Every finding on record at Hallmark Nursing Center

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development of transmission of disease and infection on two of two units.Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequently touched areas (door handles, call lights, bed remote);-Ensure mop pads were changed after mopping the bathroom; and,-Ensure areas were cleaned from cleanest to dirtiest.Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/4/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.II. Facility policy and procedureThe Daily Room Cleaning policy, revised 4/1/26, was provided by the nursing home administrator (NHA) on 6/3/26 at 4:08 p.m. The policy read in pertinent part, The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean and sanitary environment and reduce the potential for nosocomial infections. Clean high-touch surfaces at least daily including handwashing sinks. Clean and disinfect high touch/frequently contaminated surfaces (sinks, faucets, handles, door handles, and clean toilet seat last) at least daily. III. ObservationsOn 6/1/26 at 9:43 a.m. housekeeper (HK) #1 was cleaning room [ROOM NUMBER], a private room. The following was observed:HK #1 donned (put on) gloves and used a blue fluid labeled Oxivir (a disinfectant spray) and sprayed the bathroom sink, counter top, and toilet. She used the toilet brush to clean the inside of the toilet and tapped the toilet brush on the outer rim of the toilet. Wearing the same gloves, HK #1 went to the far side of the room and used the Oxivirr spray and sprayed the window sill and a table. -HK #1 did not change her soiled gloves after cleaning the toilet and went to the far side of the room to spray the window sill and table.HK #1 doffed her gloves, performed hand hygiene and donned on another pair of gloves. She then returned to the bathroom and wiped the sink starting at the bowl of the sink working her way up to the handles and faucet. She then wiped the counter using the same rag. HK #1 then wiped the bathroom hand rails which were visibly dry with a dry rag.-HK #1 failed to clean the bathroom sink from the top to bottom or cleanest area to the dirtiest areas. She failed to use a separate rag to clean the counter top. HK #1 also failed to apply a disinfectant spray to the hand rails or her rag before wiping them down.HK #1 used a dry broom to sweep the room from the far side of the room to the entry way. She went back to the room and used a dry rag to wipe the call light and bed remote. The call light and bed remote were visibly dry prior to HK #1 wiping them down with a dry rag.-HK #1 failed to apply any disinfectant spray on the rag or on the call light or bed remote prior to wiping them down with a dry rag. HK #1 applied a wet mop pad on the mop stick and proceeded to the far end of the room. HK#1 worked her way towards the bathroom mopping the room, she entered the bathroom to mop and came out of the bathroom continued mopping to the entry way and finished in the closet. She used the same mop pad for all areas. -HK #1 failed to change the mop pad for different areas of the room/bathroom. HK #1 said she was done cleaning the residents room at 10:17 a.m. -HK #1 failed to clean the light switches, television remote, room and bathroom door knobs during the observation. On 6/2/26 at 10:29 a.m. HK #2 was cleaning room [ROOM NUMBER], a double occupancy room. The following was observed:HK #2 was observed to clean the bathroom sink starting from the bowl, to the faucet, then the handles and lastly the counter top with the same rag. -HK #2 failed to clean the bathroom sink from the cleanest areas to the dirtiest area. She did not use a separate rag to clean the counter top.HK #2 used a dry broom to sweep the entire room starting from the far end of the room to the bathroom then to the entry. She then used a wet mop pad to mop the far side of the room, side B, continued to side A, then to the bathroom and finished at the entry way without changing the mop pad.-HK #2 failed to change the mop pad when she finished mopping side B, she did not change the mop pad when she finished mopping side A, and did not use a separate mop pad when she mopped the bathroom and then continued to mop the entry way. IV. Staff interviewsHK #2 was interviewed on 6/1/26 at 2:00 p.m. HK #2 said she cleaned the rooms everyday. HK #2 said cleaning of the rooms included spraying down and cleaning the bathroom, sink area and personal spaces such as the over-the-bed table, if the resident was agreeable. She said she cleaned the sink from the bowl up to the faucet. HK #2 said she used one mop pad to mop the entire room. She said it was important to clean areas like the light switches, call light, remotes because they were touched a lot. HK #2 said she was supposed to use one mop pad for the whole room. HK #1 was interviewed on 6/1/26 at 2:25 p.m. HK #2 said she cleaned the rooms everyday. She said she cleaned the bathrooms and the common space in the rooms with a cleaner. She said she was supposed to use the cleaning solution when cleaning the areas that were touched a lot such as the light switches, door knobs, call light and bed remote. HK #1 said she was supposed to use one mop pad for