with his pain at a 9, after receiving the [MEDICATION NAME], his pain level was most often a seven. The DON was interviewed, on 7/9/12 at 10:20 a.m. The DON was informed of the findings, and the MAR indicated [REDACTED]. 2. Failure to Follow Blood Sugar Orders/Protocol Facility Procedure #II.H.9 (revised 1/09) Hypoglycemic Incidents Purpose: To protect from complications of [DIAGNOSES REDACTED]. Procedure: 2. For blood glucose levels 70 or below, or physician's guidelines, as long as the resident was able to swallow (observe for gag reflex with tongue blade). 2a. Give a rapidly absorbed carbohydrate such as four ounces of orange, apple or grape juice or six ounces of regular soda. These amounts are equal to fifteen grams of carbohydrates. 2b. Repeat blood glucose test after fifteen minutes. 2c. Repeat administration of carbohydrate if necessary. 2d. Follow with a longer acting carbohydrate protein such as; cheese and crackers, milk and fruit or a sandwich. 2e. Notify the physician. 2f. Monitor the blood glucose levels every fifteen minutes until blood glucose levels are above 70. a. Resident #32 Resident #32, [AGE] years old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her MDS, dated [DATE], revealed unclear speech but usually understood. She had impaired vision, no behaviors, needed extensive assist for bed mobility, transfers, dressing, locomotion off the unit, personal hygiene and toileting. She also had a potential for choking. Her care plan, dated 3/30/12, for alteration in blood sugars, listed a goal for the resident to be free of hypo/hyperglycemic reactions during the next 90 days. The approaches were: -Provide insulin/hypoglycemic as ordered, -Check blood sugars (BS) as ordered, -Ensure that the resident will eat when meal arrives before giving insulin, -Must wake resident by 9:30 a.m. to eat breakfast in room and get insulin. Her insulin orders included: Insulin NPH 24 units each morning Insulin NPH 4 units at bedtime Regular insulin 6 units with dinner For sliding scale insulin administration, the following number of units were ordered to be given related to the blood sugar (BS) readings: BS below 100 hold (no insulin) BS 150-200 2 units BS 201-250 3 units BS 251-300 6 units BS 301-350 8 units BS 351-400 10 units BS over 400 give 12 units and call the MD Accuchecks (BS) to be done before meals and bedtime. Call physician if BS was below 70 or above 400. [MEDICATION NAME] 1 mg if blood sugar below 80. Review of the medical chart revealed low blood sugars (BS) and nurse's notes on the following dates: -On 7/3/12 at noon the BS was 35 followed by 91. The notes documented that after her shower the resident became unresponsive. Her BS was 35. [MEDICATION NAME] was administered and within 15 minutes the resident became talkative. Her BS was 81. "Color continues to be pale 200 cc of orange juice given BS 91 Lunch tray arrived." However, there was no evidence the physician was called. There was no documentation to show when the resident's BS was re-checked, no follow up during the meal or indication that she ate her meal. On 7/5/12 during the p.m. shift (there was no time), the resident's blood sugar was 66. There were no notes indicating the physician was called or that the blood sugar was re-checked. On 7/7/12 at 11:45 a.m., the resident was acting strange per the CNA. The residents BS was checked and found to be 31. [MEDICATION NAME] administered and the resident was observed for 20 minutes. The BS increased to 66, 92 and then 118. However, no times were listed to show when the blood sugars were re-checked and no indication that the physician was contacted. On 6/5/12 at bed time, the resident's BS was 69. No documentation was found to show the BS was re-checked or indication the physician was called. On 6/6/12 at noon, the resident's BS was 67. No documentation was found to show the blood sugar was rechecked and no indication the physician was called. On the evening of 6/15/12, the resident's BS was 62. No documentation was found to show the blood sugar was rechecked and no indication the physician was called. On the evening of 6/29/12, the resident's BS was 62. No documentation was found to show the blood sugar was rechecked and no indication the physician was called. On the evening of 6/30/12, the resident's BS was 65. No documentation was found to show the blood sugar was rechecked and no indication the physician was called. In May 2012 there were 8 times the residents blood sugar was low: -5/3/12: the BS was 66 in the p.m. -5/4/12: the BS was 68 in the p.m. -5/9/12: the BS was 54 in the a.m. -5/16/12: the BS was 67 in the p.m. -5/22/12: the BS 66 in the a.m. -5/23/12: the blood sugar was 62 in the p.m. -5/2712: the BS was 58 at noon. -6/29/12: the BS was 68 in the a.m. Review of the nurse's notes showed no documented interventions for the low BS or evidence the physician was called. On 7/9/12 at 10:30 a.m., the resident's nurse was interviewed. She said the resident sometimes was non-compliant with her diet. She had no