Every finding on record at Granite Rehabilitation and Wellness

Based on medical record review, staff interview, and performance improvement plan review, the facility failed to implement interventions and treatment to prevent the deterioration of wounds for 1 of 3 sample patients (#10) reviewed for skin conditions. The findings were:Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 6/22/26. 1. Review of the initial progress note by the nurse practitioner showed resident #10 was admitted to the facility on [DATE] for post-acute care following an inpatient hospitalization for RSV [respiratory syncytial virus]. The resident had a medical history which included dementia and chronic skin ulcers. The initial assessment showed the resident had a venous stasis ulcer to the outer right ankle. The following concerns were identified:a. Review of the progress note dated 4/10/26 showed the resident's left extremity swollen and tight but intact, dry flaky skin washed off and moisture oint [ointment] applied. The right lower leg is very swollen with large ulcers that are open red moist to left inner ankle and right outer ankle, ulcer purple and red with moist center. Heel area is hard callous appearing very thick dried skin, as are large dry patches to lower extremity. The nurse practitioner examined the wounds and a culture was ordered. b. Review of the wound clinic examination on 5/28/26 showed the clinic performed an assessment and debridement of bilateral lower extremities. The wound clinic note showed that the patient's primary care provider listed doxycycline as an allergy this week therefore .an antibiotic change .will be sent back to [facility name]. In addition, the wound care note showed that the resident was to return to the clinic in 1 week, and to keep wraps to bilateral lower legs clean and dry until next clinic visit. An after-visit summary (AVS) and report of consultation were also included in the medical record dated 5/28/26. The AVS showed the resident was seen for a primary diagnosis of venous stasis ulcer of the right lower extremity and included upcoming appointment dates and times for podiatry and wound care. The follow up appointment for wound care was scheduled for 6/5/26 at 1 PM. The report of consultation showed Pt [patient] may shower, please keep lower leg wraps covered, clean and dry until next visit. All wound care will be done in clinic.c. Review of a progress note for Alert Charting: Skin Issue on 6/9/26 showed resident c/o [complaint of] legs hurting, increased edema at calf area. Wraps to BLE [bilateral lower extremities] from Wound clinic noted to have urine on them. Wraps removed wounds cleaned and foam protective dressings applied with alginate.d. Review of a 6/16/26 progress note for Alert Charting: Medical Change of Condition at 4:41 AM showed the resident's BLE [bilateral lower extremity] wounds worsening. Goes back to wound clinic today 3:30 PM .C/o [complaint of] 8/10 pain. PRN [as needed] Tylenol 500mg not effective .legs hurting in bed BLE weeping, leaving puddle on floor and bedding. DON, after hours call NP [nurse practitioner] notified.e. Review of the progress note for eINTERACT SBAR Summary for providers on 6/16/26 at 5:20 PM showed that the resident was admitted from [facility name] wound care clinic. f. Review of the medical record showed no evidence the patient went to the wound care clinic after the 5/28/26 visit until the visit on 6/16/26.2. Interview with the DON on 8/7/26 at 2:06 PM revealed that the resident did not receive care at wound care clinic between 5/28/26 and 6/16/26 as the provider order for the 6/5/26 appointment was not obtained. The DON stated that the resident treatment with Lasix contributed to the weeping of the resident's wounds. The DON also stated that a PIP [Performance improvement plan] was conducted for wound care and for missed appointments for residents. 3. Review of the performance improvement plan for appointments, initiated on 6/16/26, showed corrective measures including audits of resident medical records for any missed or late appointments in the previous 30-day period, systemic change involved in-service education, reporting of missed appointments to the SSD (social services designee) or DON and initiated the SSD monitoring appointments daily and receiving follow-up documentation upon return of the resident to the facility to ensure orders are provided to nursing and additional appointments are made as necessary. In addition, the SSD was tasked with continued monitoring for late or missed appointments and reporting negative patterns or trends to the QAPI committee for review and resolution for a minimum of three months. 4. Review of the performance improvement plan for wound care, initiated 6/16/26, showed corrective action which included systemic change with in-service education provided to all licensed nurses related to wound evaluation and assessment and notification of actual and potential wound decline. The DON was tasked with reviewing any identified deterioration in wound status and reporting any negative patterns or trends to the QAPI committee for review and resolution for a minimum of three months.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure adequate interventions and monitoring were provided to prevent significant weight loss and resulting harm for 2 of 8 sample residents (#2, #10) reviewed for nutrition, and offer sufficient fluid intake for 1 of 4 units (secure unit) reviewed for hydration. The findings were: Related to adequate nutrition interventions and monitoring 1. Review of the admission MDS dated [DATE] showed resident #2 had a BIMS score of 8 out of 15 which indicated moderate cognitive impairment, diagnoses which included cerebrovascular accident (CVA) and malnutrition, and required partial to moderate assistance with eating once the meal was placed before the resident. Review of the admission care plan dated 2/2025 and last revised on 2/25/26 showed the resident required meal setup with assisting and cueing for meals. The following concerns were identified: a. Observation on 3/24/26 at 12:54 PM showed resident #2 had a meal tray on his/her bedside table. The resident was asleep, and there were no staff at the bedside to assist with the meal. b. Observation on 3/25/26 at 6:09 PM showed staff delivered a meal tray and woke resident #2 up to eat. The resident stated oh it's dinner time, the tray was left at his/her bedside by staff, and the staff left the room. Continued observation at 6:43 PM showed activity staff #1 warmed the resident's tray and assisted the resident with eating. c. Review of the medical record showed resident #2 weighed 173 pounds on 2/2/26 and 159.9 pounds on 3/9/26, which indicated a 7.57% weight loss in less than 3 months. Further review showed a nutrition evaluations had been completed on 2/23/26 and 3/20/26 which indicated the resident required meal set-up and assist with cueing for eating. d. Review of the facility policy titled Weights dated 7/30/24 showed 1.a. New admits: Weigh the day of admission then weekly for one month; If the weights and nutritional status are stable after one month, weigh the resident monthly. There was no evidence resident #2 was weighed more than twice in the first month of admission. 2. Review of the significant change MDS dated [DATE] showed resident #10 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, diagnoses which included Alzheimer's disease, weakness, and malnutrition, and s/he required partial to moderate assistance with eating once the meal was placed before the resident. Review of the care plan dated 2/11/26 and last revised 2/25/26 showed the resident required partial to moderate assistance by 1 staff with eating meals. The following concerns were identified: a. Observation on 3/25/26 at 5:48 PM showed 2 CNAs woke resident #10 for dinner, s/he went back to sleep, and they did not stay to assist him/her with eating dinner. b. Observation on 3/26/26 at 8:33 AM showed resident #10 had a meal tray at his/her bedside, and no staff assisted with the meal. Meal trays were being delivered to other residents after resident's meal was delivered. c. Review of the medical record showed resident #10 weighed 188 pounds on 1/1/26 and 169 pounds on 2/1/26, which indicated a 10.11% weight loss in one month. Further review of the medical record showed a nutrition evaluation for weight loss dated 2/6/26 showed the resident required meal set up and assist as needed for eating. d. Review of the facility policy titled Weights dated 7/30/24 showed 1.b. Weekly Weights: The following are guidelines for residents who may need to be weighed weekly (not all inclusive) . significant weight loss/gain defined by 5% loss in 30 days. Resident #10 was weighed on 2/1/26 and there was no evidence that they were weighed again until 2/13/26. 3. Interview with the regional dietitian on 3/26/26 at 11:57 AM revealed she received monthly weight loss reports from the facility. She or her staff spoke with nursing staff to obtain additional pertinent information for each residents' possible weight change, and interventions were planned accordingly. The nursing staff was responsible to notify residents' families of changes. 4. Interview with LPN #3 on 3/26/26 at 12:13 PM revealed residents who required assist from one person for meals received their trays last, and the staff who delivered the tray should immediately assist the resident. 5. Interview with CNA #1 on 3/26/26 at 12:17 PM revealed residents who were able to eat in their room independently received their trays first. Residents who ate in the dining area were served second, residents who required assistance with meals were served last, and the staff who delivered the tray was to assist the resident with their meal. 6. Interview with the DON on 3/26/26 at 12:20 PM revealed her expectation for meal assisted trays was that they were served last, and the staff who delivered the tray assisted the resident with their meal. 7. Review of facility policy titled Weights dated 7/30/24 showed 1.a. New admits: Weigh the day of admission then weekly for one month; If the weights and nutritional status are stable after one month, weigh the resident monthly; 1.b. Weekly Weights: The following are guidelines for residents who may need to be weighed weekly (not all inclusive) . significant weight loss/gain defined by 5% loss in 30 days. Related to sufficient fluid intake 1. Observations on 3/25/26 starting at 3:25 PM showed the residents in the secure unit were seated at tables in the dayroom. No drinks were offered to residents throughout extended observation from 3:25 to 5:41 PM. 2. Interview with CNA #2 on 3/23/25 at 5:35 PM revealed drinks were not stored in the unit refrigerator, and the residents were served drinks at mealtime only. Further interview revealed there was a hydration station on the 3rd floor unit, however she was unable to leave the secure unit to obtain drinks because often she was the only aide on the unit. 3. Interview with LPN #2 on 3/23/25 at 5:37 PM revealed the residents received drinks at each meal. 4. Interview with CNA #2 on 3/25/26 at 3:55 PM revealed some residents had water at their bedside, but others were unable to because they spilled it. 5. Interview with the FANS Manager #2 on 3/25/26 at 6:36 PM revealed drinks were kept at the hydration station on the 3rd floor outside of the locked unit, and the nurse kept a pitcher of water on the cart to use when they passed medications. She reported she had ordered containers similar to the ones kept on the other units hydration stations but they did not fit under the cabinets on the secure unit. She stated the staff had been told they could not keep pitchers of drinks on the unit because several residents had touched the pitchers. She stated her expectation was for fluids to be offered every hour, and she confirmed routine fluids were not being offered.

Based on observation, medical record review, resident, resident representative, and staff interview, facility incident review, and policy and procedure review, the facility failed to ensure residents' environment was free of accident hazards on 3 of 4 resident care units (1st floor, 2nd floor, 3rd floor) reviewed for safe water temperatures and for 2 of 3 sample residents (#5, #97) reviewed for falls. The facility implemented a plan of correction regarding the fall during van transport for resident #5, prior to the survey, and verified during the survey. The facility was determined to be in compliance for the fall during van transport on 3/11/26. The findings were: Related to resident falls: 1. Review of a quarterly MDS assessment dated [DATE] showed resident #97 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and depression. The following concerns were identified: a. Review of an incident report dated 1/1/26 and timed 4:15 PM showed Resident was outside ambulating per careplan, when visitor witnessed resident trip and fall and immediately called into facility and notified facility that resident had fallen. LPN [#1] responded and completed vital signs, resident became agitated wanting to stand up and nurse and CNA assisted resident to stand up, resident regained balance quickly after staff assisted to stand. The incident review showed Immediate Action Taken was Resident assisted to standing position and times two nurses came into building. Assessed resident. Noted heavy bleeding from upper left eye of face. 911 called immediately. Notified on call and DNS and FNP [name] resident going to [hospital] for treatment and follow up. Laceration above left eye noted by EMS to have rock in skin. Resident has history of Alzheimer's. Notified family [name] R/P of fall. Resident had some grimacing noted. Neuro checks to be initiated upon return. Orders in order set. Further review showed Predisposing Physiological Factors was marked for confused. b. Review of a progress note dated 1/1/26 and timed 5:38 PM showed .Alert Charting: Skin Issue (New/Worsened/Change) Acute s/s [signs and symptoms], tachycardia, fever, chills, n/v [nausea vomiting], wound drainage, pain, mentation, Interventions, outcomes, Vitals: [NAME] by notified staff resident had fall outside. Resident had noted bleeding to left upper eye. Laceration noted. Resident sent to [hospital] at present for evaluation via stretcher . c. Review of an elopement risk assessment dated [DATE] showed the resident had a history of wandering, had medical diagnosis of dementia/cognitive impairment, and had diagnosis impacting gait/mobility or strength. Further review showed the resident was not at risk for elopement due to s/he understands sign out policy. d. Interview with the resident's representative on 3/26/26 at 12:13 PM revealed prior to the resident's fall s/he seemed to be alert; however, s/he had a monitor on him/her and was not supposed to go outside without supervision. The representative revealed when the resident fell, the representative was notified by the facility and was told a visitor had put in the code and let the resident out. Further interview revealed the resident passed away on 1/6/26. e. Review of an Order Audit Report dated 3/26/26 showed a wandergard bracelet was ordered on 2/28/25 and discontinued on 3/12/25. f. Interview with LPN #1 and the DON on 3/26/26 at 11:53 AM revealed the resident ambulated with a walker and liked to go for walks at times. The LPN indicated the resident was alert and oriented to person and place, would go outside for 15 minutes, and was free to come and go. The LPN revealed on the day the resident fell outside, s/he had notified the DON prior. The LPN revealed a visitor notified the facility the resident had a fall by calling the building and letting them know. The LPN revealed she came down stairs, helped the resident up, and assisted the resident inside. The LPN confirmed the resident had a laceration on his/her face and she called the ambulance. The LPN revealed the resident returned from the hospital and later went on hospice due to a brain tumor. The DON indicated the resident's low BIMS score was due to him/her not wanting to answer questions for the exam. Further the DON revealed the facility had an assessment indicating the resident was safe to walk outside independently. g. Interview with LPN #2 on 3/26/26 at 12:06 PM confirmed she was the other nurse working on the day of the resident's fall. She revealed the resident was alert and oriented times 3 or 4 with his/her confusion usually being related to time. She confirmed the facility was notified of the resident's fall via phone call from someone who was driving by. She revealed she and LPN #1 went downstairs and found the resident outside with a gash on his/her forehead. She confirmed the resident was assisted inside, cleaned up, and sent to the hospital. 2. Review of a significant change MDS assessment dated [DATE] showed resident #5 had a BIMS score of 12 out 15, which indicated the resident was cognitively intact, and diagnoses which included other fusion of the spine, repeated falls, and pain. Further review showed the resident had upper and lower extremity impairment on one side, used a wheelchair, and was dependent on staff for transfers. The following concerns were identified: a. Interview with the resident on 3/24/26 at 9:20 AM revealed recently s/he had a fall from his/her wheelchair while riding in the facility van. The resident revealed the social worker was driving and s/he thought they had hit a vehicle in front of them or the driver hit the brakes hard, which resulted in him/her sliding out of his/her wheelchair and landing between the two front seats. The resident revealed at the time of the incident, s/he was not properly secured in the wheelchair. b. Review of an incident report dated 3/4/26 and timed 4:45 PM showed the resident was picked up at the hospital by social services staff member #1. The resident was positioned in his/her wheelchair with a full body lift sling underneath him/her. The incident report showed while driving the resident back to the facility, a vehicle in front of the van stopped abruptly causing the social services staff member to abruptly stop as well and the resident slid forward in his/her wheelchair. The incident report showed the social services staff member pulled over to assist the resident and after evaluating the resident's position, assisted the resident to the van floor in a controlled fashion. The incident report showed after assisting the resident to the floor, the social services staff member provided standby support to assist the resident back into the wheelchair. Further review showed the social services staff member continued to the facility where the resident was assessed upon arrival. c. Interview with social services staff member #1 on 3/25/26 at 3:44 PM revealed he picked the resident up from the hospital because s/he had been taken to the emergency room. He revealed while they were driving back to the facility, a vehicle in front of them slammed on the brakes and he told the resident to hold on. He revealed when he hit the brakes, the resident slid out of his/her wheelchair. He revealed he pulled up a little and found a safe place to pull over. He revealed when he pulled over, the resident was positioned on the wheelchair leg rest with his/her back pressed against the wheelchair. The social services staff member revealed he thought the resident fell because the seatbelt catch did not function correctly. He revealed he physically assisted the resident back into the wheelchair, started to head back to the facility, and contacted the administrator on the way. d. Observation on 3/26/26 at 8:09 AM showed the facility van had 4 securement straps which were affixed to the floor of the van and each strap had a hook on the end that attached over the wheelchair frame. Each strap applied a constant pulling pressure to ensure securement. The observation showed the seat belt with a shoulder harness which was used was a common shoulder type seatbelt. Further observation showed the seatbelt could be lengthened and retracted without restriction, and would not prevent movement in the wheelchair. Interview with the social services director at that time confirmed the seatbelt with a should strap which was used in the van was the traditional style. Further interview revealed there was a strap that secured to the mounting bracket of the seatbelt with a shoulder strap and the mounting bracket of the rear floor securement which prevent movement when it was secured; however, he confirmed the additional strap was not in use at the time of the incident. e. Interview with a facility vendor on 3/26/26 at 12:42 PM revealed the facility's van was assessed on 3/4/26 following an incident and assessed a second time following another incident the same day. The vendor revealed the second incident was the result of a seatbelt failure and parts were ordered to fix it; however, it would take time for the seatbelt parts to arrive. f. Review of an action plan for Van Incident #2 last updated on 3/18/26 showed the van was taken in to vendor to verify seat belt function on 3/4/26 and a decision was made to remove the van from service until new seatbelts were purchased and installed. Observations to verify the van was not in use for transport was performed during the survey. Additionally, the facility implemented van driver education and audits for resident securement which were verified during the survey. The plan was determined to be fully implemented and the facility was in substantial compliance with wheelchair securement during transport on 3/11/26. Related to safe water temperatures 1. Observation on 3/26/26 at 10:12 AM showed the first floor shower room reached a maximum temperature 130.5 degrees F during a 5 minute continuous monitor of water flow which was verified by the maintenance assistant. 2. Observation on 3/26/26 at 1:15 PM showed the second floor shower room reached a maximum temperature 125.1 degrees F during a 5 minute continuous monitor of water flow which was verified by the maintenance assistant. 3. Interview with the maintenance assistant on 3/26/26 at 1:38 PM revealed the maximum water temperature reading exceeded 110 degrees F in 11 resident rooms' bathroom sinks when he checked during a continuous water flow for 7 to 10 minutes. In room [ROOM NUMBER] the temperature was 134.4 degrees F, in room [ROOM NUMBER] the temperature was 129.5 degrees F, in room [ROOM NUMBER] the temperature was 129 degrees F, in room [ROOM NUMBER] the temperature was 125.2 degrees F, in room [ROOM NUMBER] the temperature was 115.3 degrees F, in room [ROOM NUMBER] the temperature was 135.1 degrees F, if room [ROOM NUMBER] the temperature was 137.6 degrees F, in room [ROOM NUMBER] the temperature was 143.2 degrees F, in room [ROOM NUMBER] the temperature was 133.3 degrees F, in room [ROOM NUMBER] the temperature was 140.5 degrees F, and in room [ROOM NUMBER] the temperature was 128.9 degrees F. Further interview revealed the facility shut off the water and contracted a plumber during the high water temperature evaluation to correct the excessive temperatures.

Based on observation and resident and staff interview, the facility failed to provide the residents with a comfortable and homelike environment in 3 of 3 showering areas. The findings were:1. Interview with Resident #71 on 3/23/26 at 3:09 PM revealed .the temperature of the showers are usually cold and sometimes it will fluctuate from cold to super hot and back to cold during the entire shower.2. Interview with resident #55 on 3/24/26 at 3:06 PM during resident council revealed the temperature in the second floor shower room was too cold or too steamy.3. Observation on 3/26/26 at 9:40 AM showed the second floor shower room water temperatures fluctuated consistently between 68.3 degrees Fahrenheit (F) to 102.6 degrees F during a 5 minute continuous flow of water which was verified by the maintenance assistant.4. Interview with the maintenance assistant on 3/26/26 at 9:50 AM confirmed the residents complained about the fluctuating temperatures in the second floor shower room. He revealed residents were often taken to another floor for showers. 5. Observation on 3/26/26 at 10:12 AM showed the first floor shower room water temperatures fluctuated consistently between 107.2 degrees F to 130.5 degrees F during a 5 minute continuous flow of water which was verified by the maintenance assistant. 6. Observation on 3/26/26 at 10:57 AM showed the third floor shower room water temperatures fluctuated consistently between 70.9 degrees F to 92.2 degrees F during a 5 minute continuous flow of water which was verified by the maintenance assistant.7. Observation on 3/26/26 at 1:15 PM the facility requested a recheck in second floor shower room that showed the water temperatures fluctuated consistently between 82 degrees F to 125.1 degrees F during a 5 minute continuous flow of water which was verified by the maintenance assistant.