the whole room. The housekeeper director was interviewed on 6/1/26 at 4:27 p.m. The housekeeping director said she expected the housekeeping staff to spray down the room such as the bathroom, high-touch areas and personal areas such as the tables with their cleaning solution. She said they use Oxivir and it has a one minute dwell time. She said the housekeepers should start on the B side of the room and work their way out of the room. The housekeeping director said if the cleaning solution dried before the housekeeper was able to wipe the area the housekeeper should either respray the area or their rag before cleaning the area. The housekeeping director said an area should not be wiped down with a dry rag because the area would not get the maximum cleaning and disinfectant. The housekeeping director said sinks should be washed from the top down to the bowl and the counter top should be wiped down with a separate rag. The housekeeping director said this was done so there was no cross-contamination. The housekeeping director said high-touch areas should be cleaned daily, which included light switches, call lights, bed remotes, television remotes, bedside tables and doorknobs. She said these were important to clean properly for infection control. The housekeeping director said the housekeepers should sweep the whole room with a dry broom, including the bathroom prior to mopping the floor. She said the housekeepers then would place the wet mop pad on and mop the whole room starting from the side B side and working their way to the bathroom, the bathroom should be the last floor mopped. The housekeeping director said it would be the discretion of the housekeeper if the mop pad was changed before each section depending if the floor was soiled. The housekeeping director said this included the bathroom. She said it would be more sanitary to use one mop pad to mop the bathroom and change the mop pad to continue with the room. The infection preventionist and the director of nursing (DON) were interviewed together on 6/2/26 at 9:00 a.m. The infection preventionist said high-touch areas included hand rails, door handles, faucets and the DON added call lights, television remote and the bed control. Both agreed these items should be cleaned daily with a chemical disinfectant cleaner in order to prevent the spread of an infection. The infection preventionist and the DON said the most effective way to clean a room was from cleanest to the dirtiest part of the room and a sink should be cleaned from the top down. The infection preventionist said at least three mop pads should be used to clean a double occupancy room and at least two mop pads for a private room. They said the bathroom should have a separate mop pad. They said using the same mop pad increases the chances of potential infections.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with accepted professional standards in two of six medication carts. Specifically, the facility failed:-Ensure insulin Lantus (insulin) and NovoLog (insulin) pens were labeled with open dates;-Ensure expired medications were removed from the medication cart;-Ensure injectable medications were not stored with a needle attached; and-Ensure medications were stored by administration route. Findings include:I. Professional referencesAccording to the Lantus (insulin glargine) 100 Units/ml manufacturer guidelines retrieved on 6/3/26 from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf Always check the expiration date of the pen. After 28 days, throw your opened Lantus pen away - even if it still has insulin in it.According to the NovoLog FlexPen (insulin aspart) manufacturer guidelines retrieved on 6/3/26 from https://www.novolog.com/taking-novolog.html Dispose after 28 days, even if there is insulin left in the pen.According to the Ozempic semaglutide (a semaglutide primarily used to treat adults with type 2 diabetes by lowering blood sugar and reducing the risk of cardiovascular events) manufacturer guidelines retrieved on 6/3/26 from https://www.ozempic.com/ozempic-pen/dosing.html The Ozempic pen you are using should be disposed of after 56 days, even if it still has Ozempic left in it. Always remove and safely discard the needle after each injection and store the Ozempic pen without an injection needle attached. Always use a new needle for each injection. Keep the pen cap on when not in use.II. Facility policy and procedureThe Delivery and Storage of Medications and Supplies policy, dated 1/15/04, was provided by the nursing home administrator (NHA) on 6/3/26 at 4:08 p.m. It read in pertinent part, Staff receiving the delivery of medications, solutions, and supplies from the pharmacy must ensure that all products are promptly and properly checked for appropriate storage at the facility per pharmacy instructions. Staff receiving the delivery of medications, solutions, and supplies from the pharmacy must ensure that all products are promptly and properly checked for appropriate storage at the facility per pharmacy instructions.The Insulin Pen Administration policy, revised 5/27/25, was provided by the NHA on 6/3/26 at 4:08 p.m. It read in pertinent part, The facility will ensure residents with orders for insulin