explanation why the blood sugars were dropping. Even though there was no documentation to show the physician was contacted, the nurse stated she had previous notes regarding contacting the physician. However, no notes or documentation was found or provided to show this. b. Resident #119 On 5/19/12 this [AGE] year old resident (#119) was admitted to the facility. The Face Sheet documented the resident had the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 13. The resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident had impairment on both sides of her lower extremities (hip, knee, ankle, foot). The resident had diabetes mellitus, arthritis and a [MEDICAL CONDITION]. The resident had fallen in the past month. Care Plan, dated 6/5/12, documented the resident had a health maintenance alteration related to diabetes mellitus manifested by potential for altered blood sugars. The plans/approaches documented to provide hypoglycemic medications as ordered, to check blood sugars as ordered and as needed, and to monitor for hypoglycemic/hyperglycemic reactions and treat as ordered or per facility protocol. physician's orders [REDACTED]. The resident was administered [MEDICATION NAME] 40 units SQ each day in the morning for diabetes mellitus II. Nurse Practitioner (NP) notes, dated 6/15/12, documented the resident was seen at the request of nursing staff for evaluation and treatment of [REDACTED]. The staff also reported the resident had a poor appetite and was currently on [MEDICATION NAME] and [MEDICATION NAME]. The NP wrote to hold the [MEDICATION NAME] and continue the [MEDICATION NAME] as ordered: also to encourage the resident to eat. A Fax Communication to Physician, dated 6/26/12, documented the resident had three consecutive days with low blood sugars into the 40s and 50s with poor appetite: "Can we look at adjusting insulin dose to prevent low blood sugars?" Response by physician was a new order for [MEDICATION NAME] 38 units. Nurse Practitioner (NP) notes, dated 6/26/12, documented the resident was seen at the request of the nursing staff for evaluation and treatment of [REDACTED]. sugar levels have done well running in the 40s and 50s in the morning fasting. On the 21st the level was 59 and on the 24th it was 55." The resident was currently receiving [MEDICATION NAME] at 38 units in the morning. The NP wrote, "we will decrease her [MEDICATION NAME]: please see current orders." The Medication Record, dated 6/1/12, documented the resident had eleven blood sugar levels below 70 on the following dates: -1st: midday the level was 44 and at p.m., the level was 56, -4th: the p.m., level was 57, -6th: the midday level was 47, -9th: the p.m., level was 59, -11th: the p.m., level was 58, -21st: the p.m., level was 65, -24th: the am level was 55, -27th: the am level was 56, -28th: the am level was 53, and -30th: the am level was 67. The Daily Skilled Notes (GSS #183) dated the 1st, 4th, 6th, 9th, 11th, 21st, 24th, 27th, 28th and 30th did not document the nursing staff followed the Facility Procedure #II.H.9 (revised 1/09) Hypoglycemic Incidents in the following regards: -the resident did not have their blood sugar level taken/recorded every fifteen minutes until the blood sugar level was above seventy, -the resident was not administered the correct rapidly absorbed carbohydrate and -the resident's physician was not notified. Daily Skilled Note (GSS #183), dated 6/28/12 at 1415 (2:15 p.m.), documented the resident blood sugar level was 53 at breakfast with a Glucerna shake administered. The resident's blood sugar level at lunch was 128. Daily Skilled Note (GSS #183), dated 6/30/12 at 1525 (3:25 p.m.), documented resident's blood sugar in the a.m. was 67 with Glucerna given. The blood sugar at noon was 187. July Blood Sugar Levels Daily Skilled Note (GSS #183), dated 7/1/12 at 0320 (3:20 a.m.), documented the resident requested her blood sugar to be taken. Her blood sugar level was 58. The resident was given Glucerna along with one [MEDICATION NAME] for hip pain. At 0400 (4:00 a.m.) the resident's blood sugar level was 100. There was no further documentation on the (GSS #183) to show the nursing staff followed the Facility Procedure #II.H.9 (revised 1/09) Hypoglycemic Incidents in the following regards: -the resident did not have their blood sugar level taken/recorded every fifteen minutes until the blood sugar level was above seventy, -the resident was not administered the correct rapidly absorbed carbohydrate, and -the resident's physician was not notified. Daily Skilled Note (GSS #183), dated 7/2/12 at 2200 (10:00 p.m.), documented the resident's blood sugar level was 54 by dinner (5:00 p.m.) with Glucerna administered and a meal was provided to the resident. The resident's blood sugar level at 1800 (6:00 p.m.) was 107. There was no further documentation on the GSS #183 the nursing staff followed the Facility Procedure #II.H.9 (revised 1/09) Hypoglycemic Incidents in the following regards: -the resident did not have their blood sugar level