Based on medical record review, staff and resident interview, facility incident review, and standard of practice review, the facility failed to ensure treatment and care was provided to 1 of 4 sample residents (#5) reviewed for falls. The findings were:1. Review of a significant change MDS assessment dated [DATE] showed resident #5 had a BIMS score of 12 out 15, which indicated the resident was cognitively intact, and diagnoses which included other fusion of the spine, repeated falls, and pain. Further review showed the resident had upper and lower extremity impairment on one side, used a wheelchair, and was dependent on staff for transfers. The following concerns were identified:a. Interview with the resident on 3/24/26 at 9:20 AM revealed recently s/he had a fall from his/her wheelchair while riding in the facility van. The resident revealed the social worker was driving and s/he thought they had hit a vehicle in front of them or the driver hit the brakes hard, which resulted in him/her sliding out of his/her wheelchair and landing between the two front seats. The resident revealed at the time of the incident, s/he was not properly secured in the wheelchair.b. Review of an incident report dated 3/4/26 and timed 4:45 PM showed the resident was picked up at the hospital by social services staff member #1. The resident was positioned in his/her wheelchair with a full body lift sling underneath him/her. The incident report showed while driving the resident back to the facility, a vehicle in front of the van stopped abruptly causing the social services staff member to abruptly stop as well and the resident slid forward in his/her wheelchair. The incident report showed the social services staff member pulled over to assist the resident and after evaluating the resident's position, assisted the resident to the van floor in a controlled fashion. The incident report showed after assisting the resident to the floor, the social services staff member provided standby support to assist the resident back into the wheelchair. Further review showed the social services staff member continued to the facility where the resident was assessed upon arrival.c. Interview with social services staff member #1 on 3/25/26 at 3:44 PM revealed he picked the resident up from the hospital because s/he had been taken to the emergency room. He revealed while they were driving back to the facility, a vehicle in front of them slammed on the brakes and he told the resident to hold on. He revealed when he hit the brakes, the resident slid out of his/her wheelchair. He revealed he pulled up a little and found a safe place to pull over. He revealed when he pulled over, the resident was positioned on the wheelchair leg rest with his/her back pressed against the wheelchair. The social services staff member revealed he thought the resident fell because the seatbelt catch did not function correctly. He revealed he physically assisted the resident back into the wheelchair, started to head back to the facility, and contacted the administrator on the way. Further interview revealed the social services staff member did not have a nursing background and confirmed the resident was not assessed until the van returned to the facility. 2. Interview with the DON on 3/26/26 at 1:05 PM revealed residents should be assessed prior to moving residents following a fall and confirmed social services staff member #1 did not have training to assess or physically assist with transfers of a resident. 3. Review of Wolters Kluwer's Lippincott Nursing Procedures Ninth Edition, copyright 2023, page 1780, showed .Nursing Alert Don't move the patient until you fully evaluate the patient's status to prevent further injury if an injury has occurred as result of the fall .

Based on observation, staff interview, and policy review, the facility failed to ensure outdated food was disposed of in 1 of 1 kitchen. 1. Observation on 3/23/26 at 2:05 PM in the main kitchen showed there were 5 sealed cups of thickened orange juice that had a best-buy date of 11/8/25 in the refrigerator used for the storage of drinks that were provided to residents. 2. Observation on 3/23/26 at 2:09 PM showed the FANS Manager #2 threw away a case of thickened orange juice cups that had been stored in the dry storage room. 3. Interview with the FANS manager #1 on 3/23/36 at 2:05 PM revealed all drinks in the refrigerator were for resident use, and resident #27 received thickened liquids. Further interview confirmed the juices were outdated, and the juice cups should not be served to residents. 4. Review of the facility policy titled Food Storage last updated 10/2017 showed .11. The manufacturer's expiration date, when available, is the use by date for unopened items .

Based on medical record review and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (#1) reviewed for behavioral and emotional needs. This failure resulted in actual harm to resident #1 who was arrested for aggravated assault and taken to jail. The findings were: 1. Review of the 1/25/25 admission MDS assessment showed resident #1 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, depression, and an unspecified injury of the head. The resident had a BIMS score of 3 out of 10 which indicated severe cognitive impairment, exhibited disorganized thinking which was continuously present, and did not exhibit any behaviors or rejection of care during the 7-day look-back period; however, the resident wandered daily. The resident required partial/moderate assistance with oral hygiene, toileting hygiene, showering, dressing, personal hygiene; and required supervision for eating. Further the resident required supervision to minor assistance to perform the functional abilities of rolling left and right, sitting to lying, lying to sitting, sitting to standing, transfers, and walking. The pain assessment interview showed the resident denied being in pain; however, received as needed pain medication. The resident was 67 inches tall, weighed 184 pounds, was continent of both bowel and bladder, and received an antidepressant, an antipsychotic, and an anticoagulant during the look-back period. Review of the care area assessment showed the facility was to develop a comprehensive care plan in the areas of cognitive loss/dementia, visual function, communication, urinary incontinence, behavioral symptoms, falls, nutritional status, dental care, pressure ulcer, and psychotropic drug use. Review of a 1/17/25 history and physical from the resident's provider showed the resident had diagnoses which included severe early onset Alzheimer's dementia with mood disturbance, anxiety, and a current moderate episode of major depressive disorder. The provider noted the resident was on Seroquel (an antipsychotic) and had no behaviors since arriving at the facility. A follow-up was to occur in 1 month or sooner for acute concerns. The following concerns were identified: a. Review of the 1/13/25 hospitalist history and physical examination notes showed the resident presented to the emergency room following an episode of syncope which resulted in a fall with head trauma. The resident was administered intravenous halolperidol (antipsychotic medication used to treat mental and behavioral health conditions) due to agitation; blood work and imaging were completed and the resident was admitted to the hospital. Review of the assessment and plan showed the principal problem was syncope and collapse with an active problem of severe dementia with mood disturbance. The physician noted due to the resident's dementia with mood disturbance s/he would be started on a low dose of Seroquel at bedtime, provide PRN (as needed) halolperidol, and a 1-to-1 sitter at his/her bedside. Review of a 1/14/25 hospitalist progress note showed the resident did not sleep much .Has been up and fidgety. Has been pulling off telemetry leads, [s/he] has been redirectable but [s/he] is just constantly up and moving around. Further review showed the physician increased the dose of Seroquel to 25 mg at bedtime, and continued the PRN halolperidol and 1-to-1 sitter at bedside. b. Review of the 1/16/25 After Visit Summary showed a medication list which included quetiapine (antipsychotic); allopurinol (used to treat gout); atorvastatin (hypercholesterol medication); donepezil (medication to treat dementia associated with Alzheimer's disease); apixaban (an anticoagulant); fluoxetine (an antidepressant); levothyroxine (medication to treat hypothyroidism), and melatonin (used to treat insomnia). Review of a hospitalist progress note showed Patient likes to wander. Hard to redirect to be still for a prolonged period of time. Agree with not prusuing (sic) furhter (sic) testing given [his/her] dementia. c. Review of the resident's care plan, initiated 1/23/25, showed [resident name] has a behavior problem (wandering) r/t [related to] diagnosis of dementia and nursing home adjustment. Interventions were to administer medications as ordered .anticipate and meet [resident's] needs; caregivers to provide opportunity for positive interaction, attention. Stop and talk with [him/her] as passing by .Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed . Further the care plan showed [Resident] has impaired cognitive function/dementia or impaired thought processes, impaired decision-making, long-term memory loss, short-term memory loss. Interventions were to Administer medications as ordered .Ask yes/no questions in order to determine the resident's needs .Use [resident's] preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door, etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated .Cue, reorient and supervise as needed .Keep [resident's] routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. d. Review of the resident's care plan, initiated on 1/17/25, showed [Resident] uses antipsychotic medications (Seroquel) r/t Dementia in other diseases classified elsewhere, severe, with mood disturbance. Interventions included Administer PSYCHOTROPIC medications as ordered by physician .Monitor target behaviors: verbal aggression, irritable (sic) .Non-drug interventions: redirect. In addition, [Resident] is on sedative/hypnotic therapy (melatonin) r/t sleep disorder unspecified. Interventions included to Administer SEDATIVE/HYPNOTIC medications as ordered by physician .Monitor target behaviors: disturbed sleep pattern .Non-drug intervention: encourage good sleep hygiene and [Resident] uses antidepressant medication (fluoxetine) r/t Depression, unspecified. Interventions included Administer ANTIDEPRESSANT medications as ordered by physician .Monitor target behaviors: tearfulness, isolation .Non-drug interventions: encourage activities, encourage family friends to visit. e. Review of the resident's care plan, revised on 1/24/25, showed [Resident] has a d/x [diagnoses] of depression, unspecified, and Generalized anxiety disorder. Interventions included to Administer medications as ordered .Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others, or thoughts of harming someone, possession of weapons or objects that could be used as weapons. There was no evidence an assessment had been completed to address the resident's wandering and behaviors or a resident-centered care plan which included non-pharmacological interventions had been developed. f. A nurse's note dated 1/21/25 and timed 12:02 AM showed resting in bed at this time. Monitored for intrusive wandering. No attempts at exit seeking at this time . g. A nurse's note dated 1/21/25 and timed 6:23 AM showed Resident is a fall risk, dementia, behaviors. Resident wanders up and down halls, often intrusively, and in [his/her] confusion will disturb others' belongings. Is cooperative and is easily redirectable. Very confused and forgetful, does not have social awareness. Has difficulty speaking when overstimulated. Unable to follow simple commands and is frequently reminded on fall precautions and call light. Has been continent, requires help finding room and BR (bathroom), but can perform ADL's (activities of daily living) with cueing. h. A nurse's note dated 1/22/25 and timed 2:49 PM showed .Resident walks up and down halls. Touches other residents belongings. Moves chairs around. Very confused. Resident peed in the trash can today. Hard to redirect. Unable to follow simple commands. Very hard to educate, due to dementia. Educated to not pick up things off the floor. No signs or symptoms of pain. i. A social services note dated 1/23/25 and timed 12:10 PM showed .Son reported that he wanted to come and see [the resident] and have [him/her] sign POA paperwork. SSD (social service director) discussed with son that [the resident] does not have the mental capacity to legally sign POA paperwork. SSD informed him that he would need to pursue guardianship . j. A nurse's note dated 1/24/25 and timed 5:30 PM showed Resident kept coming through the nurses station and [s/he] was asked not to on several occasions so when this nurse stood up and asked [him/her] to please turn around, [s/he] grabbed my R arm and shoved me out of the way. This nurse called for help from the CNA to assist in redirection. k. A nurse's note dated 1/25/25 and timed 10:59 PM showed [Resident] has been wandering and more restless than usual this evening. Had visit from [his/her] sons this evening that seems to have left [him/her] wound up a bit. More difficult to redirect this evening, and a bit more on edge when answering questions, slightly becoming verbally aggressive. l. A nurse's note dated 1/26/25 and timed 2:37 PM showed .resident walks up and down halls. Touches other residents belongings and goes behind the nurses desk and gets into stuff. Moves chairs around. Very confused. Unable to follow simple commands. Needs cueing all the time. Very hard to educate, due to dementia. Educated to not pick up things off the floor. Educated on not going into other residents rooms. No signs or symptoms of pain. Continues to work with PT (physical therapy). m. A nurse's note dated 1/28/25 and timed 11:12 AM showed Resident has been trying to help [resident room number] stand up and pulling [female resident]. [The resident] was also noted to be rubbing [female resident's] legs this morning . The resident was redirected and educated not to touch other residents. n. A nurse's note dated 1/29/25 and timed 12:24 PM showed Resident was walking around dining room with fork and butter knife. When this nurse approached and asked if I could hold those for [him/her] and show [him/her] where to sit [the resident] hit my R index finger with the butter knife and left red indentation. No break in skin. CNA came to help redirect Resident to table and took [his/her] silverware until meal time. o. A nurse's note dated 1/30/25 and timed 4:11 PM showed [Provider name] contacted regarding increase in physically aggressive behaviors towards staff and increased intrusive wandering. Order received for PRN Seroquel 25 mg every 6 hours for 1 day as [provider name] will see resident and evaluate change in behaviors further . p. A nurse's note dated 1/30/25 and timed 5:13 PM showed Resident noted to be urinating on fake plant, resident educated that this is not appropriate behavior, resident told this nurse to fuck off. Will continue to monitor. q. A nurse's note dated 1/30/25 and timed 5:37 PM showed [Provider name] was here this afternoon and notified of resident going into rooms and getting into residents beds, by a resident. Review of the resident's medical record showed no evidence of this provider visit. Interview with the DON on 6/24/25 at 1:27 PM confirmed the progress note was not in the resident's record; however, was able to retrieve it from the provider's electronic medical record system. r. A nurse's note dated 1/31/25 and timed 8:24 PM showed [Res] generally confused and disoriented, requiring very frequent redirection. Res did show some aggression toward this nurse immediately after [his/her] blood was drawn, making a mean face and mumbling while trying to kick toward me and shaking [his/her] fist. Res reassured and given space, now resting in bed. s. A nurse's note dated 2/1/25 and timed 2:34 PM showed [Resident] is getting agitated this afternoon after having a calm morning. [S/he] is following very closely behind people in the hallway, going into rooms, getting in personal space, messing with things on the counters and carts, trying to get into the elevator and getting upset with redirection. t. A nurse's note dated 2/2/25 and timed 10:51 AM showed We have noticed that [the resident] is cooperative in the am, but as the day goes on [s/he] starts to get more agitated and less cooperative. Appears to sundown. [The resident] does not take [his/her] evening meds well as we often have to switch nurses to try to give them . u. A nurse's note dated 2/2/25 and timed 11:58 AM showed .[resident] likes to follow females (staff and residents) down the hall at a close distance. [S/he] also likes to hide in the cubbies at the end of the hallways and needs redirection back to the dining room. v. A nurse's note dated 2/2/25 and timed 1:40 PM showed CNA reported that Resident walked down hallway and was attempting to go into another resident's room and upon redirection, Resident called CNA a fucking bitch. w. A late entry nurse's note written by LPN #2, dated 2/2/25 at 4:55 PM, showed Resident went into another resident's room and I was behind [him/her] with that resident's pills and I asked [him/her] to get out of the room because it wasn't [his/her] room. [The resident] got angry and grabbed the tray table like [the resident] was going to shove it into [the female resident] The nurse intervened to prevent the female resident from being harmed. The note further described the resident as getting physically aggressive by stepping on the nurse's left foot to immobilize her and grabbed her throat with both of [his/her] hands. Assistance arrived at the scene and the resident was escorted to his/her room. The nurse notified the DON and called the police. The police arrived at the facility and arrested the resident for aggravated assault. 2. Review of a 1/31/25 skilled nursing progress note from the resident's provider (retrieved from the provider's electronic medical record by the DON) showed the chief complaint was the resident had been urinating in and on the plants around the unit and crawling into the beds of female residents on the unit. The assessment and plan showed Due to increase in behaviors and sexual tendencies, will increase Prozac from 10 to 30 mg daily. Increase seroquel to BID (twice a day). Monitor for medication effectiveness and any worsening of behaviors. A follow-up was to occur in 1 month or sooner for acute concerns. There was no evidence a behavioral care plan had been developed. 3. Interview with the social service director on 6/24/25 at 1:01 PM revealed the resident had severe dementia; was confrontational; would wander in and out of other resident's rooms; was not easily de-escalated; and required a lot of redirection. Further, the social service director stated the facility was hesitant about placing the resident in the secure unit because the resident would not do well behind locked doors. Documentation was requested from the social service director related to what interventions were attempted; however, no documentation was received. 4. Interview with the DON on 6/24/25 at 1:27 PM revealed the resident exhibited both verbal and physical aggressive behaviors from the beginning and had a history of alcohol abuse and polysubstance abuse. The DON stated the resident was difficult to redirect and she thought the resident purposefully repeated some behaviors. Further the DON stated residents requesting admission to the facility were evaluated by the admissions department and were determined to be green which was to admit; yellow which required more review, and red was denied. The DON was not aware of what color the resident's review was; however, the facility required 48 hours without a 1-to-1 sitter and without chemical intervention before the resident could be admitted . 5. Interview with LPN #1 on 6/24/25 at 3:52 PM revealed upon admission the resident wandered the halls; needed to be busy; and an intervention was to redirect and offer the resident an activity. In addition, the LPN stated she talked to the resident's providers daily; however, confirmed she had failed to chart the conversations. The LPN stated following the incident on 2/2/25 the police arrested the resident and handcuffed him/her before being escorted out of the facility. The LPN described the resident as being angry as s/he was taken away. 6. Interview with the ED on 6/24/25 at 3:52 PM revealed she thought the facility was misled by the resident's referral documentation as they thought the resident was nonverbal. In addition, the ED stated many of the residents that come from the hospital have notes related to 1-to-1 sitters and the use of chemical interventions for behaviors and there was nothing in the resident's history to indicate s/he could be violent. 7. Interview with the DON on 6/24/25 at 3:52 PM revealed the facility determined the secure unit would increase the resident's agitation due to the locked doors and therefore was placed where the resident was not as restricted.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure a safe and orderly discharge from the facility for 1 of 5 sample residents (#1) reviewed for discharge. The findings were: 1. Review of the 1/25/25 admission MDS assessment showed resident #1 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, depression, and an unspecified injury of the head. The resident had a BIMS score of 3 out of 10 which indicated severe cognitive impairment. Review of the medical record showed the resident was discharged from the facility on 2/2/25. The following concerns were identified: a. Review of a late entry note written by LPN #1, dated 2/2/25 and timed 4:55 PM, showed Resident went into another resident's room and I was behind [him/her] with that resident's pills and I asked [him/her] to get out of the room because it wasn't [his/her] room. [The resident] got angry and grabbed the tray table like [the resident] was going to shove it into [the female resident] The nurse intervened to prevent the female resident from being harmed. The note further described the resident as getting physically aggressive by stepping on the nurse's left foot to immobilize her and grabbed her throat with both of [his/her] hands. Assistance arrived at the scene and the resident was escorted to his/her room. The nurse notified the DON and called the police. The police arrived at the facility and arrested the resident for aggravated assault. Further review showed .Then one of the policeman (sic) came back up to take pictures of the facility and my neck and arm and then they asked me to print off any documentation that I had regarding [his/her] and behaviors. b. Interview with LPN #1 on 6/24/25 at 3:52 PM revealed following the incident on 2/2/25 the police arrested the resident and handcuffed him/her as s/he left the facility. The LPN described the resident as being angry as s/he was taken away. Further, the LPN stated the police officer returned to the facility after taking the resident to jail, interviewed her, took pictures, and requested information related to the resident. The LPN stated she provided the resident's information to the police office; however, did not document what information was provided. c. Review of the 2/2/25 discharge notice addressed to the resident at the [local detention center] showed This letter will serve as formal notification that it is the intention of Granite Rehabilitation and Wellness to discharge you on February 2, 2025, as you assaulted a staff member and were arrested for aggravated assault. You are being immediately discharged for the following reasons 1. for placing the safety of the individuals in the facility in danger, 2. the health of individuals in the facility are in danger, and 3. you have not resided in the facility for 30 days. You are being discharged to the [NAME] County Detention Center . d. Review of a social services note dated 2/2/25 and timed 6:23 PM showed ED called Son/POA [proper name] and notified him that the [local law enforcement] arrested [the resident] for aggravated assault on [LPN #1]. Also informed him that an immediate discharge notice is being given to [the resident]. e. Review of a social services note dated 2/2/25 and timed 7:39 PM showed ED drove to the [local detention center] to deliver the discharge notice to [resident name]. Was told by the deputy that they could not accept the notice tonight. Let her know that the ED would be back in the morning to provide the notice. Deputy stated that the regular business hours would be better for the jail staff. f. Review of a social services note dated 2/3/25 and timed 10:15 AM showed ED took the discharge notice to the [local detention center] gave it to [jail staff name] at the information desk who said she would get it to [the resident]. Also sent a copy regular mail and Certified mail to [the resident]. Sent a copy regular mail and Certified mail to [resident's son/POA]. Son called ED this morning and asked if [the resident] could come back. Reminded him of our conversation last night about discharge. Again, informed him that [the resident] stepped on the nurse's foot so she couldn't move, looked at her and said, I am going to fucking kill you put both hands around her neck and tried to strangle her. [The resident] was arrested by the [local law enforcement], taken to jail and charged with aggravated assault. 2. Review of the recapitulation of resident stay, signed by the DON on 2/20/25, showed Resident discharged on 2/2/2025 after attempting to strangle a nurse while restraining her. Police were called for assistance, and the resident was arrested for aggravated assault. After arrest [nurse practitioner] was contacted regarding incident and stated that [the resident] is not safe to be in this setting and the medical group, he works for would no longer treat [the resident]. The DON was unable to provide the nurse practitioner's assessment. 3. Review of the medical record showed no evidence the facility had ensured the receiving facility could meet the needs of the resident; the appropriate information was communicated to the receiving provider; and documentation from a healthcare provider as to why the discharge was necessary. 4. Interview with the DON and ED on 6/24/25 at 3:52 PM confirmed no further documentation was available. 5. Review of the Transfer and Discharge policy, published May 2002, showed .3. Transfers and discharges may occur for any of these reasons: .c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. The health of individuals in the facility would otherwise be endangered .4. When the facility transfers or discharges a resident under any of the above circumstances outlines (sic) in 3 (a-f), the facility documents the transfer or discharge in the medical record and appropriate information is communicated to the receiving care institution or provider. At a minimum the following information is provided: a. Contact information of the practitioner responsible for the care of the resident. b. Resident representative information, including contact information. c. Advanced Directive information. d. Special instructions or precautions for ongoing care. e. Comprehensive care plan goals. f. Other necessary information including a copy of the discharge summary.