administration through the use of a pen delivery device is performed in accordance with current standards or practice and manufacturer's guidance. III. Observations and interviewsOn 5/28/26 at 2:25 p.m. the North medication cart on the East side of the facility was observed with registered nurse (RN) #1. The following items were found:A Lantus (insulin glargine) pen was found with no open date labeled on it. There was insulin medication present in the pen. RN #1 said she was going to do an investigation and call her colleague who worked the shift before her. RN #1 said she would call him and ask if he opened the insulin pen. RN #1 said she would keep the pen in the cart until the investigation was completed. RN #1 said if she needed to discard the pen, she would put it in the sharps container located on the cart.An Ozempic medication pen was found in the drawer of the medication cart (med cart). There was no open date on the pen and the Ozempic medication cap was not on the pen. Instead, there was a needle attached to the tip of the Ozempic pen and there was a loose white cap covering the needle. RN #1 said the resident received Ozempic once a week. RN #1 said she gave the resident a dose around 12:00 lunch time. RN #1 said she gave the dose and was going to put the pen back in the refrigerator, but did not know where the medication cap was. RN #1 said she believed the Ozempic pen had the open date written on the cap. RN #1 said if she found the Ozempic cap with the open date on it, she would put the pen back in the refrigerator. RN #1 said the needle that was attached to the pen was not used. RN #1 said she knew it was not used because she put it on the pen so that she could store the pen in the medication cart until she found the cap. -The needle was connected to the Ozempic pen during storage in the medication cart (see professional reference above).A second Lantus (insulin glargine) pen was found with no open date labeled on it. RN #1 said it was important to have open dates on insulin medications because insulin was only good for 28 days after opening the medication. RN #1 said if the insulin pen was expired, the facility would replace it and order another insulin pen from the pharmacy. RN #1 said going forward, she would make it a habit to check her insulin pens on a daily basis.On 5/28/26 at 3:10 p.m the South medication cart on the East side of the building was checked with RN #2. The following items were found:A Lantus (insulin glargine) SoloStar pen was found in the med cart with no open date labeled on it. RN #2 was interviewed on 5/28/26 at 3:15 p.m. RN #2 said she could not find an open date on the Lantus pen.A NovoLog flex pen containing insulin aspart was found in the medication cart with 4/6/26 written on it in black. - The insulin pen was 24 days over the pharmacy recommendation date to dispose of it (see professional reference above) RN #2 was interviewed on 5/28/26 at 3:15 p.m. RN #2 said she was not sure what the date written in black meant. RN #2 said she was not sure if the written date identified the open or expiration date of the medication. RN #2 said the resident received the medication once daily.RN #2 said if the written date was the open date, the medication was expired because it had been more than 30 days since it was opened. RN #2 said it was important to have an open date on the pen, because some medications were only active for a certain amount of time. RN #2 said this was based on the manufacturer guidelines. RN #2 said she would re-order and waste the medication. RN #2 said she would waste the medication by bringing it to the medication room and placing it with other discontinued medications. RN #2 said the unit manager would then take the medications to be disposed of properly. In one drawer of the cart, not separated by dividers, there was an opened bottle of Pro T Gold (a medical-grade, ready-to-drink liquid collagen protein supplement) with residue on it next to Salonpas patches (an over-the-counter topical medication used to temporarily relieve aches and pains in muscles and joints) and a box of opened lancets (tiny, sterile medical needles used to prick the skin and draw small drops of blood often used to take blood sugars).RN #2 was interviewed on 5/28/26 at 3:15 p.m. RN #2 said she was not sure how the medications were supposed to be stored or if they were supposed to be stored by route.IV. Additional staff interviewsThe director of nursing (DON) was interviewed on 5/28/26 at 4:50 p.m. The DON said the nurse who opened the insulin or Ozempic pen was responsible for labeling the pen with the open date. The DON said it was important to have open dates on insulin pens, because insulin pens expired after 28 days. The DON said the proper way to give Ozempic was to put a needle on the pen, properly administer the medication, put the needle in the sharps container, and then put the lid back on the pen and properly store it. The DON said if an Ozempic pen was in the medication cart drawer with a needle attached to it, the medication was probably compromised because the needle was open to air. The DON said medication cart drawers should have medications sorted by route for infection control reasons.