taken/recorded every fifteen minutes until the blood sugar level was above seventy, -the resident was not administered the correct rapidly absorbed carbohydrate, and -the resident's physician was not notified. Daily Skilled Note (GSS #183), dated 7/3/12 at 1415 (2:15 p.m.), documented the resident had a blood sugar level of 60 at breakfast with Glucerna administered to the resident. There was no further documentation on the GSS #183 the nursing staff followed the Facility Procedure #II.H.9 (revised 1/09) Hypoglycemic Incidents in the following regards: -the resident did not have their blood sugar level taken/recorded every fifteen minutes until the blood sugar level was above seventy, -the resident was not administered the correct rapidly absorbed carbohydrate, and -the resident's physician was not notified. On 7/10/12 at 2:40 p.m., the Director of Nursing (DON) observed/agreed the Medication Record, dated 6/1/12, documented the resident had eleven blood sugar levels below 70. The DON stated it was her expectation nursing staff follow the Facility Procedure #II.H.9 (revised 1/09) Hypoglycemic Incidents. On 7/10/12 at 3:25 p.m., the Nursing Home Administrator (NHA) stated it was his expectation nursing staff follow facility procedures. 3. Failure to Assess/Monitor Following an Injury Resident #74, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], revealed he was usually understood and could usually understand. He had impaired vision and hearing. He needed total assist with bathing and personal hygiene, dressing and extensive assist with transfers, bed mobility and toileting. He was frequently incontinent of urine. His care plan for skin, dated 6/19/12, listed the goal for the resident to have no skin breakdown during the next 90 days. The problem was alteration in skin integrity related to [MEDICAL CONDITION], weakness, assist with bed mobility and transfers. The approaches were: -Reposition every two hours, -Mattress with pressure redistribution, -Pressure relieving pad for the wheelchair, -Observe skin daily. Report any changes to the nurse, -Skin checks weekly. The resident was observed, on 7/5/12 at approximately 4:45 p.m. He had a bruise on his right arm. There was a quarter size bruise in the middle of the left forearm with two other dime size bruises on his hand and wrist area. There was a fading bruise on the upper right arm. The resident was unable to say where the bruises originated. There were no nurses' notes about these bruises and there was no incident report concerning these bruises. The resident's wife was interviewed, on 7/9/12 at approximately 5:00 p.m. She stated that the resident had many bruises and said the resident bruised easily. On 7/10/12 the director of nursing (DON) at 10:30 a.m., was interviewed about the bruises on his right arm. (He now had a large bruise covering more than half of his lower forearm.) The DON said she was not aware of the bruise. Regarding possible causes, the DON said the resident used the hand rail to pull himself along in the hall way, and said the resident would hit his arm on the hand rail and that caused the bruising. The DON acknowledged they could look into skin protection for the resident. Moreover, there was no documentation of the bruise found in the medical record. 4. Lack of Neurological Assessments Resident #119 Reference According to the Resident Assessment and Monitoring for Long-term Care Established Tools and Guidelines for Clinicians, HC Pro Publishing, 2006, Barbara Acello, pages 58 and 59: --Standards of long-term care nursing practice require for an unknown or suspected head injury, neuro-checks (neurological checks) for a minimum of 72 hours. --Immediately after a fall, monitor neuro-checks = should be done every 15 minutes. If the resident is stable, time between neuro-checks may be increased to every 30 minutes for 2 hours, every 60 minutes for two hours, every four hours for twenty-four hours and then once a shift. Facility Procedure Neurological Evaluation #II.N.5 (issued 3/2011) Purpose: To establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. Use: Following an un-witnessed fall (when a head injury may be suspected) Procedure: 4. After the completion of initial neurological evaluation with vital signs, continue with evaluations every thirty minutes times four, then every shift times three days or as appropriate or more frequently as directed by the physician. Subsequent neurological evaluations should be compared to baseline and previous neurological evaluations. All items on the GSS #497 should be completed with each evaluation. On 5/19/12, this [AGE] year old resident (#119) was admitted to the facility. The Face Sheet documented the resident had the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 13. The resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident had impairment on both sides of her lower extremities (hip, knee, ankle, foot). The resident had diabetes mellitus, arthritis and a [MEDICAL CONDITION]. The resident had fallen in the past