Based on observation, resident and staff interviews, review of payroll-based journal (PBJ) data, and review of facility staff postings, the facility failed to ensure sufficient nursing staff was provided to ensure sufficient nursing staff to provide resident care. The census was 83. The findings were: 1. Interview with resident #13 on 8/4/24 at 2:15 PM revealed the facility did not have enough staff. Interview with the resident on 8/5/24 at 9:59 AM revealed the facility had set days for showers but It doesn't always work out that way due to short staffing. The resident revealed s/he cannot sit up in the wheelchair for very long due to pain and staffing was short which made him/her not want to get up as it resulted in longer periods of sitting and increased pain. 2. Interview with resident #41 on 8/4/24 at 2:15 PM revealed there is not enough CNAs. It can take 45 minutes to 1 hour to answer call bells. 3. Interview with resident #75 on 8/5/24 at 2:38 PM revealed there was not enough CNAs and staff does not fill water mugs. 4. Interview with resident #58 on 8/5/24 at 11 AM revealed his/her call light was not always answered and they definitely don't have enough [staff]. 5. Interview with resident #9 on 8/5/24 at 1:57 PM revealed the first thing out of their mouth is they're understaffed; they don't have enough staff tonight. I hear this every night. There's only 1 of them here instead of 2. The resident stated it's gotten bad in reference to answering the call light. 6. Interview with resident #14 on 8/5/24 at 10:11 AM revealed the facility needed more staff on all shifts and s/he was unable to get help in a timely manner. 7. Interview with resident #60 on 8/5/24 at 9:49 AM revealed the facility did not have enough staff to provide assistance to residents. 8. Interview with resident #45 on 8/5/24 at 1:45 PM revealed staffing was ok; however, sometimes the resident did not receive showers because there was not enough staff. 9. Interview with resident #12 on 8/5/24 at 11:08 AM revealed the facility did not have enough staff and s/he had to wait between 35 and 40 minutes to get assistance. 10. Interview with resident #32 on 8/5/24 at 10:48 AM revealed the facility did not have enough staff and resident had to wait between 30 and 40 minutes for someone to answer the call light. Further interview revealed, at times, staff would enter his/her room, shut off the call light without providing assistance and s/he did not always get showers as scheduled. 11. Observation of 3rd floor on 8/4/24 at 4:58 PM showed 2 CNAs assisting residents with care and answering call lights. Interview with CNA #3 at that time revealed staffing was not sufficient to provide care to residents. 12. Observation of 2nd floor on 8/5/24 at 9:46 AM showed there were 2 CNAs assisting residents with care and answering call lights. Interview at that time with CNA #2 confirmed 2nd floor had 2 CNAs and she revealed it was supposed to be staffed with 3 CNAs. She revealed staff were unable to provide care to 43 residents with 2 CNAs and some residents did not receive showers or other types of care. 13. Interview with LPN #1 on 8/5/24 at 5:26 PM revealed this staffing [during the survey] is not normal, usually it's only 1 nurse and 1 CNA on this unit. 2nd floor only has 2 aides. Sometimes the food is an hour late. 14. Review of payroll-based journal (PBJ) data for the previous 4 quarters showed low weekend staffing and 1 star staff rating triggered for all 4 quarters. 15. Review of facility staff posting on 8/7/24 at 8:45 AM revealed NA (nurse aide) hours were included in the daily staff posting. 16. Interview with the DON on 8/6/24 at 3:52 PM revealed the facility did not employ NAs, they use hospitality aides (HSA), which were unable to provide resident care, and the HSAs hours were indicated as NA on the daily staff posting. 17. Review of Hospitality Aide job description on 08/07/24 at 8:30 PM showed .the Hospitality Aide may not perform direct patient care . 18. Review of facility wide self-assessment dated [DATE] showed the facility required 160 care hours for CNAs with an average census of 84. 19. Review of the daily staff postings for July 2024 showed the facility had an average of 148 hours for CNAs and an average daily census of 83.2 20. Interview with the nursing staffer on 8/7/24 at 8:36 AM revealed the corporation provides minimum staffing based on resident census. She revealed minimum staffing on day shift and evening shift would be 3 CNAs for 2nd floor, 2 CNAs on 3rd floor, and 1 CNA in the secure unit. She revealed night shift minimum staffing would be 2 or 3 CNAs on 2nd floor, depending on the census, 2 CNAs on 3rd floor, and 1 CNA in the secure unit. Further interview confirmed HSAs were not able to provide direct resident care; however, they were counted as part of and figured into the daily nursing staff hours. 35081

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitoring of target symptoms was completed for 1 of 5 sample residents (#10) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 12 out 15, which indicated the resident was cognitively intact, and diagnoses which included anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and post-traumatic stress disorder. Review of the physician's orders showed the resident received risperidone (antipsychotic) 2 milligrams (MG) by mouth daily for schizoaffective disorder and buspirone (antianxiety) 10 MG by mouth 3 times per day for anxiety disorder. The following concerns were identified: a. Review of the care plan last revised on 7/23/24 showed no evidence the facility identified resident specific target symptoms for each medication. b. Review of the medication administration record for June, July, and August 2024 showed no evidence the facility identified resident specific target symptoms for each medication or had a process to monitor resident specific target symptoms. 2. Interview with the DON on 8/7/24 at 11:04 AM confirmed the target symptoms had not been identified as medication specific and revealed the facility was unable to evaluate the effectiveness of medications. 3. Review of the policy titled Psychotropic Drugs last revised October 2022 showed .2. Psychotropic drugs can be therapeutic and enhancing quality of life for residents suffering from mental illnesses (schizophrenia, depression, etc.), the Interdisciplinary Team (IDT) validates there are appropriate diagnoses of behavioral symptoms, so the underlying cause of the symptoms is recognized, and the condition is treated appropriately .

Based on observation, staff interview, and policy review, the facility failed to ensure medications available for resident use were not expired in 1 of 3 storage areas (2nd floor medication room). The findings were: 1. Observation of the 2nd floor medication storage room refrigerator on [DATE] at 4:44 PM showed a box of Bisacodyl (laxative) suppositories with an expiration date of ,d+[DATE]. Review of the manufacturer's literature indicated not to use after the expiration which was on the carton and blister. Further review showed the expiration date referred to the last day of that month. 2. Interview with RN #1 on [DATE] at 4:44 PM revealed the all medications stored in the medication storage room refrigerator were available for resident use. 3. Review of the policy titled House Supplied (Floor Stock) Medications dated ,d+[DATE] showed .Floor stock medications kept in the original manufacturer's container must have expiration date and lot numbers clearly visible. Unless otherwise specified, the expiration date is limited to the expiration date on the original container or one years' time from date of opening, whichever comes first .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure a care plan was developed for 1 of 2 sample residents (#10) with post-traumatic stress disorder. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 12 out 15, which indicated the resident was cognitively intact, and diagnoses which included anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and post-traumatic stress disorder. Review of a PASRR Level II review dated 4/16/23 showed recommended services included individual therapy. The following concerns were identified: a. Review of the care plan last revised on 6/30/24 showed no evidence a care plan was developed related to behavioral health related to post-traumatic stress disorder or bipolar disorder. d. Interview with the social services assistant on 8/6/24 at 10:57 AM revealed the resident did not receive any behavioral health support and she was not aware residents needed to receive behavioral health services. 2. Review of the policy titled Trauma-informed care last revised October 2022 showed .1. Upon new admissions, the trauma-informed care evaluation is completed by the Licensed Nurse. 2. Based on the evaluation results, the appropriate provider and IDT notifications are made to support the care of a resident with past or present history of trauma. 3. The resident's care plan is updated to reflect goals and interventions including non-pharmacological means to provide care for the resident .

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure resident activities of interest were provided for 1 of 1 sample resident (#12) with activity concerns. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #12 had a [BIMS] score of 15 out of 15, which indicated s/he was cognitively intact, and diagnoses which included anxiety disorder and schizophrenia. Review of the activities care plan last revised on 2/19/24 showed the resident had little or no activity involvement related to [s/he] wishes not to participate. [Resident name] enjoys music. Interventions included explaining the importance of social interaction, encourage participation, invite/encourage family members to attend activities with the resident, assist/escort the resident to activity functions, and remind the resident s/he can leave activities at any time. The following concerns were identified: a. Interview with the resident on 8/5/24 at 11:08 AM revealed the facility did not offer activities s/he would like to attend and the facility did not provide one-to-one activities for the resident; however, s/he revealed It would be nice if they did. b. Review of an activity progress note dated 5/7/24 showed the resident had no activity participation and the resident enjoyed visits from his/her father and watching television. c. Interview with the activity director on 8/6/24 at 2:44 PM revealed the resident did not participate in activities and activity staff performed one-to-one activities; however, she was unable to say what type of one-to-one activities were performed which the resident was unable to do independently. Further she revealed the care plan should indicate the resident's activities. 2. Review of the policy titled Activity Program last revised July 2015 showed .5. Activities include individual, small and large groups, one-to-one, and independent activities to meet resident's needs, abilities, and interests. For residents confined to, or who choose to, remain in their room, the Activity Department provides and assists with in-room activities/projects/leisure pursuits in keeping with needs, abilities, and interests .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure behavioral health services were provided to 1 of 2 sample residents (#10) with post-traumatic stress disorder. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 12 out 15, which indicated the resident was cognitively intact, and diagnoses which included anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and post-traumatic stress disorder. Review of a preadmission screening and resident review (PASARR) Level II review dated 4/16/23 showed recommended services included individual therapy. The following concerns were identified: a. Review of a social services note dated 4/25/24 and timed 10:09 AM showed the facility contacted a behavioral health facility, at the request of the resident, to schedule mental health services. The behavioral health facility sent paperwork to be completed and returned prior to scheduling an appointment. Review of a social services note dated 4/29/24 and timed 10:32 AM showed the facility contacted the behavioral health facility as the required paperwork was not received. b. Review of a social services note dated 7/29/24 and timed 11:58 showed the behavioral health facility was unable to accept new patients and social services was going to speak with the resident about scheduling with a new provider. c. Review of the care plan last revised on 6/30/24 showed no evidence a care plan was developed for behavioral health related to post-traumatic stress disorder or bipolar disorder. d. Interview with the social services assistant on 8/6/24 at 10:57 AM revealed in April, the resident was experiencing some grief and she attempted to schedule behavioral health services. The social services assistant revealed she thought the services had been scheduled; however, when she called and checked in July, she was told they were not accepting new patients. Further interview revealed the resident did not receive any behavioral health support and she was not aware residents needed to receive behavioral health services. 2. Review of the policy titled Trauma-informed care last revised October 2022 showed .1. Upon new admissions, the trauma-informed care evaluation is completed by the Licensed Nurse. 2. Based on the evaluation results, the appropriate provider and IDT notifications are made to support the care of a resident with past or present history of trauma. 3. The resident's care plan is updated to reflect goals and interventions including non-pharmacological means to provide care for the resident . 3. Review of the policy titled Mental Health Rehabilitation Services last revised July 2015 showed .1. Social Services review all residents receiving a Level II PASARR screening for indication of mental health rehabilitation services. 2. The services are coordinated by Social Services and performed by qualified professionals from inside the Center or from community as provided or arranged through state agency .

Based on observation, medical record review, staff interview, and professional standard of practice review, the facility failed to ensure infection prevention practices were implemented during for 1 of 2 sample residents (#81) observed for personal care. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #81 had a BIMS score of 9 out 15, which indicated moderate cognitive impairment, and diagnoses which included benign prostatic hyperplasia and cerebrovascular accident. Further review showed the resident had an indwelling catheter, was always continent of bowel, and was dependent on staff for toileting hygiene. The following concerns were identified: a. Observation on 8/6/24 at 8:58 AM showed CNA #1 assisted the resident to his/her room, applied a gown, gloves, and facemask, and prepared to transfer the resident from the wheelchair to bed. The CNA placed the resident's catheter drainage bag on her gown, positioning it above the resident's bladder, and allowed visible urine in the tubing to flow backward toward the resident's bladder. After being unable to find a gait belt, the CNA placed the drainage bag under the resident's wheelchair, and removed a gait belt from her torso, under her gown. The CNA applied the gait belt to the resident's torso and again placed the resident's catheter drainage bag on her gown, above the resident's bladder, which allowed the visible urine in the tubing to flow backward toward the resident's bladder. CNA #2 assisted CNA #1 to transfer the resident into bed. CNA #1 placed the resident's catheter drainage bag in a pink basin by the resident's bed, and removed the resident's pants. CNA #1 performed perineal care to the resident, cleaning the resident front to back and clean to dirty; however, the resident was incontinent of stool and, after removing feces from the resident's rectal area, the CNA used her contaminated gloved hand to obtain more wipes from inside the wipe container. b. Interview with the DON on 8/6/24 at 3:04 PM confirmed the catheter drainage bag should not have been raised above the resident's bladder and the CNA should not have used her contaminated hand to obtain additional wipes from the wipe container. 2. Review of [NAME]/[NAME] seventh edition Nursing Interventions & Clinical Skills copyright 2020 showed .Care and Removal of an Indwelling Catheter .Implementation .Routinely check drainage tubing and bag .e. drainage bag is positioned below level of the bladder with urine flowing freely into bag .

Based on observation, resident and staff interview, medical record review, and resident grievance form review, the facility failed to ensure adequate staffing in 1 of 1 kitchen (main kitchen). The census was 72. The findings were: 1. Review of a grievance form dated 3/12/24 showed resident #2 reported breakfast is always cold and was promised lunch would be saved and reheated upon arrival from dialysis. Further review showed Department Manager Investigation and Findings: Was brought up at resident meeting. I checked with [resident name] and [s/he] said everything was much better .Action Taken: Kitchen was notified. We are now heating residents meals appropriately when [s/he] is gone for meetings . 2. Review of a grievance form dated 4/2/24 showed 5 residents reported chicken over cooked, meal slow, not flavorful. Further review showed Department Manager Investigation and Findings: [NAME] no longer here, new cook hired . 3. Review of a grievance form dated 4/2/24 showed resident #5 reported Dinner was supposed to start at 4:30 PM. It is now 6 PM and we have yet to be served anything other than beverages. Further review showed Department Manager Investigation and Findings: Dinner service starts at 5:30, Working with staff on timing. 4. Review of a grievance form dated 4/8/24 showed resident #7 reported tomato soup is burned. Food is late and cold. I don't always get what I order. Further review showed Department Manager Investigation and Findings: Statements are true. Corrective actions have been taken. Corrective action taken with staff .Action Taken: Retrain staff. 5. Observation of a sign posted on the wall by the elevator on the 3rd floor showed residents meal times were: breakfast at 7:30 AM, lunch at 12 and supper at 5:30 PM. 6. Observation on 4/10/24 showed residents on second floor were seated at tables, waiting for lunch service, by 12 PM. Further observation showed the meal service, in the 2nd floor dining room, began at 1 PM. 7. Observation on 4/11/24 showed lunch service on second floor began at 1:02 PM. Further observation showed the meal service was stopped at 1:12 PM to obtain additional hoagie buns and 1 resident was served a meatball sandwich on a hamburger bun at 1:30 PM because the facility ran out of hoagie buns a second time during meal service. All meals were served by 1:30 PM. Interview with resident #8 at that time revealed the meal was cold. 8. Observation of the 3rd floor lunch service on 4/10/24 at 11:56 AM the food arrived to the 3rd floor. Lunch service continued until 1:08 AM when the final resident meals were delivered. Observation of the lunch meal on 4/11/24 showed by noon there were 8 residents in the dining room and room trays were being delivered. At 12:40 PM there were 11 residents in the dining room and all residents were served by 12:50 PM. 9. Observation of resident #6 on 4/10/24 at 3:10 PM showed the resident had no teeth. Review of the medical showed the resident required a high protein diet for wound healing. Interview with the resident on 4/10/24 at 3:20 PM revealed the food served at the facility was too tough to chew and/or needed to be cut into bite sized pieces for the resident. The resident complained of the facility serving food that could not be eaten and meals that had been served progressively later than the meal time window. The resident had resorted to ordering fast food delivered and supplementing meals with protein shakes to meet food preferences and improve intake. 10. Interview with resident #37 on 4/10/24 at 1 PM confirmed the food service was consistently slow and the result was cold food and/or long wait times for the meals to be delivered to the residents. An additional interview on 4/10/24 at 2:52 PM revealed the meals were often delivered cold and tasteless and the resident considered this a long time problem. 11. Interview with the daughter of resident #17 on 4/11/24 at 11:05 AM revealed that the food served for dinner on Tuesday night was not appetizing to the resident so the daughter brought dinner in for the resident the second night. Further interview revealed the resident complained about receiving cold eggs for breakfast this morning. 12. Interview with resident #38 on 4/11/24 at 10:20 AM revealed the meat served at meals was dry and tough and the vegetables were either mush or raw. 13. Interview with resident #35 on 4/10/24 at 11:59 AM revealed residents had recently discussed meal concerns during resident council; however, they were trying to be understanding of a recent tragedy suffered by dietary staff members. 14. Interview with resident #34 on 4/10/24 at 2:50 PM revealed meat served with meals was not thoroughly cooked and the only alternatives offered were sandwiches or soup. The resident revealed the facility reported dining concerns were related to not having enough staff and not being able to hire new staff. Further interview revealed the meals were always late, up to an hour, and the facility did not respond to resident concerns. 15. Interview with resident #30 on 4/10/24 at 3:09 PM revealed meals were always late, were not cooked properly, did not follow the menu, and had small portions. 16. Interview with resident #31 on 4/10/24 at 3: 10 PM revealed the facility reported they had seven dietary staff members recently quit and the food was not cooked well. The resident revealed meals were served an hour after they were supposed to be and the portions kept getting smaller. 17. Interview with the administrator and dietary manager on 4/12/24 at 9:15 AM revealed meals were scheduled to be served at 7:30 AM, 12 PM, and 5:30 PM. They revealed the dietary department had turned over pretty much all the staff and had recently changed food providers. The new menu required meals to be made from scratch and they were still training new staff. They revealed 2 staff members in dietary were off due to a traumatic event and food service issues had been ongoing. Further interview revealed there were three additional staff openings in dietary and performance improvement plan had been developed; however, it had not been fully implemented at that time.