Based on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the residents' environment for two (#21 and #50) of three residents reviewed out of 39 sample residents.Specifically, the facility failed to ensure Resident #21 and Resident #50's call lights were within reach when the residents were in their room.Findings include:I. Facility policy and procedure The Resident Call System policy and procedure, reviewed on 12/23/25, was received from the nursing home administrator (NHA) on 6/3/26 at 4:08 p.m. It read in pertinent part, The nurses`s stations in the facility will be equipped to receive resident calls with the communication system through audible or visual signals, from resident rooms, toilets, and bathing facilities. All portions of the system will be maintained and function accordingly. The facility will maintain procedures and an alternate communication system in the event the system becomes inoperable. The call lights should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident`s room. The call system must be accessible to the resident at each toilet and bath or shower facility, and would be accessible to a resident lying on the floor in this area.II. Resident #21 A. Resident statusResident #21, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included dementia, complete transverse atypical femoral fracture of the left leg (a stress fracture to the thigh bone). The 5/12/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. The resident was dependent on staff for most activities of daily living (ADL). B. Resident interview and observationsResident #21 was interviewed on 5/27/26 at 2:30 p.m. Resident #21 said she was not sure where her call light was. She said she could not find it. She said she needed assistance to go to the bathroom. She said she was not sure how to call for the nurse without the call light. Resident #21 was interviewed a second time on 6/1/26 at 8:39 a.m. She said she needed to use the toilet. She said she did not know how to call for assistance. She said she did not know where her call light was. During the interview the resident was feeling around the bed when asked about the location of the call light. The resident was unable to find the call light within her reach. She said it happened to her all the time that she could not find her call light. She said she could yell for assistance but her voice was loud enough for the staff to hear. On 5/27/26 at 2:30 p.m. Resident #21 was sitting in her wheelchair by her bed. Both call lights were on the bed approximately three to four feet away from her. The call light was out of reach for Resident #21. Resident #21 was alone in her room.On 6/1/26 at 8.30 a.m Resident #21 was sitting in her wheelchair by her bed. One of the call lights was on the headboard and the other call light was on the bed. Both call lights were out of reach. Resident #21 was alone in her room. At 12:32 p.m. Resident #21 was sitting in her wheelchair eating. One of the call lights was on the head of the bed and the other call light was on the bed. Both call lights were out of reach for Resident #21. On 6/2/26 approximately at 3:00 p.m. Resident #21 was lying in her bed. Both call lights were clipped on the headboard. The headboard was not in reach of Resident #21. C. Record reviewThe ADL care plan, revised on 5/8/26, revealed Resident #21 had self-care performance deficit due to being legally blind, a recent hip fracture, and impaired mobility. The care plan documented Resident #21 had two pancake call lights. Pertinent interventions included placing one of the call lights at the resident's hip and the one clipped to the resident's sheet. The care plan revealed that she was at risk for falls. D. Staff interviewsCertified nurse aid (CNA) #2 was interviewed on 6/2/26 at 4:22 p.m. CNA #2 said Resident #21 needed assistance from staff to get to the bathroom. She said Resident #21 used her call light if she needed assistance. CNA #2 said she clipped one call light onto Resident #21`s clothes if she was in her wheelchair. She said the other call light should be clipped to the sheet. She said the call light should always be available for Resident #21. She said if the call light was not clipped on Resident #21`s clothes, Resident #21 could not find it because she was blind. She said the Kardex (document the staff used for identifying resident care needs) indicated if a resident was not able to use the