month. The Care Plan, dated 6/5/12, documented alteration in mobility related to a pelvic fracture manifested by inability to independently transfer, move in bed, and a fall risk. The plans/approaches were keep call light in reach and remind to call for assistance, low locked bed, room/floor free of clutter, and monitor medications for adverse side effects. A Care Plan update 7/2/12, documented the resident was educated not to self transfer and call for assistance. Physical Therapy was notified of all and an alarm was "placed for now due to secondary confusion and forgetfulness." The Hospital History and Physical, dated 5/16/12, documented the resident was seen in the emergency room for a left inferior and superior pubic ramus fracture. The resident also had a history of [REDACTED]. A Falls Data Collection Tool (GSS #194), dated 5/22/12, showed the resident scored an 18: high risk for falls. An Incident Details report, dated 7/1/12, documented the resident was found on the floor in the upright position with bilateral lower extremities extended in front of her. The Licensed Practical Nurse (LPN) heard a loud noise and found the resident sitting on the floor in front of her closet. The call light was not on at the time of the fall. The resident stated she was looking for someone to walk with her. The resident received a dime size laceration/abrasion on the mid back of her spine. The resident was re-educated on having staff present when she was up ambulating: will place either a tabs or pressure alarm on for safety. The resident's family and physician were notified. The section of the report asking if the resident hit their head was not checked. The report also did not document the resident making any statement regarding not hitting their head at the time of the fall. The Daily Skilled Notes (GSS #183), dated 7/1/12 at 1540 (3:40 p.m.), documented this Registered Nurse (RN) and an LPN were in the hallway when we heard a loud thump. The resident was found in the sitting position on the floor in front of her closet with both legs extended in front of her. The resident stated she was trying to find someone to walk with her. Resident was re-educated on using the call light and waiting for assistance before ambulating for safety reasons. A small dime sized abrasion was noted to spine. The area was cleansed and a dressing was applied. The resident had no complaints of pain. The range of motion was within normal limits. The note documented "will place either a tabs or pressure alarm in bed and recliner" since it was reported the resident had been self-transferring and ambulating independently over the last few days and the resident was a fall risk. A FAX Communication to the physician, dated 7/1/12, documented the resident fell this afternoon and a small abrasion was noted on her back. First aide provided and will monitor. On 7/9/12 at 10:15 a.m., the Director of Nursing (DON) provided the facility procedures on Fallen or Injured Resident #II.F.2 (revised 4/11). The procedures documented, in pertinent part: 9. If a head injury is suspected, the charge nurse needs to initiate a Neuro-Check Flow Sheet (GSS #497). Check the pulse oximetry and blood glucose if resident is diabetic. If desired, initiate the Condition Change and Observation (GSS #241). Also review the resident's medications (e.g., anticoagulants) for potential complications. The DON stated the charge nurse would assess the resident to determine if neuro-checks should be performed. The DON stated it was her expectation nursing staff follow facility procedures. On 7/10/12 at 2:30 p.m., a Nurse Manager (NM) stated it was her expectation nursing staff initiate the Neuro-Check Flow Sheet (GSS #497) for unwitnessed falls with evidence of a head injury and for unwitnessed falls where the resident was unable to state (recall) if they did not hit their head. On 7/10/12 at 3:25 p.m., the Nursing Home Administrator (NHA) stated it was his expectation nursing staff follow facility procedures. On 7/10/12 at 3:40 p.m., the DON stated there were no continuous neurological assessments (Neuro-Check Flow Sheet (GSS #497) for the resident's unwitnessed fall on 7/1/12. 5. Failure to Ensure Adequate Monitoring and Follow Up after a Status Change Resident #143 According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to the resident's initial temporary care plan, dated 2/1/12, the resident had a self-care deficit related to a left [MEDICAL CONDITION]. She required assistance with activities of daily living. She had a mobility impairment and required a mechanical lift for transfers. The admission assessment, dated 2/1/12, showed the resident had bruising from her left hip to her left ankle, multiple bruises on the right chin, and bruising to the back of the resident's left leg. a. Record Review According to the admitting physician's orders [REDACTED]. -[MEDICATION NAME] 2.5 milligrams daily for [MEDICATION NAME] following a left [MEDICAL CONDITION]. -[MEDICATION NAME] 250 milligrams twice daily for [MEDICAL