Based on observation, resident, resident representative, and staff interview, medical record review, and facility grievance review, the facility failed to ensure bathing was performed per the plan of care on 2 of 2 resident care units (second floor, third floor). The census was 72. The findings were: 1. Review of a Grievance Form dated 3/12/24 showed resident #7 reported s/he was not being asked if s/he wanted a shower; however, it was documented s/he refused. Further review showed Department Manager Investigation and Findings: Times the I'm asked don't work with activities, I would like later showers and Actions/Recommendations: Shower times changed to evenings 2. Review of the .ADL self-care performance . care plan last revised on 1/10/24 showed resident #1 prefers to bathe/shower twice weekly and PRN and Provide sponge bath when a full bath or shower cannot be tolerated. The following concerns were identified: a. Review of the bathing record between 12/1/23 and 1/15/24 showed the resident had showers documented as being provided on 14 times during the period and a bed bath was documented twice on the same day. b. Interview with the resident on 4/11/24 at 12:46 PM revealed s/he discharged from the facility following care and food concerns by him/her and family. S/he revealed s/he only received 2 showers during his/her short stay, the first shower was provided 3 weeks after s/he admitted to the facility and the second was given 2 weeks later. Further interview revealed the resident's daughter voiced concerns about care and food to the facility; however, nothing was done to correct it. c. Interview with the resident's representative on 4/11/24 at 3:18 PM confirmed the resident was discharged due to concerns with care and food while the resident was at the facility. Further interview revealed the resident did not receive showers as frequently as s/he was supposed to. 3. Review of the . ADL self-care performance . care plan last revised on 3/30/24 showed resident #22 prefers to bathe/shower twice weekly and PRN. The following concerns were identified: a. Observation on 4/10/24 at 11:51 AM showed a sour body odor smell was present in the hallway, on second floor B hall, near the room of resident #22. b. Observation on 4/10/24 at 3:02 PM showed the resident had a sour body odor present in his/her room. Interview with the resident at that time revealed s/he received bed baths in lieu of showers due to showers being hard on him/her. Further interview revealed s/he would prefer to take a shower; however, it was easier on him/her and for staff to perform a bed bath. c. Review of the bathing record between 1/11/24 and 4/8/24 showed the resident received a shower 6 times on 1/17/24, 2/1/24, 2/15/24, 2/28/24, 3/4/24, 3/10/24 and 4/1/24; however, the resident was also documented as refused on 2/1/24. Further review showed the resident received a bed bath 23 times during the time period. 4. Review of the medical record showed resident #6 was admitted on [DATE] and was scheduled for bathing on Tuesday and Fridays. The following concerns were identified: a. Observation on 4/10/24 at 3:10 PM showed the resident required a lift and 2 people to transfer, assist with positioning and hygiene/grooming assistance. The resident was provided a partial bed bath, during the transfer, to include peri-care with wipes. Interview with the resident at that time revealed the resident would prefer a shower; however, the water got cold before the shower is completed so a bed bath was routinely performed. b. Review of the bathing record between 1/11/24 through 4/8/24 showed the resident had not received a shower and had received 18 bed baths. 5. Review of the plan of care showed resident #29 preferred a shower on Tuesday and Friday evenings. The following concerns were identified: a. Observation of the resident on 4/10/24 at 1:05 PM showed the resident was wheelchair bound and dependent on others for ADLs. The resident's hair that was long and appeared greasy. b. Review of the bathing record for February 2024, March 2024, and April 2024 showed the resident received 9 showers, 7 bed baths and had 9 documented refusals. The resident's last shower was provided on 4/5/24. 6. Observation on 4/11/24 at 1:23 PM of resident #17 showed the resident was in isolation for infection prevention, sitting in a wheelchair. Interview with the resident at that time revealed the resident was admitted 2 days prior and was offered a shower the second night s/he was at the facility and the resident stayed up as late as I could;'' however, nobody arrived for the shower. The resident further revealed that on the morning of the interview a CNA offered a shower and when the resident agreed the resident was told that only a bed bath was available, not a shower, so the resident declined the bed bath and stated, so I am still in my pajamas. Interview with the resident's daughter on 4/11/24 at 11 AM confirmed the resident moved in on Tuesday (4/9/24) and during a visit on Wednesday evening, they were told the resident was on the shower list that night; however, the resident did not get a shower. 7. Observation on 4/10/24 at 11:49 AM showed a sour body odor smell was present in the hallway, on second floor B hall, near the room of resident #36. Observation on 4/10/24 at 3:57 PM showed the sour body odor remained present near the room of the resident. Observation on 4/11/24 at 10:30 AM showed the resident's room had a sour body odor present. Interview with the resident at that time revealed the facility only provided the resident with bed baths; however, the resident stated it was his/her choice. 8. Interview with resident #31 on 4/10/24 at 3:10 PM revealed some residents did not receive showers as often as they should and they had bad body odor. Further interview revealed s/he thought it was due to staff not wanting to use the mechanical lift to transfer residents to the shower. 9. Interview with the social services director on 4/12/24 at 12:05 PM confirmed residents should be showered per their preference and if the resident refused a shower, they should receive a bed bath. Further interview revealed that resident #6 may not be aware that the hot water issues have been resolved and showers may be an option again in the future. 10. Interview with the DON on 4/12/24 at 11 AM revealed she expected staff to offer residents a shower and if they refused, offer a bed bath. She revealed the facility found out some staff members were only providing bed baths to residents who were on COVID precautions because they thought the residents could not leave their room for a shower. She revealed the facility had performed staff education because of a high number of resident refusals and documented bed baths. Further interview revealed the bed baths did not clean residents as thoroughly as a shower.

Based on observation, resident and staff interview,review of grievance forms, and medical record review, the facility failed to ensure palatable food was served in 1 of 1 kitchen (main kitchen). The census was 72. The findings were: 1. Review of a grievance form dated 3/21/24 showed resident #1 reported tortilla was dry and chewy, could not eat. Further review showed Discussed with resident. There was nothing unusual about tortilla, maybe it was the brand. 2. Review of a grievance form dated 3/12/24 showed resident #2 reported breakfast is always cold and was promised lunch would be saved and reheated upon arrival from dialysis. Further review showed Department Manager Investigation and Findings: Was brought up at resident meeting. I checked with [resident name] and [s/he] said everything was much better .Action Taken: Kitchen was notified. We are now heating residents meals appropriately when [s/he] is gone for meetings . 3. Review of a grievance form dated 3/21/24 showed resident #3 reported Resident did not like dinner meal, [s/he] was very disappointed and refused to eat, [s/he] was offered an alternate and as refused that because [s/he] said [his/her] appetite was ruined. Further review showed Department Manager Investigation and Findings: Spoke with resident [s/he] stated [s/he] would just start eating McDonalds because management sucks .Action taken: We are changing this meal to grilled cheese and tomato soup from now on . 4. Review of a grievance form dated 3/21/24 showed resident #4 reported Resident said [his/her] dinner was not fit to eat. The dinner was French onion soup with grilled cheese sandwich and German cucumber salad. Further review showed Department Manager Investigation and Findings: Spoke with resident. {S/he did not remember the grievance but was thankful the menu would be changed .Action Taken: We are on a new menu and will be changing this menu to tomato soup and grilled cheese . 5. Review of a grievance form dated 4/2/24 showed 5 residents reported chicken over cooked, meal slow, not flavorful. Further review showed Department Manager Investigation and Findings: [NAME] no longer here, new cook hired . 6. Review of a grievance form dated 4/7/24 showed resident #6 reported clearly ordered turkey sandwich no cheese was given ham. Further review showed Department Manager Investigation and Findings: Resident was given turkey sandwich after was served ham .Action Taken: Staff was instructed to serve the proper meal that was ordered. 7. Review of a grievance form dated 4/8/24 showed resident #7 reported tomato soup is burned. Food is late and cold. I don't always get what I order. Further review showed Department Manager Investigation and Findings: Statements are true. Corrective actions have been taken. Corrective action taken with staff .Action Taken: Retrain staff. 8. Review of a grievance form dated 4/9/24 showed resident #2 reported Grill [sic] cheese sandwich was burnt again. Bosses went home and no one else would fix another one. Had 1/2 egg salad sand and 4 strips [NAME] [chicken] for dinner. Further review showed Department Manager Investigation and Findings: Meeting was held. assured [him/her] I am here long days. New cook is cooking manager in center for all 3 meals. Served Cesar salad [with] chicken .Action Taken: New cook making grilled cheese Egg salad sand [sandwich] served as snack only. Alternates were available. 9. Observation on 4/11/24 showed lunch service on second floor began at 1:02 PM. Further observation showed the meal service was stopped at 1:12 PM to obtain additional hoagie buns and 1 resident was served a meatball sandwich on a hamburger bun at 1:30 PM because the facility ran out of hoagie buns a second time during meal service. All meals were served by 1:30 PM. Interview with resident #8 at that time revealed the meal was cold. 10. Observation of resident #6 on 4/10/24 at 3:10 PM showed the resident had no teeth. Review of the medical record showed the resident required a high protein diet for wound healing. Interview with the resident on 4/10/24 at 3:20 PM revealed the food served at the facility was too tough to chew and/or needed to be cut into bite sized pieces for the resident. The resident revealed s/he was served food that could not be eaten and meals had been served progressively later than the meal time window. Further interview revealed the resident had resorted to ordering fast food delivery and supplementing meals with protein shakes to meet food preferences and improve intake. 11. Interview with the daughter of resident #17 on 4/11/24 at 11:05 AM revealed that the food served for dinner on Tuesday night was not appetizing to the resident so the daughter brought dinner in for the resident the second night, in addition, that the resident complained about receiving cold eggs for breakfast this morning. 12. Interview with resident #37 on 4/10/24 at 1 PM confirmed the food service was consistently slow and the result was cold food and/or long wait times for the meals to be delivered to the residents. An additional interview on 4/10/24 at 2:52 PM revealed the meals were often delivered cold and tasteless and the resident considered this a long time problem. 13. Interview with resident #34 on 4/10/24 at 2:50 PM revealed meat served with meals was not thoroughly cooked and the only alternatives offered were sandwiches or soup. The resident revealed the facility reported dining concerns were related to not having enough staff and not being able to hire new staff. Further interview revealed the meals were always late, up to an hour, and the facility did not respond to resident concerns. 14. Interview with resident #30 on 4/10/24 at 3:09 PM revealed meals were always late, were not cooked properly, did not follow the menu, and had small portions. 15. Interview with resident #31 on 4/10/24 at 3: 10 PM revealed the facility reported they had seven dietary staff members recently quit and the food was not cooked well. The resident revealed meals were served an hour after they were supposed to be and the portions kept getting smaller. 16. Interview with resident #38 on 4/11/24 at 10:20 AM revealed the meat served at meals was dry and tough and the vegetables were either mush or raw. 17. Interview with the administrator and dietary manager on 4/12/24 at 9:15 AM revealed dietary department had turned over pretty much all the staff and had recently changed food providers. The new menu required meals to be made from scratch and they were still training new staff. They revealed 2 staff members in dietary were off due to a traumatic event and confirmed food service issues had been ongoing. Further interview revealed performance improvement plan had been developed; however, it had not been fully implemented at that time. They confirmed the meal issues had not been corrected.

Based on observation, resident, resident representative, and staff interview, and grievance log review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 4 grievance areas (food service and palatability). The census was 72. The findings were: 1. Review of a grievance form dated 1/9/24 showed the daughter of resident #1 was angry the resident was getting a roommate and stated the resident was only served a small amount of soup . Further review showed Action Taken: Interview with RD [registered dietitian] who was assisting /monitoring meal observed resident bowls appropriately filled .Resident discharged AMA on 1/9/24 .prior to resident leaving dinner tray was observed and was consistent with what resident ordered for dinner. Soup bowl empty with soup ring at appropriate level . 2. Review of a grievance form dated 3/12/24 showed resident #2 reported breakfast is always cold and was promised lunch would be saved and reheated upon arrival from dialysis. The review showed Department Manager Investigation and Findings: Was brought up at resident meeting. I checked with [resident name] and [s/he] said everything was much better .Action Taken: Kitchen was notified. We are now heating residents [sic] meals appropriately when [s/he] is gone for meetings . Further review showed the grievance was not marked as resolved or unresolved. 4. Review of a grievance form dated 3/21/24 showed resident #3 reported Resident did not like dinner meal, [s/he] was very disappointed and refused to eat, [s/he] was offered an alternate and as refused that because [s/he] said [his/her] appetite was ruined. Further review showed Department Manager Investigation and Findings: Spoke with resident [s/he] stated [s/he] would just start eating McDonalds because management sucks .Action taken: We are changing this meal to grilled cheese and tomato soup from now on . 5. Review of a grievance form dated 3/21/24 showed resident #4 reported Resident said [his/her] dinner was not fit to eat. The dinner was French onion soup with grilled cheese sandwich and German cucumber salad. Further review showed Department Manager Investigation and Findings: Spoke with resident. [S/he] did not remember the grievance but was thankful the menu would be changed .Action Taken: We are on a new menu and will be changing this menu to tomato soup and grilled cheese . 6. Review of a grievance form dated 4/2/24 showed 5 residents reported chicken over cooked, meal slow, not flavorful. Further review showed Department Manager Investigation and Findings: [NAME] no longer here, new cook hired . 7. Review of a grievance form dated 4/2/24 showed resident #5 reported Dinner was supposed to start at 4:30 PM. It is now 6 PM and we have yet to be served anything other than beverages. Further review showed Department Manager Investigation and Findings: Dinner service starts at 5:30, Working with staff on timing. 8. Review of a grievance form dated 4/7/24 showed resident #6 reported clearly ordered turkey sandwich no cheese was given ham. Further review showed Department Manager Investigation and Findings: Resident was given turkey sandwich after was served ham .Action Taken: Staff was instructed to serve the proper meal that was ordered. 9. Review of a grievance form dated 4/8/24 showed resident #7 reported tomato soup is burned. Food is late and cold. I don't always get what I order. Further review showed Department Manager Investigation and Findings: Statements are true. Corrective actions have been taken. Corrective action taken with staff .Action Taken: Retrain staff. 10. Review of a grievance form dated 4/9/24 showed resident #2 reported Grill [sic] cheese sandwich was burnt again. Bosses went home and no one else would fix another one. Had 1/2 egg salad sand and 4 strips [NAME] [chicken] for dinner. Further review showed Department Manager Investigation and Findings: Meeting was held. assured [him/her] I am here long days. New cook is cooking manager in center for all 3 meals. Served Cesar [sic] salad [with] chicken .Action Taken: New cook making grilled cheese Egg salad sand [sandwich] served as snack only. Alternates were available. 11. Observation on 4/10/24 showed residents on second floor were seated at tables, waiting for lunch service, by 12 PM. Further observation showed the meal service in the 2nd floor dining room began at 1 PM. 12. Observation on 4/11/24 showed lunch service on second floor began at 1:02 PM. Further observation showed the meal service was stopped at 1:12 PM to obtain additional hoagie buns and 1 resident was served a meatball sandwich on a hamburger bun at 1:30 PM because the facility ran out of hoagie buns a second time during meal service. All meals were served by 1:30 PM. Interview with resident #8 at that time revealed the meal was cold. 13. Interview with resident #35 on 4/10/24 at 11:59 AM revealed residents had recently discussed meal concerns during resident council; however, they were trying to be understanding of a recent tragedy suffered by dietary staff members. 14. Interview with resident #34 on 4/10/24 at 2:50 PM revealed meat served with meals was not thoroughly cooked and the only alternatives offered were sandwiches or soup. The resident revealed the facility reported dining concerns were related to not having enough staff and not being able to hire new staff. Further interview revealed the meals were always late, up to an hour, and the facility did not respond to resident concerns. 15. Interview with resident #30 on 4/10/24 at 3:09 PM revealed meals were always late, were not cooked properly, did not follow the menu, and had small portions. 16. Interview with resident #31 on 4/10/24 at 3:10 PM revealed the facility reported they had seven dietary staff members recently quit and the food was not cooked well. The resident revealed meals were served an hour after they were supposed to be and the portions kept getting smaller. 17. Interview with the administrator and dietary manager on 4/12/24 at 9:15 AM revealed meals were scheduled to be served at 7:30 AM, 12 PM, and 5:30 PM. They revealed the dietary department had turned over pretty much all the staff and had recently changed food providers. The new menu required meals to be made from scratch and they were still training new staff. They revealed 2 staff members in dietary were off due to a traumatic event and food service issues had been ongoing. Further interview revealed there were three additional staff openings in dietary and performance improvement plan had been developed; however, it had not been fully implemented at that time and the dietary concerns had not been resolved. 18. Interview with the social services director on 4/12/24 at 11:50 AM revealed residents could verbalize or write down grievances. After grievances were received, they were passed on to the department manager to address. The social services director revealed the department manager was responsible for resolution and notification of individuals who filed the grievance. Further interview confirmed the meal concerns had not been resolved.

Based on observation, staff interview, and review of the facility's policy, the facility failed to ensure staff correctly donned personal protective equipment (PPE) prior to resident care for 1 of 5 sample residents (#17) who were on transmission-based precautions. The findings were: 1. Observation on 4/10/24 at 12:05 PM showed resident #17 had a sign on the outside of the room that indicated the resident was on droplet/contact precautions and a PPE cart was outside the door that contained gowns, masks, gloves, and eye shields. Staff member #1 was observed at that time donning PPE and entered the room with the gown on backwards, tied at the neck and open in the front leaving the staff member unprotected by the gown as she entered the resident's room. An additional observation at 12:07 PM showed the gown was open in the front and clothing was exposed when the staff member opened the door to exit and removed the PPE inside the room. 2. Interview with staff member #1 on 4/10/24 at 12:07 PM confirmed the resident was on transmission-based precautions but she was not concerned about the improper donning of the gown because the resident was not symptomatic. 3. Interview with LPN #1 on 4/10/24 at 12:13 PM regarding the observation revealed the staff member needed education regarding the proper way to wear the gown before entering the room of residents in isolation. 4. Interview with the nurse manager #1 on 4/10/24 at 4:15 PM verified remedial training for donning and doffing PPE was being conducted in the facility, at that time, and it would include staff member #1. 5. Review of the facility's policy, Standard Precautions'', dated May, 2015 showed 1. Standard Precautions apply to the care of all residents regardless of their diagnosis, or suspected or confirmed infectious status .4 .a. Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities .

Based on observation, medical record review, resident, guardian and staff interview, facility-reported incident review, and policy and procedure review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (#2) reviewed for resident-to-resident altercations. This failure resulted in harm to resident #2 who experienced sexual abuse a reasonable person would have found humiliating, intimidating, demeaning, and degrading. The findings were: Review of the 10/28/22 quarterly minimum data set (MDS) assessment showed resident #2 had a brief interview for mental status (BIMS) score of 9 of 15, indicating moderate cognitive impairment. Further review showed the resident had diagnoses which included multiple sclerosis and non-Alzheimer's dementia. Observation and an unsuccessful interview with the resident on 11/23/22 at 11 AM showed the resident in his/her room in a wheelchair in no distress. At that time an interview was attempted, and the resident appeared confused and could only respond to questions in the moment that included, How are you today? The resident was unable recall the past. Review of the 8/29/22 annual MDS assessment showed resident #1 had a BIMS score of 15 of 15, indicating intact cognition. Further review showed the resident had diagnoses which included other symptoms and signs involving cognitive functions and awareness, anxiety disorder, unspecified impulse disorder, dysthymic disorder, and mild cognitive impairment of uncertain or unknown etiology. Observation and interview with the resident on 11/23/22 at 11:05 AM showed the resident sitting on the side of his/her bed in no distress, and at that time s/he could answer simple questions appropriately, though s/he denied ever having any negative contact with residents or staff. Review of the resident's care plan showed the following plan initiated 4/6/21 and revised on 10/31/22: [Resident's name] has times of being sexually inappropriate. [Resident name] has a history of exhibiting sexual attraction/feelings towards minors. A revision on 10/31/22 showed the resident had touched another resident in an unwanted sexual manner, and interventions that included supervision when the resident was near other residents in order to ensure the resident was not close enough to touch other residents were included. An additional care plan initiated 1/14/21 and revised 6/7/22 showed the resident's inappropriate sexual behavior did not include other individuals. The issues identified were: Bold sexual behaviors, fondling, masturbation, and self flogging. The following concerns were identified: 1. Review of a facility incident reported to the state survey agency on 10/31/22 showed an incident between residents #1 and #2 occurred on 10/30/22. The review showed resident #1 had allegedly touched resident #2 in an unwanted manner on the leg and in the groin area. 2. Interview with certified nurse aide (CNA) #2 on 11/23/22 at 10:40 AM revealed she witnessed resident #1 touch the leg of resident #2, then grab resident #2 in the groin. She then stated resident #2 was saying no and pushing resident #1 away with his/her hand. CNA #2 stated there were no other witnesses to this incident. She stated she removed resident #2 to safety in his/her room and reported the incident to the charge nurse. Interview with licensed practical nurse #1 on 11/23/22 at 10:30 AM revealed she did not witness the incident on 10/30/22 between resident #1 and resident #2. She was told by a CNA that the incident occurred, and she reported it at that time to supervision. 3. Review of the progress notes for resident #2 showed the following notes: a. 10/30/22 at 20:29 [8:29 PM]: Resident was in the dining room when another resident placed [his/her] hand on [his/her] lap, grabbing [his/her] groin area. Resident was very upset, yelling at [him/her]. Residents separated, this resident was taken to [his/her] room and comforted. ADON [assistant director of nursing] and DON [director of nursing] notified. b. 11/2/22 at 23:32 [11:32 PM]: Observation continues r/t [related to] previous episode of unwanted touching from another res [resident]. The other res [resident #1] was observed after supper to come into the dining room and go over to table where this res [resident #2] was sitting with [his/her] tablemate's playing cards. [Resident #2] sat up very stiff with shoulders squared and stopped talking. This nurse instructed the other res to leave the area and come back over to the nurse's station, then went back to check on this res. [Resident #2] thanked this nurse for intervening, stating 'I don't want [him/her] around me'. Res reassured [s/he] is being watched and we will keep [him/her] away. Later in the evening [resident #2] was observed self-propelling w/c [wheelchair] past nurse's station to try and head to [his/her] room. [Resident #1] was at the station at the time near the phone. As [resident #2] approached the nurse's station res made contact with this nurse. I helped res go quickly past the station keeping wide [NAME] of space between the two residents, and took [the resident] to [his/her] room. Upon arriving at the room res again thanked this nurse, stating [s/he] didn't want [him/her] to talk to [him/her]. When I asked res questions regarding how [s/he] is feeling, [s/he] stated [s/he] does not feel afraid of [him/her], only angry at [him/her], and wants to be left alone. Stated [s/he] forgets about it until [s/he] sees [him/her] and then remembers. Also stated [s/he] feels a bit like nobody believes [him/her]. Res reassured that I have known [him/her] for almost [AGE] years now and I know [s/he] would never make an accusation like that which was untrue and that we do believe [him/her], and that [s/he] is not alone in feeling this way. Encouraged to keep talking and let us know how [s/he] is doing, even if [s/he] just needs to be angry or cuss about it. Res became a bit tearful and thanked this nurse and gave me a hug. Res states [s/he] hopes [s/he] will forget about it again. 4. Review of the care plan for resident #2 showed a plan initiated on 10/31/22 and revised on 11/22/22 to address the following: Problem: [Resident's name] is at risk for feelings of trauma or re-traumatization due to past trauma [s/he] has experienced that includes sexual abuse. The plan included goals and interventions to address sexual abuse. 5. Interview with the guardian of resident #1 on 11/23/22 at 10:20 AM revealed the facility notified her of the 10/30/22 sexual abuse allegation against resident #1 which involved resident #2. She further stated she had never heard an allegation of sexual misconduct between resident #1 and anyone else until that allegation. 6. Interview with the administrator on 11/23/22 at 3:45 PM revealed the facility took the sexual abuse allegation of 10/30/22 between resident #1 and resident #2 seriously, protected resident #2 by making staff aware, reported to the state, and resident #1 was relocated to the first floor for additional oversight, as s/he continued to approach resident #2. 7. Review of the policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation published December 2003 and updated October 2022, showed a Policy Statement as follows, Each resident has the right to be free from abuse including .sexual . Further review showed sexual abuse included any non-consensual sexual contact of any type with a resident. Review of the Procedure showed, .3. Prevention: The Center implements written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on observation, medical record review, resident and staff interview, facility incident investigation review, performance improvement plan review, and staff education and monitoring documentation review, the facility failed to ensure residents were transferred in a safe manner for 1 of 3 (#1) residents reviewed for appropriate transfer assistance. This failure resulted in harm to resident #1, who was transferred inappropriately and sustained a fracture. Corrective measures were implemented by the facility prior to survey, and and compliance was determined to be met on 3/29/22. The findings were: Review of the 6/11/22 quarterly MDS assessment showed resident #1 had diagnoses which included diabetes mellitus type II, other fracture, and [CONDITION(S)]. The review showed the resident had a brief interview for mental status score of 15, which indicated s/he was cognitively intact. The review also showed the resident required extensive assistance with mobility and transfers. Review of the care plan showed a plan, initiated on 3/3/22, that required assistance of 2 staff members for transfers. Review of a late entry nursing progress note dated 3/24/22, timed 5:41 PM and titled, Alert Charting: Fall/Accident/Injury showed the following: Patient was transferred by staff to the shower chair and 2 nurses assessed to note no injuries at that time. In the AM patient had increased pain and MD [medical doctor] was notified and telehealth appointment was given. MD ordered x-ray and sent out. Noted fracture of R [right] tibia . Review of the 3/25/22 nursing progress note timed 1:07 PM showed the following: Reported to me by the night nurse that resident's knee got injured during a transfer .Resident assessed and unable to straighten right leg, without resident yelling out. I had PT [physical therapy] assess and they were unable to straighten right leg out. Resident did request earlier to go to hospital. MD notified and management. Resident okay with [name of radiology center] for x-rays. Waiting for a return phone call from MD. Review of a 3/24/22 facility incident investigation showed the following regarding an incident in the resident's room, Nursing Description: Patient was transferred by staff to the shower chair and 2 nurses assessed to note no noted injury at that time. In the AM patient had increased pain and MD was notified and telehealth appointment was given. MD ordered x-ray and sent out. Noted fracture of R [right] tibia .Patient Description: I was getting up to the showers and slid my leg because of my slippers and extended my leg. Review of incident logs from January 2022 to current showed no additional incidents related to staff-assisted transfers. The following concerns were identified: 1. Interview with resident #1 on 7/13/22 at 4:20 PM confirmed she had an injury to her right lower leg in March 2022 during a staff-assisted transfer, but could not remember the details, such as how many staff members were present to assist the resident at the time of the incident. The resident stated s/he was better now. 2. Interview with emergency direct care worker (EDCW) #1 on 7/14/22 at 2:30 PM confirmed she transferred the resident on the evening of 3/24/22, and the resident had an assisted fall. The EDCW confirmed no other staff were assisting and no other staff were present during that time. The EDCW stated it was her first time caring for the resident, and she confirmed she failed to refer to the care plan, any other documentation, or to ask any other staff member how the resident was supposed to be transferred. 3. Interview with the administrator on 7/14/22 at 3 PM confirmed her expectation that staff follow the care plan for patient transfers. Review of the 3/25/22 performance improvement project (PIP) titled, CNA Tasks Transfers showed the following: Goal: To validate CNAs [certified nurse aides] are able to articulate where to find CNA transfer status. Measure: Monthly-staff interviews to validate where people find transfer status of our residents. Education can be done during all staff, huddles, walking rounds. Root Cause Analysis-Transfer statuses often change due to resident decline or improvement. Work with IDT team during clinical (which includes therapy) to ensure care plans get updated and it is added to the ISP. ISP is where all clinical staff can find transfer status for residents, and staff educated to ensure they use two people assist if not sure. Measure monthly times 3 to ensure compliance . Reviewed: 6/28/22 QAPI [quality assurance performance improvement]-Add additional 1 month review to ensure compliance with new staff and turnover. Review of the 3/29/22 Inservice Education Summary showed the summary included Transfer Status, and staff signed in to the inservice.

Based on medical record review, staff interview, review of policy and procedures, facility incident report review, review of the facility's Standards for Code Blue and review of professional standards, the facility failed to ensure basic life support was administered to 1 of 1 sample resident (#2) who required emergency life support, and failed to ensure staff were familiar with facility policies related to CPR. The facility failed to implement the advance directive for 1 of 1 sample resident (#2) that expired in the facility that had elected to receive CPR in the event of cardiopulmonary arrest. At the time of the survey 53 out of 117 residents had elected to receive CPR in the event of cardiopulmonary arrest. This resulted in a determination of an immediate jeopardy situation and substandard quality of care for these residents. The findings were: 1. Review of the WyoPOLST (Wyoming Providers Orders for Life Sustaining Treatment) form dated [DATE] (and signed by the physician on what appeared to be [DATE]) revealed resident #2 requested to be resuscitated in the event of no pulse and is not breathing. Further review showed the POLST was reviewed with the resident on [DATE], [DATE], [DATE], and [DATE] and the resident elected to maintain a full code status. Review of an unsigned and undated Standards for Code Blue provided by the facility on [DATE] at 9:40 AM showed Any person who discovers that a resident is unresponsive should immediately notify the employee in charge. Steps to take immediately: 1. Activate the Code Blue a. To activate the Code Blue in your Center: i. Announce Code Blue and the location of the unresponsive resident by shouting or paging overhead (#39) at least three times .ii. Establish the Resident's Code status . Interview with the administrator on [DATE] at 1:15 PM revealed the Standards for Code Blue was a process the facility had been using forever. The following concerns were identified: a. Review of a progress note created by RN #1 dated [DATE] at 2:18 AM showed At 0110 (1:10 AM) this morning Resident was found not breathing, unresponsive, no pulse and no heartbeat with auscultation. Pupils nonreactive (physician name) notified and Resident pronounced dead at 0120 (1:20 AM). There was no evidence staff initiated CPR. b. Review of an Investigator's Interview Statement of Event, signed by the DON and dated [DATE], showed CNA #1 was interviewed by the facility, and described the event. The CNA told the facility she had answered the resident's call light and had started to help him/her when she was called to assist another CN[NAME] Upon returning to the resident's room ,[DATE] minutes later she found the resident unresponsive and attempted to rouse (him/her) with no response. The CNA then ran out of the room to go find the nurse. Ran up and down halls calling out for nurse and couldn't find her. Finally found her in the bathroom. Nurse finished up going to the bathroom and than (sic) went down to (the resident's) room. (The resident) was unresponsive when CNA found (him/her) + 15 min/20 min later the nurse went to the room (By the time CNA tried to arouse (him/her) and find the nurse). c. Review of an Investigator's Interview Statement of Event signed by the DON and dated [DATE], showed RN #1 was interviewed by the facility and described the event. She told the facility the CNA had looked for me and I was in the restroom. Further review showed the nurse went to the resident's room to check the resident's status and noted color changes, no heartbeat, no lung sounds, was unresponsive, and was not warm to the touch. The nurse stated she immediately called the physician. In addition, RN #1 recalled receiving POLST education, however she had misunderstood the parameters with following through with the POLST. d. Review of the medical record and the investigation documentation provided by the facility showed no evidence CNA #1 or RN #1 had used the intercom system to activate Code Blue or made an attempt to contact a nurse on a different floor on [DATE] between 12:55 AM and 1:20 AM. e. Interview with LPN #1 on [DATE] at 6:07 PM revealed she was working on the third floor the night the incident occurred and Code Blue had not been activated. Further, RN #1 had contacted her approximately 30 minutes after the resident had expired, informed her the physician had been notified, orders had been received for transport, and then requested information in regard to where to find mortuary papers. LPN #1 asked the RN about the resident's code status and was informed the resident had been a Full Code; however the resident had expired before interventions had been instigated. The LPN stated she never set eyes on the resident. f. Interview on [DATE] at 2 PM with the DON, administrator, and the corporate district DON confirmed the CNA had not called Code Blue, however the CNA had gone down every hall two times until she found the nurse in the bathroom. Further, the nurse did not check the resident's chart to establish the resident's CPR status until after she had completed her assessment. The DON revealed the investigation had determined it was definitely between 10 and 15 minutes from when the CNA found the resident unresponsive until the nurse arrived in the resident's room. g. Review of the incident report submitted to the State Survey Agency on [DATE] showed the incident type was documented as Failure to provide Services and stated the resident was a Full Code, and confirmed the facility staff failed to initiate CPR. The documentation further showed RN #1 was immediately educated regarding Wyoming POLST and full code. The facility developed a plan of action and as part of the action plan had started educating all licensed nurses and implemented random daily nurse interviews regarding the POLST and full code status. h. Review of the facility's action plan in response to this incident showed the root cause was determined to be Nursing staff will verbalize how a code status is verified via POLST form and procedure to carry out based upon full code or DNR status. All charts will have current and updated POLST forms in place. 1) Licensed Nurses will verbalize Advanced Directives choice and explanation of full code versus DNR details. Corrective actions taken were provide education to nursing staff in regard to the POLST form, verification of code status before initiation of interventions if resident is unresponsive, full code versus DNR status and procedure to carry out accordingly. In addition, an audit was conducted on [DATE] of current resident's charts to ensure the POLST forms were complete. Monitoring included weekly random audits for nursing staff for 4 weeks on identification of how to verify code status and initiate a code status according to the policy and procedure. However, the action plan failed to address the unavailability of the nurse and the CNA's failure to activate a Code Blue to obtain assistance. i. Review of an Inservice Education Summary form dated [DATE] showed 26 nurses (RNs and LPNs) had received training on the topic of POLST/CPR/Full code protocol. j. Interview on [DATE] at 3:05 PM with the staff development coordinator (SDC) revealed she had educated the licensed nurses on [DATE] following the incident; however she had realized in the last week CNAs also needed to be educated. This education was to include the corporation's policy of only licensed nurses being allowed to perform CPR; and if a resident was found unresponsive they were to find a nurse, call code blue, retrieve the resident's chart, and return to the resident's room. The intercom system was activated by dialing #39 on the telephone. Further, she had begun the process to educate the CNAs individually and planned to finish at the all-staff in-service which was to be held on [DATE]. k. Review of an undated Inservice Education Summary form provided by the SDC showed the topic was CPR, codes, POLST. Further review showed 15 CNAs and 2 HSAs had completed the education. Review of the facility's personnel roster (updated on [DATE]) showed the facility employed 50 CNAs (31 full-time, 3 part-time, 13 PRN, 1 unspecified, 2 restorative aides) and 13 hospitality aides. l. Interviews with 9 CNAs on [DATE] between 1:20 PM and 4:08 PM revealed how they would respond if they found an unresponsive resident. Seven of the 9 CNAs described a response that was inconsistent with the facility's Standards for Code Blue, as evidenced by the following: i. CNA #2 stated she would yell for help, try CPR, and if no one came would run out of the room to get help. ii. CNA #3 stated she would check on the resident and then go get a nurse. iii. CNA #4 stated she would yell code and then find a nurse. iv. CNA #5 stated she would yell code blue and find a nurse. In addition, if she was unable to find a nurse she would call 911 and start CPR. v. CNA #7 stated she would notify the nurse, call a different floor if a nurse was not available, and check the resident's code status in their chart. vi. CNA #9 stated she would push the call light, find a nurse, and start compressions. In addition, if she could not find a nurse she would ask another CNA for assistance. vii. CNA #10 stated she would look for signs of life, call for a nurse, stay in the resident's room, and start CPR. In addition, she thought #39 was used to activate the intercom, however she was not sure. m. Review of the Advance Directive policy, last updated (MONTH) (YEAR), showed a policy statement of The Center relates information regarding advance directive to each resident and honors each advance directive that is given to it. Review of the Cardiopulmonary Resuscitation policy, last updated (MONTH) (YEAR), showed .CPR is initiated for those residents who: a. Have requested, through advanced directive or POLST/POST, to have CPR initiated when cardiac or respiratory arrest occurs . n. Interview with the administrator on [DATE] at 4:52 PM revealed the facility did not have a policy in regard to the procedure to follow if a resident, visitor, or staff member was found unresponsive. In addition, the administrator stated the Advance Directive policy and the CPR policy were sufficient and a policy that outlined the steps to take when a resident was found unresponsive was not necessary because it was a standard of care. o. Review of the POLST/Code Status/Full Code audit sheets updated on [DATE] showed 53 of the 117 residents had a code status of Full Code. This number was confirmed on [DATE] at 5:30 PM by the district DON 2. According to Perry, Potter, and Ostendorf in Nursing Interventions and Clinical Skills, 7th edition, 2020, page 812 .Immediate recognition of [MEDICAL CONDITION] and activation of emergency medical response are critical. Early CPR and recommended health care team-level coordination that switches the provider who performs chest compressions every 2 minutes improves the performance of high-quality CPR (AHA, (YEAR)). 3. According to the American Heart Association Emergency Cardiovascular Care website found at https://eccguidelines.heart.org; (retrieved [DATE]), Part 3: Ethical Issues, Withholding and Withdrawing CPR, Out-of-Hospital [MEDICAL CONDITION] (OHCA), Terminating Resuscitative Efforts in Adult OHCA, BLS out-of-hospital system showed Rescuers who start BLS should continue resuscitation until one of the following occurs: a. Restoration of effective, spontaneous circulation b. Care is transferred to a team providing advanced life support c. The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy d. Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met. 4. On [DATE] at 6 PM, the administrator was notified of the immediate jeopardy related to the facility's failure to initiate CPR for resident #2, and failure to ensure facility staff were familiar with facility policies or standards of care related to CPR. The facility's removal plan included the following corrective actions: a. Education will be provided to all staff including nursing, dietary, activities, and housekeeping in regard to the WyoPOLST form, verification of code status before initiation of interventions if a resident was unresponsive, Full Code versus DNR status, announcement of the standards for code blue, and CPR initiated by a licensed nurse only. The education was to begin on [DATE] at 6 PM and continue until all staff had been educated prior to work. b. An audit was conducted on [DATE] of all current residents to verify their code status and physician signature. c. An audit was conducted on [DATE] on all current employees to verify current CPR/BLS certification. d. A Mock Code Blue Drill was conducted on [DATE] at 7 AM and would continue every shift for the next 24 hours and then one time per week for 4 weeks, monthly for two months, and once per quarter. e. A monitoring system was put into practice to ensure staff were able to identify code status and initiate a code. In addition, audits would be conducted to ensure current residents' POLST forms were complete; licensed staff had current CPR/BLS certification, and a CPR-certified nurse was on duty at all times. The removal plan was accepted on [DATE] at 1:44 PM, and the immediate jeopardy was removed on [DATE] at 2:40 PM. However, deficient practice remained at a scope and severity of G (Actual harm that is not immediate jeopardy).