call light for any reason. Registered Nurse #4 (RN) was interviewed on 6/2/26 at 4:36 p.m. RN #4 said Resident #21 rarely used her call light due to her cognitive impairment. RN #4 said Resident #21 was blind. RN #4 said Resident #21 was aware of her needs. She said the staff checked on Resident #21 a couple times an hour.RN #4 said the care plan called for one pancake light to be placed at the resident's hip and one pancake light to be clipped to the resident's sheet when Resident #21 was in her room. She said the call lights should be within reach for Resident #21. The director of nursing (DON) was interviewed on 6/2/25 at 5.45 p.m. The DON said the call light was there for Resident #21 to use for assistance even though Resident #21 might not understand how to use the call light. The DON said Resident #21 had two pancake lights in her room. The DON said she expected frequent rounding from her staff. III. Resident #50A. Resident statusResident #50, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO diagnoses included nontraumatic acute subdural hemorrhage (a rare, life-threatening condition where blood rapidly accumulates between the brain and the skull without a head injury), parkinsonism (an umbrella term for a group of neurological disorders that cause motor symptoms similar to those of Parkinson's disease ), Alzheimer`s disease, muscle weakness, and repeated falls. The 3/16/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 12 out of 15. The resident required substantial to maximal assistance for most ADL.B. Resident interview and observationsResident #50 was interviewed on 5/27/26 at 2:38 p.m. Resident #50 said the staff hung the call light on the wall with a hook, which was too far for him to reach if he was in bed or in his wheelchair. He said he repeatedly asked staff not to hang it on the wall but the staff kept hanging it there. Resident #50 was interviewed again on 5/28/26 at 9:20 a.m. He said the staff either put the call light on a plastic hook on the wall, which was farther away from his hands or on its wire as the wire comes out of the wall. He said he could not reach either location. Resident #50 said that the staff clipped the call button on the wire the night before. He said the call lights should be laying on his bed if he was in his wheelchair. He said he mentioned it to the CNA's several times, but the staff kept ignoring him. He said he was not able to call for help if the call light was on the wall. He said he was not able to yell for help because his voice was too weak for the staff to hear. On 5/28/26 at 8:30 a.m. Resident #50`s call light was clipped on the wall. The call light was clipped back on its wire near to the power outlet. The bed was alongside the wall and it was blocking Resident #50 to get to the call light. Resident #50 was sitting in his wheelchair near the bed. On 6/2/26 at 3:28 p.m. Resident #50`s call light was hanging from a plastic hook on the wall. The bed was alongside the wall and it was blocking Resident #50 to get to the call light. Resident #50 was sitting in his wheelchair near the bed. C. Record reviewThe ADL care plan, revised 10/8/25, revealed Resident #50 had self-care performance deficit due to Alzheimer`s, Parkinson's disease`s, and subdural hemorrhage. Pertinent interventions included encouraging him to use the call light for assistance and having call light in reach. Resident #50 was identified to be at risk for falls. D. Staff interviewsCNA #1 was interviewed on 6/2/26 at 3:33 p.m. She said she came into Resident #50`s room to change the bed a few minutes ago and found the call lights hanging on the wall. RN #3 was interviewed on 6/2/26 at 3:30 p.m. She said that the staff should put the call light on the bed so Resident #50 would be able to reach it. She said Resident #50 had a tendency to lean over while in his wheelchair and that put him at risk for a fall. She said it was easier for Resident #50 to reach the call light if it was on his bed. She said it was important to leave the call lights on the bed to prevent future falls. The DON was interviewed on 6/2/26 approximately at 4:30 p.m. She said the call light should be available for Resident #50. She said Resident #50 was mobile in his wheelchair in his room and the call light should be on the bed for him to reach whenever he needed. She said Resident #50 would not be able to reach the call light if it was on the wall.