CONDITION]. On 2/7/12, the resident had a complete blood count analysis performed. The laboratory results showed the resident's hemoglobin and hematocrit levels were low. There was no evidence the laboratory results were reviewed with the resident's physician. Hemoglobin - 11.7, Reference Range (12.8 - 16.5) Hematocrit - 34.4, Reference Range (38.0 - 49.0) On 2/13/12, a nurse's note documented the resident was experiencing pain on her right side, stating, "My whole right side hurts." The notes were reviewed and showed the resident had previously not complained of pain to her right side. There was no evidence the resident's physician was informed of this new onset of pain. On 2/14/12, a nurse's note documented in pertinent part, "C/o (complains of pain R(ight) lower back. 5 x 4 soft lump noted with old bruising. Torodol and Tylenol given. INR (international normalized ratio - a lab value showing the effectiveness of anticoagulant medications) 3.8. Family present for care conference. Dr appt at 1330. Pt had nausea, vomiting in transport van and was returned to facility without seeing surgeon for visit." Despite the resident continuing to complain of pain to her right side and a lump developing in the area, there was no evidence the resident's physician was informed of these issues. On 2/14/12, the resident also had another complete blood count analysis performed. The laboratory results showed the resident's hemoglobin and hematocrit levels had further dropped. Hemoglobin - 10.7, Reference Range (12.8 - 16.5) Hematocrit - 31.2, Reference Range (38.0 - 49.0) On 2/15/12, the resident began complaining of persistent, severe pain. The corresponding nurse's note showed, "Pt alert to self and time. 0645 pt c/o 9/10 abd(ominal) pain that radiated to back. [MEDICATION NAME] given per order without relief. Pt called out into hall x 5 about severe pain. On call MD paged. Pt then stated no pain to abd just R hip. R hip has skin discoloration dark purple area measures 27 cm x 12 cm that goes from R lower abd to back. Pt INR 3.8. C/o pain remains. Pt does not remember what could have occurred. Hypoactive bowels Pt c/o nausea, AM meds held due to nausea. MDs office paged. New orders to transfer to ER (emergency room ) ...Incident report completed." The incident report dated 2/15/12 showed: "ALLEGED NATURE OF INCIDENT: Bruise COMMENTS: Pt has skin discoloration to R abd 27 cm x 12 cm dark purple. PT INR 3.8. Pt was also transferred to MD appt yesterday with seatbelt. TYPE OF INJURY: Bruise/Contusion WHAT TYPE OF ASSESSMENT AND/OR MEDICAL TREATMENT WAS DONE AS A RESULT OF THE INCIDENT: PT transferred to ER. Pt assessed head to toe pain assessment 9/10 pain. WHAT IMMEDIATE INTERVENTIONS HAVE BEEN PUT IN PLACE TO PREVENT THIS INCIDENT FROM HAPPENING AGAIN: Education on transfers, MD notified." After the resident was sent to the emergency roiagnom on [DATE], she did not return to the facility. After her discharge, a 2/16/12 interdisciplinary team (IDT) note documented, "IDT met and reviewed incident report. This nurse was asked/told by nurse yesterday when in report. Discussed possible causes and determined she had high INR, bruises easily, and had been at an appointment on previous day in w/c with a seatbelt in back of transport bus. Staff say very weak and felt poorly so probably leaning forward and caused bruising. CNA (certified nurse aide) who worked previous day states was not there when dressed." The 2/15/12 investigation documented: "SUMMARIZE FACTORS THAT MAY HAVE CONTRIBUTED TO THIS INCIDENT: INR 3.8. Transfer to MD appt in van with belt. Pt vomiting at time. RESULTS OF INVESTIGATION: Resident on daily [MEDICATION NAME]. INR 3.8. Out for appt with MD. Started vomiting. Taken by w/c accessible van - resident in w/c (wheelchair) with seat belt for potentially sustained bruise from seat belt when vomiting." The resident's hospital records from her emergency room and subsequent admission to the hospital, dated 2/17/12, were obtained from the hospital and revealed the resident had an intramuscular hemorrhage in her right abdominal wall. The hospital note documented in pertinent part: "Had a left [MEDICAL CONDITION] in late January. She underwent operative repair and did reasonably well. She had a little bit of confusion. She was discharged to a skilled nursing facility. Since then, she had had increasing right flank pain and an elevated INR...The patient has evidence of intramuscular hemorrhage in her right abdominal wall along with [MEDICATION NAME] use. CT was done in the emergency room confirming the hemorrhage. She is going to be admitted for pain control and make sure her INR comes down and her hemoglobin does not drop too much." b. Staff Interview On 7/9/12 at 12:31 p.m., the registered nurse (RN) who documented the resident's initial complaint of right sided pain and who discovered the lump was interviewed. She said it was not unusual for the resident to be in pain and she was not aware the resident had not had documented right sided pain previously. The