Based on medical record review, staff interview, facility investigation review, facility incident report review, review of policy and procedures, and review of professional standards, the facility failed to provide services to a resident that were necessary to avoid physical harm. Specifically, the facility failed to implement advance directives for 1 of 1 sample residents (#2) who experienced cardiopulmonary arrest in the facility and had elected to receive CPR in such an event. This failure resulted in harm to resident #2 who was found unresponsive, staff failed to initiate CPR, and the resident expired. Corrective measures were implemented by the facility, and compliance was determined to be met on [DATE]. The findings were: 1. Review of the WyoPOLST (Wyoming Providers Orders for Life Sustaining Treatment) form dated [DATE] (and signed by the physician on what appeared to be [DATE]) revealed resident #2 requested to be resuscitated in the event of no pulse and is not breathing. Further review showed the POLST form was reviewed with the resident on [DATE], [DATE], [DATE], and [DATE] and the resident elected to maintain a full code status. The following concerns were identified: a. Review of a progress note created by RN #1 dated [DATE] at 2:18 AM showed At 0110 (1:10 AM) this morning Resident was found not breathing, unresponsive, no pulse and no heartbeat with auscultation. Pupils nonreactive (physician name) notified and Resident pronounced dead at 0120 (1:20 AM). There was no evidence staff initiated CPR. b. Review of an Investigator's Interview Statement of Event, signed by the DON and dated [DATE], showed CNA #1 was interviewed by the facility, and described the event. The CNA told the facility she had answered the resident's call light and had started to help him/her when she was called to assist another CN[NAME] Upon returning to the resident's room ,[DATE] minutes later she found the resident unresponsive and attempted to rouse (him/her) with no response. The CNA then ran out of the room to go find the nurse. Ran up and down halls calling out for nurse and couldn't find her. Finally found her in the bathroom. Nurse finished up going to the bathroom and than (sic) went down to (the resident's) room. (The resident) was unresponsive when CNA found (him/her) + 15 min/20 min later the nurse went to the room (By the time CNA tried to arouse (him/her) and find the nurse). c. Review of an Investigator's Interview Statement of Event signed by the DON and dated [DATE], showed RN #1 was interviewed by the facility and described the event. She told the facility the CNA looked for me and I was in the restroom. Further review showed the nurse went to the resident's room to check the resident's status and noted color changes, no heartbeat, no lung sounds, was unresponsive, and was not warm to the touch. The nurse stated she immediately called the physician. In addition, RN #1 recalled receiving POLST education, however she had misunderstood the parameters with following through with the POLST. d. Review of the medical record and the investigation documentation provided by the facility showed no evidence CNA #1 or RN #1 had used the intercom system to activate Code Blue or made an attempt to contact a nurse on a different floor on [DATE] between 12:55 AM and 1:20 AM. e. Interview with LPN #1 on [DATE] at 6:07 PM revealed she was working on the third floor the night the incident occurred and Code Blue had not been activated. Further, RN #1 had contacted her approximately 30 minutes after the resident had expired, informed her the physician had been notified, orders had been received for transport, and then requested information in regard to where to find mortuary papers. LPN #1 asked the RN about the resident's code status and was informed the resident had been a Full Code; however the resident had expired before interventions had been instigated. The LPN stated she never set eyes on the resident. f. Interview on [DATE] at 2 PM with the DON, administrator, and the corporate district DON confirmed the CNA had not called Code Blue, however the CNA had gone down every hall two times until she found the nurse in the bathroom. Further, the nurse did not check the resident's chart to establish the resident's CPR status until after she had completed her assessment. The DON revealed the investigation had determined it was definitely between 10 and 15 minutes from when the CNA found the resident unresponsive until the nurse arrived in the resident's room. g. Review of the facility's incident report submitted to the State Survey Agency on [DATE] showed the incident was documented as Failure to Provide Services. The report showed the resident had elected to receive CPR in the event of cardiopulmonary arrest, and confirmed the facility failed to initiate CPR. 2. Review of the Advance Directive policy, last updated (MONTH) (YEAR), showed a policy statement of The Center relates information regarding advance directive to each resident and honors each advance directive that is given to it. Review of the Cardiopulmonary Resuscitation policy, last updated (MONTH) (YEAR), showed .CPR is initiated for those residents who: a. Have requested, through advanced directive or POLST/POST, to have CPR initiated when cardiac or respiratory arrest occurs . 3. According to Perry, Potter, and Ostendorf in Nursing Interventions and Clinical Skills, 7th edition, 2020, page 812 .Immediate recognition of [MEDICAL CONDITION] and activation of emergency medical response are critical. Early CPR and recommended health care team-level coordination that switches the provider who performs chest compressions every 2 minutes improves the performance of high-quality CPR (AHA, (YEAR)). 4. According to the American Heart Association Emergency Cardiovascular Care website found at https://eccguidelines.heart.org; (retrieved [DATE]), Part 3: Ethical Issues, Withholding and Withdrawing CPR, Out-of-Hospital [MEDICAL CONDITION] (OHCA), Terminating Resuscitative Efforts in Adult OHCA, BLS out-of-hospital system showed Rescuers who start BLS should continue resuscitation until one of the following occurs: a. Restoration of effective, spontaneous circulation b. Care is transferred to a team providing advanced life support c. The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy d. Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met. 5. Review of the facility's action plan in response to this incident showed the root cause was determined to be: Nursing staff will verbalize how a code status is verified via POLST form and procedure to carry out based upon full code or DNR status. All charts will have current and updated POLST forms in place. 1) Licensed Nurses will verbalize Advanced Directives choice and explanation of full code versus DNR details. Corrective actions taken were provide education to nursing staff in regard to the POLST form, verification of code status before initiation of interventions if resident is unresponsive, full code versus DNR status and procedure to carry out accordingly. In addition, an audit was conducted on [DATE] of current resident's charts to ensure the POLST forms were complete. Monitoring included weekly random audits for nursing staff for 4 weeks on identification of how to verify code status and initiate a code status according to the policy and procedure. a Interview on [DATE] at 3:05 PM with the staff development coordinator (SDC) revealed she had educated the licensed nurses on [DATE] following the incident. Review of an Inservice Education Summary form dated [DATE] showed 26 nurses (RNs and LPNs) had received training on the topic of POLST/CPR/Full code protocol. b. Review of the facility's audit documentation showed 26 licensed nurses responded accurately to facility interviews regarding the facility's POLST/CPR/Full Code protocol. c. Review of the facility's audit documentation showed the audit of all current resident charts for completed POLST forms was concluded on [DATE].

Based on medical record review, staff, family, and hospital case manager interviews, and policy and procedure review, the facility failed to ensure physician orders [REDACTED].#113) who had a significant change in condition. This failure resulted in delayed treatment and further decline in condition that required transport to the emergency room . In addition, the facility failed to ensure effective pain management for 1 of 7 sample residents (#114) who were assessed as needing pain management to help maintain his/her highest practicable level of well-being. This failure resulted in a decline in health status and inability to participate in activities and bedside therapy. The findings were: 1. Review of the medical record for resident #113 showed an admission date of [DATE] with a discharge date of [DATE]. The resident had [DIAGNOSES REDACTED]. The following concerns were identified: a. An interdisciplinary progress note dated 2/19/17 and timed 12:30 AM noted the resident had a pulse of 89 beats per minute (bpm), an oxygen saturation level of 86%, and expiratory wheeze noted in RLL (right lower lung) and LLL (left lower lung), more significant wheeze in LLL. Audible crackles without stethoscope (sic). Resident displays/reports no SOB (shortness of breath). Asked resident to deep breathe and cough multiple times. Resident attempted each time but struggled to produce a productive cough. Resident is in no acute distress .left resident in bed in the lowest position, to go back to sleep. Will continue to monitor. Further review of progress notes showed the next entry was dated three days later, on 2/22/17 and timed 2 PM, and showed the resident was started on [MEDICATION NAME] (an inhalation solution that dilates lung cells) every 6 hours for 5 days and [MEDICATION NAME] (an antibiotic) for 5 days with a [DIAGNOSES REDACTED]. No evidence was provided to show the resident was assessed during the three days between progress notes, or that the resident's signs/symptoms were addressed prior to 2/22/17. b. Review of an SBAR communication form showed the medical doctor was notified of the resident's condition on 2/19/17 at 4:15 AM by fax. A faxed response dated 2/20/17 showed an order for [REDACTED]. c. Review of a progress note, dated 2/23/17 and timed 3:45 PM showed the resident had a pulse of 131 bpm and temperature of 101.1 Fahrenheit (F). d. Review of the progress note dated 2/24/17 and timed at 4 AM showed the resident had a pulse of 124, temperature of 101.6 F and oxygen saturation of 87% on 3L (liters of oxygen). The note showed the resident was short of breath and sweating. The note further showed the doctor had contacted the facility, and thought the resident may have had pneumonia and may have been going septic, and ordered for the resident to be transferred to the hospital for evaluation and treatment. The resident was transferred to the emergency department on 2/24/17. e. Interview on 10/4/17 at 3:02 PM with the DON revealed the facility had reviewed the charting and assessments for resident #113 and confirmed it was not sufficient. The DON stated the nurse who had made the progress note entry on 2/19/17 was new and had not placed the resident on alert charting for follow up from her assessment. The facility provided education to staff on 3/8/17 regarding charting requirements. f. Review of inservice education attendance sheets dated 3/8/17 indicated education was provided to staff which included 24 hour documentation. Handouts included the facility policy for Alert Charting Guidelines which stated the following for upper and lower respiratory infections: Alert charting Q (every) shift until condition improves or resolves. Vital Signs Q shift - Allow to sleep on 3rd shift unless condition warrants interruption. Lung sounds Q shift or as condition warrants. Characteristics of sputum. Activity tolerance. Oxygen use, Oxygen saturation. Dietary tolerance, fluid intake. For exacerbation of cardiac/respiratory condition, the guideline stated Alert charting Q shift. VS Q shift. Heart & lung sounds. Circulatory changes, [MEDICAL CONDITION]. Daily weight. Activity tolerance. Oxygen use, oxygen saturations. medications: [REDACTED] 2. Review of the medical record showed resident #114 was admitted from the hospital on [DATE] and [DIAGNOSES REDACTED]. Further review showed at the hospital the resident's pain was effectively managed with a [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] (all are medications for pain). Review of the nursing admission assessment revealed the resident did not have cognitive impairment and required assistance with toileting and transfers. This review also revealed the resident had constant pain in his/her lower back. Review of the physician admission orders [REDACTED]. Review of nursing notes dated 8/30/17 showed the resident received a neuromuscular block injection in the lumbar area of the spine. According to the nursing notes the resident reported the procedure greatly improved the pain, but s/he continued to need the [MEDICATION NAME] pain medication every 4 hours. Review of the physician orders, dated 8/31/17, showed an order to apply a [MEDICATION NAME] to the lower back each day for lumbar stenosis pain. The following concerns were identified regarding ineffective pain management: a. Review of the narcotic book sign out sheet for the resident showed after receiving the daily [MEDICATION NAME] the resident continued to need [MEDICATION NAME] for pain. This review revealed 25 doses of [MEDICATION NAME] were administered after the [MEDICATION NAME] was started on 8/31/17 and before the facility obtained an order for [REDACTED]. b. Review of the nursing assessments before and after administering the pain medication showed the medication was effective only for a short time. Interview with LPN #1 on 10/4/17 at 3 PM revealed the resident had a lot of pain and it was never completely controlled. The LPN stated the resident was unable to participate in a lot of activities and bedside therapy due to the pain. He further stated it was difficult to get the physician to prescribe additional medications. c. Interview with the hospital case manager on 10/9/17 at 9:10 AM revealed she visited the resident at the hospital prior to the transfer to the nursing home and was concerned when she saw the resident at the nursing home on 9/5/17 because there was a noticeable decline in health status and the resident complained of severe back pain. d. Interview with the family on 10/10/17 at 5:45 PM and again on 10/13/17 at 9:50 AM revealed the family visited 1 to 2 times daily and verbalized their concerns about the resident's pain to the nursing staff. During the interview the family member described the resident's pain as s/he was always hurting and the resident remained in bed most of the time due to the pain. e. Review of the admission and nutrition hydration status care plans, developed on 8/24/17, showed pain was an identified problem, but there were no documented interventions for this problem. The facility was unable to provide evidence of an individualized plan for managing the resident's pain, an initial pain assessment to establish desirable goals, and evaluation of this effectiveness of non-pharmacological approaches. f. Interview with the DON on 10/4/17 at 10:30 AM revealed staff talked with the physician about the resident's pain, but the physician was reluctant to prescribe different medications. Review of the documentation provided by the facility revealed the nursing staff contacted the physician on 8/31/17 and 9/5/17 to report the pain medication was not effective. This review also revealed additional efforts to report the ineffective pain management to the physician and/or request for involvement from other practitioners were lacking g. Review of hospital records showed the resident was admitted on [DATE]. Review of the hospital physicians progress note dated 9/11/17, revealed the resident had a lumbar burst fracture with retropulsion causing severe canal stenosis and impinging conus. h. Review of Pain Management Policy -495, updated June 2016, showed the following procedures were included in the measures for effective pain management: When pain is not adequately controlled by current regiment, l, or if there is newly identified pain, the Licensed Nurse (LN) contacts the physician for consideration of new or modified treatment orders. The information on the Pain Evaluation Record is used in conjunction with the Center's other evaluation and data collection tools to develop an individualized care plan including non-pharmacological interventions, if appropriate.

Based on observation, medical record review, staff interview, and review of policy and procedures, the facility failed to ensure 1 of 3 (#15) residents with constipation received appropriate care and treatment. This failure resulted in hospitalization and actual harm to the resident. In addition, the facility failed to provide timely assessments for 1 of 13 sample residents (#6) with falls. The findings were: 1. Review of the 7/25/16 annual MDS assessment showed resident #15 had [DIAGNOSES REDACTED]. Additionally, the resident required total assistance of 1 or more persons for toileting, was always incontinent of bowel and bladder, did not have a toileting program, and did not have constipation present. Review of the July 2016 Medication Administration Record [REDACTED]. Further, the resident received [MEDICATION NAME] (anti-depressant) 10 mg by mouth every day. The following concerns were identified: a. Review of the Resident Functional Performance Record for July 2016 showed the resident had a large bowel movement documented on 7/26/16. This was the only recorded bowel movement on this document for 13 days between 7/20/16 and 8/1/16. b. Review of the MAR for July 2016 showed the resident had an order for [REDACTED]. c. Review of a nurse's note dated 7/25/16 and timed 10 PM showed the resident yelled out in pain after being put to bed. Further, the note showed the resident stated My rectum hurts while having a bowel movement. d. Review of a nurse's note dated 7/26/16 and timed 6 PM showed the physician was notified because the resident kept complaining of rectal pain and was yelling out a lot. Further, the note showed the resident stated (s/he) yells sometimes for attention and (s/he) would yell even when someone wasn't touching (him/her). The facility received an order for [REDACTED]. e. Review of a nurse's note dated 7/28/16 and timed 12:45 AM showed the resident continues to cry out when turned or care given off and on. f. Review of a nurse's note dated 7/29/16 and timed 3:30 AM showed the resident yells out in pain during incontinence care. g. Review of a nurse's note dated 7/30/16 and untimed showed the resident still yells out a lot. h. Review of a nurse's note dated 7/31/16 and timed 3 PM showed the resident continues to yell out after pain medications were administered. i. Review of a nurse's note date 8/1/16 and timed 2 PM showed the physician was notified of staff and family's pain concerns. Further, the note indicated the resident was transported to the emergency department by ambulance at 1:55 PM. j. Review of the hospital discharge summary dated 8/4/16 and timed 3:19 PM showed the resident had an ileus, and obstipation (severe or complete constipation) was identified on a computed tomography scan from the emergency room . Further, the resident was not able to receive manual disempaction (removal of stool) due to the stool being high up in the rectal vault. k. Review of a nurse's note dated 8/4/16 and timed 5:45 PM showed the resident returned from the hospital with a [DIAGNOSES REDACTED]. l. Review of the Resident Functional Performance Record for August 2016 showed the resident had no bowel movement charted for 5 days from 8/9 through 8/13, 3 days from 8/17 through 8/19, and 4 days from 8/23 through 8/26/2016. Review of the MAR for August 2016 showed there was no evidence the bowel protocol was implemented when the resident had no documented bowel movement for more than 3 days. m. Review of the policy title Bowel Protocol last updated July 2014 showed .1. Each resident is placed on a daily bowel monitoring program. 2. For residents at risk for constipation/fecal impaction, the following care plan interventions are implemented: a. Initiate hydration program. b. Increase fiber in diet (refer to the diet manual for details). c. Increase exercise and physical activity (restorative and/or activities). d. Initiate a toileting/retraining program. e. Administer stool softener per physician order. 3. The licensed nurse reviews the bowel monitors daily. 4. If a resident does not have a bowel movement for 3 days administer Milk of Magnesia per physician order on day 4. 5. If Milk of Magnesia offers no results, administer a stimulant laxative suppository ([MEDICATION NAME], etc.) per physician order on day 5. 6. If resident continues to have no results from suppository, administer an enema within 4-6 hours of receiving suppository. 7. If no results from enema, notify physician. n. Interview with the DON on 9/9/16 at 3 PM revealed nurses should have implemented the facility's bowel protocol for residents without a bowel movement for 3 days or more to prevent impaction. 2. Review of the 7/19/16 admission MDS assessment showed resident #6 had [DIAGNOSES REDACTED]. Additionally, the resident required supervision for transfers, bed mobility, and toilet use. The following concerns were identified: a. Continuous observation on 9/6/16 between 4:05 PM and 5:18 PM showed the resident was in his/her room kneeling on a pillow that was positioned on the floor. The resident was leaned back against the footrest of the recliner which was pushed nearly to a closed position. CNA #1 observed the resident on the floor and asked the resident if s/he was okay and turned on the call light to notify the nurse. LPN #1 entered the resident's room where she was informed by the CNA that she knew the resident was not to be moved and she needed to get help. The LPN stated at that time, It wasn't really a fall. Further, the LPN and CNA assisted the resident off the floor by placing their hands under the resident's arms and lifting him/her to a standing position. The CNA then assisted the resident to the restroom with a walker; however, a gait belt was not used. After using the restroom, the resident was assisted to ambulate to the dining room. After the resident was found kneeling on the floor, there were no vital signs obtained and no neurological or physical assessment completed on the resident. b. Review of an interdisciplinary progress note dated 9/6/16 and timed 5 PM showed (resident's name) attempted to get out of (his/her) reclyner (sic) this afternoon-(s/he) scooted to the ft (foot) rest when staff noted (him/her)- Pt (patient) ed (education) given on call light use . c. Review of an interdisciplinary progress note dated 9/7/16 at 1 AM showed the resident had increased confusion and was assisted to bed with his/her walker. d. Review of an interdisciplinary progress note dated 9/7/16 at 7:50 PM showed the physician was notified to follow up on abnormal lab values. The facility received an order to send the resident to the emergency room for evaluation and treatment. e. Interview with the DON on 9/9/16 at 11:43 AM revealed the RAI manual version 3.0 was the facility's reference for the definition of a fall. f. Review of the CMS Resident Assessment Instrument (RAI) manual version 3.0 showed a fall as an .Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g. onto a bed, chair, or bedside mat) . g. Review of the facility policy titled Fall Evaluation and Management updated January 2016 showed .Post-Fall Documentation: 1. The center utilizes the Fall Scene Investigation Report to assist with post-fall evaluation. 2. After the resident has been evaluated and cared for, the licensed nurse: a. Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. b. The nurse completes orthostatic vital signs as listed above. c. The nurse completes a blood glucose reading at the time of the fall (only if diagnosed diabetic). d. Updates the care plan with newly identified interventions, as needed f. Alerts following shifts to fall and care plan/care directive changes per protocol. g. Resident is monitored for 72 hours post fall. h. Follows up with the physician and responsible party, as needed, to provide updates. i. Continues to follow the resident every shift for the next 72 hours, documents findings and resident condition in the Nurse's Notes .

Based on medical record review, staff interview, and policy review, the facility failed to ensure necessary treatment and services to promote healing were provided for 1 of 2 sample residents (#31) with pressure ulcers. This failure resulted in harm for resident #31. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #31 had [DIAGNOSES REDACTED]. Continued review showed the resident required extensive assistance of 2 or more persons for bed mobility, transfers and toilet use, and was at risk for skin breakdown. Review of the care plan for skin integrity impairment, not dated and printed on 2/3/16, showed the resident had an open pressure wound on his/her left heal that required daily dressing change. The following concerns were identified: a. Review of weekly skin evaluation sheets between 12/2/15 and 1/25/16 showed resident #31 had a 3 centimeter area that was pink/beefy red with serous (typically pale yellow and transparent fluid) drainage that was not staged on 12/2/15. The wound was evaluated again on 12/9/15 and described as an open blister and measured 2 centimeters by 5 centimeters. There was no weekly documentation between 12/9/15 and 1/1/16. The 1/1/16 assessment showed the area was not staged, was normal for skin, and measured 3 centimeters by 3 centimeters with serousanguinous (containing or relating to both blood and the liquid part of blood) drainage. The 1/5/16 assessment showed the area was a L.(left) heel blister and remained 3 centimeters by 3 centimeters with no drainage. Review of the 1/12/16 and 1/20/16 assessments showed the area remained unchanged. Review of the 1/25/16 assessment showed the area was a Stage III pressure ulcer and measured 3.5 centimeters by 5 centimeters by .3 centimeters. b. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. c. Review of a Physician Fax Orders Form dated 1/1/16 showed the resident's left heel where previous blister from 12/2 has reopened. The physician order [REDACTED]. d. Review of the treatment administration record for January 2016 showed the resident was to receive [MEDICATION NAME] to the left heel daily; however, the resident did not receive the treatment on 1/23/16 or 1/24/16. e. Review of a progress note dated 1/25/16 and time 5:45 PM showed dressing chg (sic) to left heel not completed on 1/23/16 or 1/24/16. Wound blister now opened. f. Review of a Nutrition Hydration Skin committee review dated 1/27/16 showed res (resident) wound to L (left) heel went from a fluid filled blister with clear fluid. Wound then deteriorated. presented as a stage III. 2. Interview with the DON and unit manager on 2/5/16 at 11:35 AM confirmed there were missed assessments between 12/9/16 and 1/1/16, the order dated 1/1/16 was not signed by a nurse or physician, and the wound deteriorated as a result of missed treatments on 1/23/16 and 1/24/16. 3. Review of the skin integrity policy updated July 2014 showed .7. Upon discovery of newly identified skin impairment (abrasion, bruise, burn excoriation, pressure sore, rash, skin tear, surgical wound, etc.), the LN (licensed nurse) completes the following: Documents skin impairment that includes measurements of size, color, presence of odor, exudates, and presence of pain associated with the skin impairment in Nurse's Notes and on the Weekly Wound Evaluation .Evaluates environment, mobility equipment, functional and cognitive ability, medications, and labs to identify interventions to promote healing/resolution of skin impairment. Implements interventions and document on the resident's care plan and Care Directive .10. Weekly Wound Rounds are to be completed by a team consisting of the DNS and Resident Care Manager's (RCM's) designee. Arterial, Pressure, Stasis, Venous Ulcers, significant surgical wounds, [MEDICAL CONDITION] evaluated, measured, and documented on the wound evaluation. This evaluation includes pain associated with the wound during wound care. If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the Physician and Resident's Responsible party are notified .