Based on record review and interviews, the facility failed to provide the appropriate services to maintain ability to carry out ADLs for one (#6) of two residents out of 39 sample residents. Specifically, the facility failed to provide Resident #6 with nursing restorative therapy as recommended by physical therapy.Findings include:I. Facility policy and procedureThe Restorative Nursing policy, reviewed 9/18/25, was provided by the nursing home administrator (NHA) on 6/3/26 at 4:08 p.m. It read in pertinent part, to promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Restorative programs may be initiated by nursing and/or therapy. Refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial function. Measurable objectives and interventions must be documented in the care plan and in the medical record. Evidence of periodic evaluation by the licensed nurse must be present in the patient's medical record.II. Resident #6A. Resident statusResident #6, age [AGE], was admitted [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included restless legs syndrome, muscle weakness, abnormalities of gait and mobility, and history of falling. The 3/11/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 10 out of 15. He was dependent on staff for toileting, lower body dressing and transfers.B. Resident and resident representative interviewResident #6 and Resident #6's representative were interviewed together on 5/27/26 at 2:20 p.m. Resident #6 said he was admitted to the facility for therapy, but had not received any recently. Resident #6's representative said he had therapy when he was first admitted to the facility and was discharged from physical therapy. The representative said het was supposed to continue with a nursing restorative therapy program. She said Resident #6 had not been receiving nursing restorative therapy consistently. She said she was told the restorative aide had been out of the building, which was causing the resident to not get the nursing restorative therapy. She said she had not been told when Resident #6 would resume consistent restorative therapy. Resident #6 and Resident #6's representative were interviewed together again on 6/2/26 at 1:30 p.m. Resident #6's representative said the resident had become weaker since the end of physical therapy. She said she had seen an overall decline and felt not having the nursing restorative therapy had contributed to his decline. Resident #6 said he felt his legs were weaker and has had an overall decline in strength. C. Record reviewA review of Resident #6's physical therapy Discharge summary, dated [DATE], revealed the physical therapist recommended Resident #6 be placed on a nursing restorative therapy program for pedaling of upper extremity and lower extremity recumbent bike with both feed strapped in for 10 minutes with monitoring of oxygen saturations.The functional goal care plan, dated 4/1/26, documented Resident #6 had limited physical mobility related to weakness. Pertinent interventions included nursing rehabilitation/restorative recumbent cross-trainer with set-up assist for 10 minutes on Mondays, Wednesdays and Saturdays.A review of the April 2026 documentation for nursing rehabilitation/restorative program revealed the recumbent cross-trainer with set-up assist for 10 minutes Monday, Tuesday and Wednesday was completed seven times out of 13 opportunities.A review of the nursing restorative therapy program evaluation, dated 4/30/26, revealed Resident #6 had been riding the recumbent cross-trainer and had been participating without difficulty. The evaluation documented Resident #6's strength was improving. -Review of Resident #6's electronic medical record (EMR) did not reveal documentation of a May 2026 nursing restorative therapy program evaluation for May 2026.A review of the May 2026 documentation for nursing rehabilitation/restorative revealed the recumbent cross-trainer with set-up assist 10 minutes Monday, Tuesday and Wednesday was completed two times out of 13 opportunities. D. Staff interviewsThe unit care coordinator, who oversaw the nursing restorative therapy program, was interviewed 6/1/26 at 3:30 p.m. The unit care coordinator said she had two restorative therapy certified nurse aides (CNA). She said the two CNAs were able to follow through with the nursing restorative therapy program set up by the physical or occupational therapists. She said the full-time CNA had been out of the building for an extended period of time and the part-time CNA was often pulled to the floor to work as a unit CNA. The unit care coordinator said both of the CNAs could be pulled to work the unit. She said there was not a back up if the restorative CNAs were not available to provide the nursing restorative therapy. The physical