Based on observation, medical record review, staff, resident and family interview, review of fall documentation, and review of facility policy and procedure, the facility failed to ensure effective supervision and interventions were implemented to prevent falls for 3 of 9 sample residents (#24, #70, #89). As a result, serious avoidable injuries occurred to sample resident #89 and the potential for serious injury occurred with resident #24. In addition, a determination of immediate jeopardy was made for 1 of 9 observed sample residents (#24) with preventative measures not consistently utilized, and 1 resident (#89) who required direct staff supervision to prevent falls. The findings were: 1. Review of the medical record showed resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] and the annual MDS assessment dated [DATE] identified the resident as being at risk for falls. The quarterly MDS assessment dated [DATE] also showed the resident had experience 2 or more falls since the previous assessment had been completed. Review of the CAA dated 7/11/14 showed the resident was at risk for falls due to decreased mobility, incontinence, dementia, disease processes, pain, medications, and history of prior falls. Review of the care plan updated on 5/19/14 identified the resident as being at risk for falls secondary to decreased mobility, decreased cognition, and history of falls, incontinence, Huntington's chorea, pain and medications. Dated interventions included encouraging the resident to request assistance as needed (7/5/13), tab alarm when in wheelchair (7/5/13), educate/remind him/her to request assistance prior to transferring (7/16/13), monitor medication side effects and report to physician (7/16/13), refer physical therapy to evaluate and treat as needed (7/16/13), half side rails X 2 to aid with positioning in bed (10/4/13), bed in low position, alarming pressure pad in bed, gray floor pad and lip mattress (10/18/13). In addition, anti-tip bars and rollbacks were supposed to be applied to wheelchair and maintenance were supposed to check for proper positioning (10/18/13). The most current intervention dated 5/7/14 was placing the resident on the falling star program. Review of the falls documentation from 1/4/14 through 7/30/14 showed the resident had experienced unwitnessed falls on 1/18/14, 5/7/14, 5/13/14, 6/7/14, and 7/24/14. Review of the fall dated 1/18/14 revealed the resident had been transported to the emergency department for evaluation. Review of a physician's progress note dated 3/18/14 showed "recommendations - Always have a medical assistant accompany the patient for office visits. Pt (patient) suffers from dementia, agitation, and is prone to falls!" The following concerns were identified: a. Observation on 7/30/14 at 11:30 AM revealed the resident was seated in his/her wheelchair beside the low bed. The resident's tab alarm clothing clip was clipped to the cord and the unit was turned off. Also, there was no pressure pad alarm in the wheelchair. The resident self-transferred from the wheelchair to the low bed using unsteady, jerky movements. LPN #4 was notified and verified the resident should have had the tab alarm clipped to his/her shirt and a pressure pad alarm in the wheelchair. LPN #4 was unaware the tab alarm was not turned on or in place, and stated the resident "probably took the (tab) alarm off." Interview at the time of the observation revealed nursing staff were responsible for making sure fall prevention interventions were in place on each shift. However, restorative was supposed to check alarms to ensure batteries were replaced and the alarms were working properly weekly. She also revealed CNAs were responsible for making sure alarms were in place when they assisted residents with ADLs. b. Review of fall documentation revealed findings of the unwitnessed fall on 5/7/14 included the resident had removed the tab alarm monitor from his/her shirt. In addition, the resident's wheelchair was supposed to have been equipped with anti-tippers, which were not in place, and anti-rollbacks, which did not touch the floor (anti-tippers prevent the wheelchair from flipping over, and anti-rollbacks prevent the wheelchair from rolling back if their rubber-tipped stoppers contact floor surfaces). The anti-tippers and anti-rollback devices had been implemented as fall prevention measures on 10/18/13. c. Interview with the restorative CNA on 7/30/14 at 3 PM showed the restorative nursing department staff were responsible for checking resident alarms to ensure they were in place and functioning properly daily. However, the last time the alarms were checked was on 6/29/14 because she was required to work the floor instead. The interview further revealed the restorative nursing program had been without a supervising nurse for the last month, since the previous supervisor resigned. In addition, she revealed residents were not receiving restorative exercises or showers, and several residents who had previously received restorative exercises had experienced an increased number of falls. The CNA verified there were 3 notebooks which contained documentation for the restorative program and daily alarm documentation that were located in the restorative nursing office. However, when the CNA went to retrieve the notebook containing the daily alarm check documentation, the notebook was "missing." d. Interview with the DON on 7/30/14 at 6:55 PM verified facility staff were aware the resident often removed his/her tab alarm. She also verified the tab alarm continued to be utilized as a preventative fall intervention for the resident and should have been attached to his/her clothing and turned on. e. Review of the fall care plan initiated on 7/16/13 identified the resident as being at risk for falling, however, the resident was not placed on the falling star program until 5/7/14. The care plan further showed no new fall prevention interventions were initiated after 5/7/14. 2. Observation of resident #89 on 7/28/14 showed a periorbital hematoma (a black eye) on the right side. Review of progress notes showed in the month of July, 2014 the resident suffered falls on 7/3/14, 7/5/14, 7/7/14, 7/12/14, and 7/30/14. Review of the resident's care plan for falls, last revised on 5/2/14, showed the resident did not like alarms, and would "cut them up if they were placed for safety." Review of a physician telephone order dated 7/10/14 showed an order to "DC (discontinue) alarms r/t (related to) resident cutting alarms. Start 15 minute checks reevaluate on 7/14/14 with IDT (interdisciplinary team) team." Review of a progress note dated 7/14/14, timed 4:01 PM, revealed "IDT NOTE FOR FALLS - ...Continues Q (every) 15 min. (minute) checks." Interview with LPN #2 on 7/30/14 at 10:50 AM revealed safety checks were the nurse's responsibility, and were not delegated to CNAs. The following concerns were identified: a. Review of Resident Monitoring Tool forms showed incomplete or missing documentation of safety checks. On 7/10/14, there was no documentation indicating that safety checks were performed between 5:15 PM and 7:45 PM. b. On 7/11/14, there was no documentation indicating that safety checks were performed between 10:45 PM and 11:45 AM. c. On 7/12/14, there was no documentation indicating that any safety checks were performed during the entire day until the resident fell at approximately 10:15 PM, at which time the resident was found on the floor in his/her room. Progress notes dated 7/12/14, timed 11:25 PM, showed "Beginning of shift resident seen in bed watching tv @ (at) 2215 (10:15 PM) cna got this nurse, entered room to find resident on floor lying right side by bed. When asked if anything hurts states my head. Resident has bruise right forehead with raised lump. Sm (small) abrasion right cheek from eyeglasses which broke (frame)..." d. On 7/13/14, there was no documentation indicating that safety checks were performed between 3:15 PM and 9:45 PM. e. On 7/14/14, there was no documentation indicating that safety checks were performed between 2:30 PM and 9:45 PM. f. On 7/18/14, there was no documentation indicating that safety checks were performed between 6:15 AM and 1:45 PM. g. On 7/19/14, there was no documentation indicating that safety checks were performed between 6 AM and 1:45 PM. h. On 7/20/14, there was no documentation indicating that safety checks were performed between 6 AM and 9:45 PM. i. From 7/22/14 to 7/26/14, there was no documentation of safety checks at all. j. From 7/28/14 through 7/29/14, there was no documentation of safety checks at all. k. Documentation of safety checks began again on 7/30/14 at 12 AM. Review of progress notes dated 7/30/14, timed at 12:29 AM, revealed "Seen in bed at 2330 (11:30 PM) remains on Q (every) 15 min (minute) safety checks. At 11:45 AM CNA called this nurse to room resident on floor lying on right side. Resident alert states head hurt. Body audit reveals blood and laceration 1.5 cm posterior left head...Sent to (hospital) ER (emergency room ) via emergent ambulance at 0015 (12:15 AM)." l. An interview with the DON on 7/30/14 at 11:25 AM, she confirmed there had been no safety checks done on the resident the evening prior to the fall with injury on 7/29/14, stating, "There are no 15 minute safety checks from yesterday because (s/he) was fine." 3. Review of the medical record showed resident #70 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively impaired, made poor decisions, required cues and supervision, and had impaired communication. The resident was also identified as requiring extensive assistance from staff for wheelchair mobility, and had experienced 2 or more falls since the prior MDS assessment. Review of the care plan updated 7/23/14 showed s/he was at risk for falls related to confusion/dementia, poor communication, decreased mobility, incontinence, diminished safety awareness and a history of falls. Dated interventions included using bedside impact absorbing floor mat while in bed (5/23/12), lipped mattress (5/23/12), bed and chair alarm (5/23/12), using a mechanical lift for transfers (6/21/12), therapy screen for wheelchair positioning (6/11/14), wheelchair cushion to be replaced with pommel cushion (7/23/14), tilt-space wheelchair in place, cushion with Velcro to prevent sliding (7/23/14). Review of falls documentation additionally revealed the resident experience an unwitnessed fall on 7/12/14 and a witnessed fall on 7/18/14, however, no IDT post-fall follow-up was documented for either incident until 7/23/14, at which time the IDT recommended using a pommel cushion in the resident's wheelchair. On 7/29/14 at 5:30 PM the DON provided an order for [REDACTED]. The following concerns were identified: a. Review of fall documentation dated 3/29/14 showed the resident was found on the mat on the floor beside his/her bed. The alarm was turned on, however, the alarm had not been sounding and the batteries had to be replaced. b. Observations on 7/28/14 at 9:40 AM and 3 PM, and 7/29/14 at 4:20 PM revealed the resident was asleep in a low bed, and the gray mat was rolled up and leaning against the footboard of the resident's bed, instead of being on the floor beside the bed. c. Review of the physical therapy note dated 6/11/14 showed the "resident's positioning in wheelchair assessed, properly positioned, wheelchair and cushion are appropriate ...staff education ongoing. " Review of a staff training documentation form with the same date showed 4 staff members were educated on wheelchair positioning (2 LPNs and 2 CNAs). d. Interviews with CNA #11 and CNA #12 on 7/29/14 at 5 PM revealed they did not recall any in-services related to positioning the resident properly in his/her wheelchair. CNA #11 stated, "(the resident) has had several wheelchairs over the past couple of months but we've never had any in-services, and some of them have been difficult to figure out, one of them the brakes were in a different place." e. Review of nursing documentation dated 7/11/14 revealed the resident was observed sliding out of his/her wheelchair " 8 " times and required staff intervention to prevent falling. Additional nursing notes showed physical therapy was not notified until 7/16/14 when the resident was again observed sliding out of his/her wheelchair and staff had to intervene to prevent the resident from falling. No documentation was made available to show the resident had been referred to and evaluated by physical therapy. Additionally there was no documentation relating to the various types of wheelchairs until a nursing note dated 7/29/14 indicated the resident was currently utilizing a tilt in space wheelchair which reclined in an attempt to reduce the risk of the resident falling forward and sliding out of the wheelchair. Review of the care plan did not reflect the wheelchair changes. f. Interview with PTA #1, who also acts as the rehabilitation director, on 7/31/14 at 1:30 PM revealed not all facility staff were in serviced on positioning the resident in his/her wheelchair, usually several staff members were educated, then they educated other staff during shift report when on shift went off duty and another shift came on duty. She also revealed she had evaluated the resident several times and several different types of wheelchairs had been used to improve the resident's posture and reduce sliding from the wheelchair. She further disclosed she did not document every time she performed a physical therapy screening assessment for residents. No additional documentation was made available related to physical therapy screening and recommending different types of wheelchairs or staff education related to the operation and positioning of the resident in the different wheelchairs. On 7/30/14 at 3:05 PM the acting administrator was notified of the immediate jeopardy. The facility's plan showed immediate changes as follow: a. Staff education was performed by professional licensed staff for proper application and placement of fall intervention equipment prior to starting on shift. b. 100% audit by floor of all 216 safety devices to validate placement in accordance with physician orders. c. Reassessment of Morse Fall risk initiated for 100% of the 18 high-risk residents based on falls in the last 30 days. d. Interview of floor staff on monitoring safety devices/equipment throughout the day. e. Assessment completed on the resident in immediate jeopardy, with no adverse outcome. Further, the facility validated the resident had physician ordered safety devices in place. The action plan was accepted on 7/30/14 at 9:27 PM and the immediate jeopardy was removed at that time. However, the deficient practice remained at a level G.

Based on resident and staff interview, medical record review, and facility policy review, the facility lacked evidence nursing staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate pain management for 4 of 8 sample residents (#25, #33, #58, #106) who had pain or discomfort and for prevention of skin breakdown for 1 sample resident (#107). In addition, the facility failed to ensure the regimen was followed as ordered by the physician for 1 of 2 sample resident (#73) who were on insulin for management of their diabetes mellitus. Finally, the facility failed to ensure 1 of 2 sample residents (#105) with respiratory problems had their needs addressed. The results of these system failures resulted in harm to these residents. The findings were: In regard to pain management: 1. Review of the medical record showed resident #58 was noted to have a red raised rash on the left side of his/her upper back on 7/1/14. The physician ordered [MEDICATION NAME] 1 mg three times per day for five days on 7/1/14 for a [DIAGNOSES REDACTED]. Pain often develops and persists for months after resolution of the rash. "This discomfort, which may be severe in patients older than 50, is known as postherpertic neuralgia...and may intensify at night or worsen when clothes rub against the skin." Further, medications such as [MEDICATION NAME] "...are effective in reducing [MEDICAL CONDITION] shedding and nerve pain damage if administered within 3 days of onset of the rash." However, review of the July 2014 MAR for this resident showed s/he did not receive the first dose until the end of the day on 7/3/14, day three after the onset of the rash, because it was "not available from pharmacy." Review of the July 2014 MAR indicated [REDACTED]. On the 6 AM to 2 PM shift on 7/4/14 the resident's pain was noted to be 5/10. Review of the 6/7/14 quarterly MDS assessment showed the resident had pain on 1 to 2 days during the 7 day look back period of assessment. Further review of the July 2014 MAR indicated [REDACTED]. Interview with the DON on 8/1/14 at 12:30 PM revealed the facility should have been able to obtain a back up supply from another pharmacy and was unsure why that did not happen. 2. Review of the physical therapy plan of care (POC) with a 7/26/14 start of care date showed resident #25 had [DIAGNOSES REDACTED]. Further, the POC showed the resident needed the therapy to reduce pain, improve body mechanics and increase strength and activity tolerance. Review of the July 2014 MAR indicated [REDACTED]. Review of the care plan for pain, initiated on 7/26/14, showed the resident's acceptable pain level was 3-4 on a scale of 0-10 with 10 being at the highest level of discomfort. The following concerns were identified: a. Review of the care plan showed the facility was to assess the resident's pain each shift, record results and any interventions taken. The July 2014 MAR indicated [REDACTED]. The resident reported a pain level of 5 or greater 5 of 14 times or 36%. Review of the nurses notes for those days with reported pain did not indicate the pain was addressed to include any interventions. b. The care plan for pain showed the facility staff was to assess and document the resident's pain to include location, duration, quality, aggravating/alleviating factors and intensity. Review of the MAR indicated [REDACTED]. It did not indicate what his/her pain level was at the time the medication was administered, the location of the pain or any aggravating/alleviating factors. It only showed s/he had muscle spasms and that the medication was effective. Review of the pain assessment documentation completed each shift on 7/26/14 showed the resident reported a pain level of 10 during the 6 AM through 2 PM shift only. The remaining two shifts indicated the pain level was within his/her acceptable range. c. Review of the physical therapy note dated 7/30/14 and timed 9:21 AM showed the resident reported severe back pain with a pain level of 10 out of 10. Further, s/he requested to hold the therapy. The therapist assistant noted the nurse was informed. Review of the nurses' notes did not indicate the pain was addressed or the physician notified. d. An interview with the resident on 7/30/14 at 5:45 PM, revealed she received a routine dose of [MEDICATION NAME] every 6 hours and the medication only lasted 3 hours. S/he reported his/her pain level would increase to 8 out of 10 at that time. Due to the pain, the resident did not participate in activities provided by the facility and could not always complete the prescribed therapy. The resident further indicated other interventions were effective for his/her pain and discussed with the staff but they were not prescribed. e. Review of the pain m onitoring flowsheet for July 2014, received after the survey team exited, showed the routine dose of [MEDICATION NAME] was assessed for effectiveness 5 times between 7/26/14 and 7/3014. The medication was admministered 19 times during that same time frame. 3. Review of the initial wound care examination dated 4/10/14 showed resident #106 had a stage 4 pressure ulcer to the left hip. Review of the treatment administration record (TAR) for June 2014 showed the dressing was to be changed every 3 days. The frequency of the dressing changes went to twice daily on 7/9/14. Review of the June and July MARs showed the resident was to receive the pain medication [MEDICATION NAME] 30 minutes prior to his/her dressing changes. The June MAR indicated [REDACTED]. In July, the TAR documentation showed the resident had 38 dressing changes completed and the medication record showed s/he only received the pain medication 2 times. There was no documentation to show the resident refused the medication. Review of the 7/8/14 physician orders for the change in wound care did not indicate the pain medication was discontinued. 4. Review of the 7/25/14 admission MDS assessment showed resident #33 had [DIAGNOSES REDACTED]. Review of the June 2014 MAR indicated [REDACTED]. Further, the resident's acceptable pain level was 0 on a scale of 0 through 10 with 10 being the highest level of pain. The pain assessment completed each 8 hour shift showed the resident had a pain level greater than his/her acceptable level 16 times. Fifteen of the pains rating were between 6 and 9. Further, the time of the assessment was not recorded and did not include the location of the pain. Review of the Tylenol doses documented as given showed the medication was given 14 times. It did not show the reason the medication was given, the pain rating prior to the dose or the resident's response after it was given. Review of the July 2014 MAR indicated [REDACTED]. Further review showed Tylenol was given 4 times. It did not show the reason the medication was given, the pain rating before or after it was given. Review of the nurses' notes showed Tylenol was given for a headache but pain ratings and assessments were not consistently completed. Review of the policy and procedure for pain management last dated 8/31/13 showed components included: "7. When pain is identified, assessment and documentation includes pain scale rating, location, duration, intensity and character." During an interview with the DON on 8/1/14 at 1:45 PM, she acknowledged the nursing staff needed to give the medication as ordered or indicate why it was not administered. Further, pain medications were to be monitored for their effectiveness. 5. During an interview with the DON on 8/1/14 at 1:45 PM, she acknowledged the nursing staff needed to give the medication as ordered or indicate why it was not administered. Further, pain medications were to be monitored for their effectiveness. In regards to insulin administration: Observation on 7/28/14 at 5:35 PM showed resident #73 (who had a [DIAGNOSES REDACTED].#1. The following concerns were identified: a. Review of the medical record revealed a new physician order dated 7/28/14 at 3 PM to "hold 6 units of [MEDICATION NAME]when BS is < (less than) 70 (mg/dl)", which was not updated on the MAR indicated [REDACTED] b. Review of the facility policy titled Diabetes Mellitus (DM), Guidelines for Management, revealed "the nurse is to compare the results of the blood glucose level with the ranges established by the physician, to notify the physician of blood glucose levels below or above the established ranges and implement any new orders as applicable"; to "monitor (resident) for hypoglycemic episodes (blood sugar results below 70 (mg/dl)) and to notify the physician." c. Interview with LPN #1 on 7/30/14 at 6 PM revealed the expectation for communicating new physician orders is to verbally, and in writing, pass on new physician orders to the next shift; if the nurse who receives the new order is not assigned to the resident, the expectation is to notify the assigned nurse. This was not done at the time the order was received and resulted in the resident receiving insulin when s/he should not have based on physician orders. In regard to skin breakdown: Review of the medical record showed resident #107 was admitted to the facility 2/26/08 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] showed the resident was always incontinent of bowel and bladder. Review of the care plan updated 1/23/14 identified the resident as having the potential for skin integrity related to [MEDICAL CONDITION], decreased mobility, and incontinence. Interventions included staff assessing skin weekly and as needed, apply skin care products to excoriated areas as needed. Review of the treatment administration record showed an order dated 7/29/08 for staff to apply [MEDICATION NAME] (an ointment to prevent and treat skin irritation) to inner thighs as needed, and an order dated 2/9/12 to apply skin protection cream to abdominal and groin folds as needed. The following concerns were identified: a. During an interview with the resident and his/her POA on 7/30/14 at 10:45 AM through 11:20 AM the resident revealed s/he had, "limited feeling below my waist because of the MS but I have a sore on my leg and it hurts, will you look at it". The resident exposed his/her upper right inner thigh and there was an oblong open area that measured approximately 1.5 cm(centimeters) by 3.5 cm by 0.3 cm deep (length, width, and depth). The resident stated, "it's been that way for about a month but it is worse, and I have told the nurses". The resident denied staff apply any ointment or cream to his/her inner thighs during peri-care. The resident opened his/her bedside table drawers and replied, "see there is no cream in here for them to put on it". The resident stated s/he, "tried to show it to the nurse but they were busy and were supposed to come back and look at it but didn't". The resident further expressed s/he, "feel like I have to beg for help and staff ignore me". b. Review of weekly skin checks showed a skin check dated 7/26/14 identified the open area as, "irritation from brief on right thigh. Lotion applied with every change". No measurements or description were recorded. c. This surveyor informed nursing staff of open area on the resident's right upper, inner thigh. Review of a nursing note dated 7/30/14 and timed for 11:10 PM revealed measurements were recorded as 3.6cm by 1.7cm and the wound was a partial thickness wound with red, [MEDICATION NAME] occurring ( no depth was recorded). The physician was notified and wound care was changed and initiated at that time. In regard to respiratory problems: According to the June 2014 MAR, resident #105 received [MEDICATION NAME] inhaler 2 puffs every 4 hours as needed for shortness of breath. This order was written by the physician on 5/20/14. Review of the June 2014 MAR indicated [REDACTED] 6/2/14 at 10:30 AM, on 6/7/14 at 5:30 PM, and on 6/9/14 at 2 PM, however, there was no evidence the resident was re-assessed to determine the effectiveness of the medication in relieving his/her shortness of breath. In addition, review of the June 2014 MAR indicated [REDACTED]. Review of the July 2014 MAR indicated [REDACTED].