therapist (PT) was interviewed on 6/1/26 at 3:48 p.m. The PT said the therapists set up a nursing restorative therapy program for the restorative CNA to follow in order to prevent decline or function the resident may have gained during therapy. The PT said a physical or occupational therapist would write up a nursing restorative therapy program and the therapist would train the restorative CNA on the nursing restorative therapy program. The PT said a resident can decline quicker if there was a nursing restorative therapy program set up and it was not being followed consistently.The director of nursing (DON) was interviewed on 6/2/26 at approximately 1:30 p.m. The DON said when a resident was no longer on skilled therapy the therapist would make a nursing restorative therapy recommendation for the resident and write out an appropriate program. She said the nursing restorative therapy program was to maintain and/or increase a resident's physical abilities. She said it was important to follow through with the therapist's recommendation to maintain the quality measures the resident achieved in therapy so the resident was functioning at their best capacity. The DON said there were three CNAs trained for the nursing restorative therapy program. She said one CNA was on an extended leave, one CNA was on vacation and one CNA was part-time. She said the part-time CNA also covers the floor. She said there was not a back up plan if the restorative CNAs were not available to provide the nursing restorative therapy.

Based on observations, record review and interviews, the facility failed to maintain effective pest control program for one (#50) of five residents reviewed out of 39 sample residents.Specifically, the facility failed to maintain pest free environment in Resident #50`s room.Findings include:I. Facility policy and procedureThe Pest Control policy and procedure, reviewed on 7/9/25, was received from the nursing home administrator (NHA) on 6/3/26 at 4:08 p.m. It read in pertinent part, The facility will maintain an effective pest control program that provides frequent treatment of the environment for pests so that the facility is free of pests and rodents. Effective pest control program- is defined as measures to eradicate and contain common household pests (bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats). The facility`s staff will do monitoring of the environment. Pest control problems will be reported to the Director of Maintenance promptly.II. Observations and interviewsResident #50 was interviewed on /27/26 at 1:51 p.m. He said he had seen ants in his room several times. He said the ants crawled on him at night when he was in his bed. He said he had complained about the ants to the staff several times, but nothing had happened since. He said he continued seeing the ants in this room. On 5/27/26 at 2:00 p.m. three ants were observed crawling alongside the baseboard in Resident #50`s room at the foot of the bed on the floor. On 5/28/26 at 8:40 a.m. five ants were observed crawling in Resident #50`s room. One ant was crawling alongside the baseboard behind the bed. Two ants were observed crawling underneath the bedside table. Two ants were observed crawling on the other side of the room, under Resident #50`s desk. Food crumbs were observed on the floor around the bed, around Resident #50 who was sitting in his wheelchair, and under his desk. There were no ant traps observed in his room. On 6/1/26 at 8:46 a.m. three ants were observed crawling along the baseboard behind Resident #50`s bed. There were approximately 10 to 15 ants by the trashcan eating on a crumb. Resident #50 was attempting to crush them with his reacher (adaptive device). He was leaning over in his wheelchair and raised his voice. III. Record reviewThe nursing home administrator (NHA) provided an email on 6/2/26 at 10:29 a.m. The email read in pertinent part, the pest control company came out today (6/2/26 - during the survey) and sprayed 211 (pest control spray) The email said the facility would always immediately address the concern as it was found and the facility got the pest control company to come to the facility as soon as possible. The email said the facility had noticed several food particles in the resident's room, so they were going to complete a deep clean of the resident's room. The email said the facility had had no concerns regarding pests through grievance forms or resident council. The email contained a receipt from the pest control company that revealed Resident #50`s room was treated with Alpine WSG insecticide and Sumari Ant gel, which both target ants.The review of the March 2026, April 2026, and May 2026 pest control company service receipts revealed the pest control company applied Alpine WSG and