Based on observation, medical record review, staff and resident interview and review of fall documentation, the facility failed to ensure effective supervision and interventions were implemented to prevent falls for 7 of 8 sample residents (#51, # 54, # 70,# 71, #72, #74, #75). As a result, serious avoidable injuries occurred to sample residents (# 51, #72 , #75). In additon, a determination of immediate jeopardy was identified for 4 of 6 observed sample residents who were not being provided safe transfers with mechanical lifts (#54, #70, #71, # 74), and 1 of 4 observed residents with alarms not consistently utilized (#72). The findings were: 1. Review of the medical record for resident #72 showed s/he was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident was previously admitted on [DATE], and review of nursing notes showed the resident had a history of [REDACTED]. Review of a fall action plan showed the 3/15/13 fall resulted in a fractured hip that required surgical intervention. This was an unwitnessed fall, and based on the documentation it was not clear as to what interventions were in place at the time of the fall. Review of the fall evaluation showed the 5/21/13 fall resulted in a fractured arm, the intervention at the time of the fall was a bed and chair alarm that was found to be "not turned on." Review of the 9/25/13 fall evaluation showed the resident fell in the bathroom. The fall was unwitnessed and the resident reported s/he was transferring him/herself to the bathroom and the "chair alarm did not sound." The following concerns were identified related to the resident's continued risk for falls: a. Review of the fall care plan showed it was initiated on 1/16/13. The resident was shown to be at risk for falls related to de-conditioning/decreased mobility at times, occasional incontinence, hearing problems, Alzheimer's, use of psychotropic medications, and status [REDACTED]. Encouraging the resident to request assistance in ambulating was added on 3/16/13, and bed side rails times two was added for mobility on 3/20/13. The remainder of the interventions to prevent falls including the use of a bed pressure alarm and wheelchair alarm were developed on 1/16/13 when the care plan was initiated. The care plan failed to show any new or changed interventions to prevent falls after the May, June, July, August and September 2013 falls. b. Observation on 10/3/13 at 10:20 AM with the RN #3 showed the resident was in bed sleeping and the bed pressure alarm was in the off position. The nurse called in CNA #4 at 10:23 AM who verified the resident had been in bed for about 15 minutes and the alarm should have been turned on. The CNA then turned on the alarm. 2. Review of the medical record for resident #70 showed s/he had [DIAGNOSES REDACTED]. The following concerns were identified with the safety of transfers for this resident: a. Observation on 10/2/13 at 2:55 PM showed the resident required extensive assist for transfers. CNA #5 assisted the resident with use of a sit-to-stand lift to transfer from the wheelchair to the toilet. During the observation the resident was noted to be weak and did not have the strength to participate with the mechanical lift transfer with his/her legs or upper body. The resident made comments during the transfer that it hurt under his/her arms, and the resident was noted to be hanging from the lift sling that was used to help support the body. b. Interview with the CNA during the transfer revealed this was the way the resident always transferred with the sit-to-stand lift, and the CNA verified the resident had knee pain and weakness which prevented the resident from being able to participate to the full extent. c. Review of the nursing care plan progress note dated 6/22/13 showed the resident was dependant on staff for all ADLs and required extensive assistance with a mechanical lift for transfers. Review of the 4/11/13 to 4/17/13 physical therapy notes showed the resident was being seen by PT to increase strength and reduce knee pain and was not making good progress with goals. The PT was discontinued on 4/25/13. Review of the 6/14/13 restorative nursing note showed due to complaints of pain with restorative therapy, the resident was not making any progress, and the program was discontinued at that time. d.Review of the medical record showed no evidence the resident was evaluated for use of the sit-to-stand lift for transfers. This resident was identified as having pain and weakness. e. Review of the 7/14/12 care plan showed the resident was at risk for falls due to limited mobility, dementia and weakness. Another care plan problem related to falls was dated 6/29/12 and showed the resident had an actual fall from the bed without injury on 6/29/12. Review of the 7/14/12 care plan for falls showed interventions included use of the sit-to-stand mechanical lift. On 8/22/12 the falling star program was added to the care plan. Further review showed there was nothing added or changed to the residents care plan interventions related to falls or transfers since 8/22/12. 3. Review of the medical record for resident #54 showed s/he was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of a 5/9/13 nursing note showed the resident was being transfered in a sit-to-stand mechanical lift when the resident became unsteady and was lowered to the floor. The resident was transfered back to bed using a Hoyer mechanical lift (full body lift not requiring the resident's strength or support). Review of the 6/20/12 care plan showed the only intervention to address fall prevention was to use the sit-to-stand mechanical lift for transfers. Review of the updated 1/17/13 care plan showed fall interventions included following the fall protocol and reminding the resident to call for assistance. The following concerns were identified: a. No changes or updates were made to the care plan after the 5/9/13 fall. b. Observation on 10/3/13 at 9:55 AM showed CNA #5 was assisting the resident with changing his/her incontinence brief. The resident was up in the sit-to-stand lift and the resident was complaining about the sling hurting under his/her arms. In addition, both of the resident's heels were hanging off of the foot platform, and it appeared as though the resident was supporting him/herself with mimimal strength in the legs. Interview with the resident at that time revealed s/he felt "safe enough, I guess." Interview with the CNA at that time verified the resident's feet should be positioned on the platform and not hanging off. She stated she hadn't noticed until the surveyor asked. c. Review of the medical record showed no evidence a safety assessment was performed to determine the safety and appropriateness of the sit-to-stand mechanical lift for the resident. 4. Review of the medical record showed resident #74 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes showed the resident had a fall on 9/9/13 at 6 PM. Interview with the DNS on 10/4/13 at 9:30 AM revealed the post fall evaluation for this resident's fall was done as a late entry on 10/3/13 due to the recognition that it was initially charted on the wrong resident (#70). Review of the post fall evaluation showed the resident slipped out of the sling while being transferred with a sit-to stand mechanical lift. The fall was in the presence of staff with no injury. Review of the care plan showed the resident was identified as a fall risk on 9/25/12 due to decreased mobility, incontinence, dementia and use of psychotropic medications. The intervention after the 9/9/13 fall from the lift was dated 10/3/13 and showed: "Resident requires to be transferred with sit-to- stand due to limited mobility and high fall risk." The following concerns were identified: a. Review of the medical record failed to show an assessment of the resident's ability to safely transfer with the lift was performed. b. Interview with the unit manager on 10/4/13 at 1 PM verified with the exception of a couple of days after the fall the resident continued to be transferred with the sit-to-stand lift. She then stated as of the morning of 10/4/13 a safety assessment was completed and a new order was received that the resident would use a full Hoyer lift at all times for safe transfers. She was not aware of why a safety assessment was not done or documented after the resident fell from the lift sling. 5. Review of the medical record for resident #71 showed s/he had [DIAGNOSES REDACTED]. Observation on 10/2/13 at 4:05 PM showed CNA #6 assisted the resident using a sit-to-stand mechanical lift to transfer from the bed to the wheelchair. During the transfer the resident was observed to be unable to participate with his/her left side. The resident was unable to hold onto the lift with his/her left arm, it hung at his/her side, the resident wore shoes and his/her feet were appropriately placed on the foot platform. The following concerns were identified: a. Review of a 3/15/13 post fall evaluation showed the resident lost his/her footing and slipped off the equipment and onto the floor while being transferred with a sit-to-stand lift. There was no injury noted, and the conclusion to the evaluation showed a lack of appropriate footwear and technique were contributing factors to the fall. b. Further record review showed on 5/23/13 (two months after the fall) the resident was evaluated by physical therapy and the therapist trained staff on safe transfer technique and the appropriate lift to be used for this resident. Review of this education by the therapist showed the resident required a specific model of sit-to-stand lift and the "flaccid leg and arm" needed to be "protected" during transfer. Interview on 10/4/13 at 12:25 PM with the PT who provided the education revealed the way to protect the residents left arm and leg during the transfer was to have two staff members present when the resident was transferred with the lift. She stated this should be included on the care plan but it was not. c. Review of the resident's care plan related to falls showed it was updated on 10/3/13 with an intervention of ensuring the resident was wearing the appropriate footwear when ambulating or mobilizing in the wheelchair. Further review showed the care plan failed to address the PT's recommendations for the sit-to-stand mechanical lift. 6. Record review for resident #75 showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] showed the resident was severely cognitively impaired, confused, required extensive assistance with ADL's, and had sustained 2 falls since the prior MDS assessment. The CAA showed the resident triggered for falls and a care plan for fall risk should be implemented. Review of physician orders [REDACTED]." The following concerns were identified: a. Review of the nursing notes showed the resident had fallen 4 times since admission on 7/2/13. The resident had an unwitnessed fall on 7/6/13, in which the nurse responded to the bed alarm and found the resident on the floor beside the bed, and no injury was documented. The resident had an unwitnessed fall on 7/7/13; the nurse responded to an alarm and found the resident on the floor. The resident was incontinent of urine, and, "the bed was wet". Review of 2 fall follow-up nursing notes dated 7/8/13 showed the resident had bruises on his/her legs and abdomen and bruised or discolored skin on his/her bilateral arms. Review of a late entry nursing noted dated 7/17/13, showed the resident had, "an unwitnessed fall on 7/16/13 with no injury noted." The resident had attempted to stand and open a drawer. The resident had an unwitnessed fall on 7/24/13 and was transferred to the emergency department where it was identified s/he had sustained a transverse fracture of the first lumbar vertebrae. b. Review of the care plan showed no care plan had been developed that identified the resident as having fallen or being at risk for falls, until the care plan dated 8/12/13 showed the resident had a lumbar fracture of his/her back related to a fall. The goal was the resident would maintain maximum mobility within prescribed restrictions. Interventions were general and included, "administer medication as ordered, allow to perform tasks, and assess and monitor ability to perform ADL's." Alarms were not listed as interventions on the care plan. c. Review of the interdisciplinary team falls review for July 2013 only listed 2 falls for the resident on 7/15/13 and 7/24/13. Recommendations for the fall on 7/15/13 included, "continue with alarms, therapy, and educate staff not to leave alone". The recommended intervention for the fall on 7/24/13 was to add a tabs monitor. The care plan was not updated to reflect the resident's falls until 8/12/13 and none of the recommended interventions were documented. d. Review of the quality assessment and assurance reports identified the resident as having repeated falls. 7. Review of the medical record for resident #51, showed the resident had numerous recurrent re-admissions to the facility. The most current re-admission was 9/24/13 and a complete MDS was not available. The most current complete annual MDS dated [DATE] showed the resident was cognitively intact and able to make decisions independently. The assessment further showed the resident required extensive assistance with ADL's including transferring, and had limited range of motion in both lower extremities. Review of a nursing note dated 6/17/13 showed the resident, "is now a Hoyer lift (a mechanical lift with a sling that required no assistance from the resident) due to (his/her) passing out episode in the sit-to-stand (mechanical lift that assist the resident to sit and stand for transfers)." The care plan revealed the resident was at risk for falls related to decreased mobility, incontinence, obesity, and arthritis. Goals showed the resident's risk for falls with injuries would be minimized over the next 90 days. Interventions dated 6/21/13 showed the resident was supposed to be transferred using a,"Hoyer lift (a mechanical lift with a sling not requiring resident strength/participation)."The following concerns were identified: a. Review of the CNA worksheet last updated 7/9/2013 showed the resident was supposed to be transferred using a Hoyer or mechanical sling lift. b. Review of a post fall evaluation dated 9/11/13 revealed the CNA was transferring the resident with a sit-to-stand lift, when the resident became,"unconscious and limp and was lowered to the floor by staff." Review of the nursing notes from 9/11/13 through 9/16/13 showed the resident complained of increasing pain in the right knee on 9/13/13, at which time the resident's pain medication was increased. While the resident refused to go to the emergency department for evaluation, s/he did agree to go for an x-ray of the right leg on 9/16/13 and was found to have sustained a distal femur spiral fracture above the right knee, at which time s/he was admitted to the hospital. c. Interview with the resident on 10/2/13 at 3 PM revealed s/he was able to recall the events of 9/11/13. The resident stated, "the aide was getting me up with the sit to stand lift and my blood pressure dropped. I became unconscious, fell out of the lift and broke my right leg". The resident was able to recall that staff were supposed to use the mechanical sling lift to transfer him/her because, "I passed out in the sit to stand lift in June." The resident revealed some of the CNA's used the sit-to-stand or the Hoyer lift, "whatever they felt safe using to get me up." The resident also revealed s/he had worsening pain in the right leg but, "did not feel like I could go to the emergency room in the van so they called the ambulance on 9/16/13 to come and get me." The interview also revealed the facility offered to take the resident to the emergency department for evaluation on 9/13/13/ but the resident refused. The resident revealed s/he had opted not to have surgical repair of the leg fracture due to multiple chronic diseases, including [DIAGNOSES REDACTED]. The resident further stated s/he,"a lot of pain and adjustments to pain meds to keep me comfortable." d. Interview with CNA #1 on 10/2/13 at 3:50 PM revealed s/he reviewed the CNA worksheet located at the nursing station to determine the type of assistive devices used to transfer residents. Interview with CNA #2 on 10/2/13 at 4 PM revealed s/he reviewed the CNA worksheet or the care plan book located at the nursing station to determine the type of assistive devices used to transfer residents. Interview with unit manager #1 on 10/2/13 at 4:30 PM revealed CNA's were supposed to check the CNA worksheets located in a file drawer at the nursing station to determine what type of lift to use when transferring residents. e. Interview with the DNS on 10/3/13 at 11:55 AM verified the CNA transferred the resident with the wrong lift on 9/11/13. Interview further revealed the CNA involved was re-educated, however, not all CNA's were re-educated regarding the use of mechanical lifts. The DNS declined a request by the surveyor to review the fall investigations, stating, "they were internal documents". f. Review of the medical record revealed no evidence a transfer assessment had been completed using the sit-to-stand or full sling mechanical lifts. g. Interview with the SDC on 10/3/13 at 10:45 AM revealed CNA's were educated and evaluated about performing safe transfers, including the use of the sit-to-stand and mechanical sling lifts, yearly and as needed on an individual basis. Interview on 10/4/13 at 2:20 PM with the acting administrator, the DNS, and the SDC revealed there was information collected in the QAPI program related to falls. The DNS reported the facility had identified an ongoing problem related to increased numbers of resident falls. The DNS and the acting administrator verified interventions and actions taken by the QAPI committee were tracking the numbers of falls, evaluating when and where they were happening, performing alarm audits, and providing staff education known as the 4 P's. The 4 P's included frequent rounding for pain, "potty needs", positioning, and proper placement of items. In the interview the DNS verified the information gathered over the past 90 days had shown a correlation between less staff and higher fall rates. Many of the falls were identified as occurring on Fridays and the weekends. The information also showed many of the resident's falls were being contributed to self transfers. Review of the monthly QAPI summaries showed in June 2013 there were 28 falls throughout the facility. In July 2013 there were 45 falls; one of which resulted in a fracture. In August 2013 there were 39 falls, and in September 2013 the numbers had not yet been calculated, but the fall logs showed 28 falls listed. One of the September 2013 falls resulted in a fracture. In addition, from October 1 through October 4, 2013 there were 3 falls. Although the June, July, and August 2013 monthly "Falls PI" reports showed staff needed to be educated on the 4 P's, there was nothing documented to show this education was completed. Interview with the SDC on 10/4/13 at 10:20 AM verified staff were provided written information on the 4 P's; however, she had not documented to whom or when the information was provided. The following concerns were identified: a. Interview further revealed the incidence of resident falls related to mechanical lift transfers was not being tracked by the facility. During the survey it was found that 5 residents had falls related to lift transfers, one resulted in a fractured hip in the month of September 2013. Interview with the SDC on 10/4/13 at 10:20 AM verified other than for one CNA who had injured her back, she had not provided any additional training related to safe transfers with lifts. She stated CNAs were checked for competency of performing safe lift transfers at orientation and annually. b. Interview with the DNS, SDC, and acting administrator verified alarm audits were being completed; however, the data was not being reported on. When an alarm was identified to be not on or working, it was immediately corrected by the restorative aide who was performing the audit. Interview with restorative aide #1 on 10/3/13 at 11 AM verified the audits were expected to be done daily. However, she said the audits were not always performed daily because she was required to work the floor instead. She stated there were always multiple alarms that were not on or working when checked. Review of the alarm audits for the past two months showed on the days audits were done, an average of 4 to 6 alarms were identified as not working. c. During the interview the acting administrator stated, "the falling star program is a good program, it just needs to be implemented." On 10/3/13 at 1:25 PM, the acting administrator and DON were notified of the immediate jeopardy. The facility's plan showed immediate changes as follows: a. 100% of residents had been re-evaluated for fall risk and those with sit-to-stand and mechanical lifts had been evaluated by a physical therapist for safety with lift transfers. Any changes had been documented and 100% of nursing staff had been educated prior to their shifts on these changes. b. 100% of high risk fall residents had been re-evaluated by professional licensed staff for appropriate fall interventions which were put into place. c. 100% of residents will be monitored and evaluated daily by direct care and professional licensed staff and any changes in transfers communicated with the DNS and SDC for evaluation and intervention. d. Education was done by professional licensed staff with 100% current nursing staff in the building. Education was conducted on proper transfers and technique, checking safety alarms every shift, and on the facility's policy and procedures for fall assessments and prevention. Competencies on lifts were done with 100% of nursing staff in the building. Specific transfer training with sit-to-stand and mechanical lifts was done by a physical therapist for 100% of residents identified as high risk. Competencies were performed on 100% of nursing staff prior to their next shift. e. 100% of alarms utilized in the facility were audited to ensure all alarms were turned on and functioning properly. The action plan was accepted on 10/4/13 at 1:26 PM, and the immediate jeopardy was removed at that time. However, the scope and severity level will remain an "H". .