Boracin for cockroaches. The documentation revealed both insecticides were effective on ants as well. The documentation indicated the pest control company applied the insecticides to the exterior and interior of the facility such as kitchen, dining room, locker room, breakroom, and laundry, but has not treated residents`s rooms. V. Staff interviewsHousekeeper #1 (HK) was interviewed on 6/1/26 at 12:41p.m. She said Resident #50 complained about the ants in his room approximately two weeks ago. She said she had not seen ants in his room until last week. She said she reported the aunts to the maintenance department last Monday (5/25/26). She said the room was treated for ants today for the first time (during survey). The director of housekeeping was interviewed on 6/2/26 at 9:05 a.m. She said she was not sure who cleaned up the ants by the trashcan on 6/1/25. She said she saw ants on that day when she started moving things around the room. She said she moved a chair from the corner of the room and found more food crumbs and ants. HK #1 was interviewed again on 6/2/26 at 1:39 p.m. She said she deep cleaned Resident #50`s room and found more breadcrumbs on the floor and sugar packets in different drawers in his room. The maintenance director was interviewed on 6/1/26 12:49 p.m. He said they spot-treated for ants if a report came in and also used the pest control company for pest control. He said if staff reported pests, he would decide whether an in-house treatment was adequate treatment. He said if the in-house spray treatment was not enough to treat the pests problem, he would call the pest control company right away. He said he had never been alerted about ants in Resident #50`s room until during the survey. He said he was told that the ants were seen around the trashcan. He said he treated the area, but did not see ants. The nursing home administrator was interviewed on NHA 6/1/26 at 1:26 p.m. He said today was the first time he was alerted about ants in Resident #50`s room. He said there were no previous ant issues reported for that room.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards out of three sample residents remained free from accident hazards. On 2/27/24, just before 2:00 p.m. certified nurse aide (CNA) #1 was providing care to Resident #1. The resident was rolled on her side during the care and the resident slid off the side of the bed, fell to the floor and sustained a left hip fracture. The resident was sent to the hospital for treatment and underwent surgical repair of the left hip fracture. Through a facility investigation, it was found that CNA #1 had not followed the resident individualized care plan accurately when she made the decision to provide care without a care partner to ensure proper technique for safety and appropriate bed mobility. The facility failed to ensure that Resident #1 received appropriate care per her comprehensive care plan for two staff members to assist with bed mobility and incontinent care which resulted in the resident falling out of bed and sustaining a hip fracture that required surgical intervention. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/14/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/28/24. I. Incident on 2/27/24 CNA #1's failure to follow the resident' s care plan to provide bed mobility with the assistance of two staff members led to the resident falling out of a high bed and sustaining a major injury (hip fracture). II. Facility plan of correction Interviews and record review during the onsite investigation on 11/14/24 revealed the facility investigated this singular event and implemented corrective actions to prevent the recurrence of the incident. A. Immediate action to correct the deficient practice for Resident #1 CNA #1 was suspended during the investigation and, upon her return on 3/1/24, CNA #1 was provided coaching and education on the facility' s policy that the resident' s care plan must be followed at all times. CNA #1 was educated on where to locate a resident' s care plan, the care plan interventions and on the expectation to check each resident' s care plan daily and before the start of care. Additionally, CNA #1 was educated that, per facility policy, the resident' s care plan was to be followed as written and that any concerns about care were to be brought to the attention of the nurse on duty. Resident #1' s care plan was revised with appropriate interventions for all care areas. All facility nurses and CNAs were educated on the facility' s policy for following each resident' s care plan, where to find the care plan and expectations for reporting concerns about care plan interventions. The education was completed on 2/27/24 and 2/28/24. B. Identification of other residents All residents (90) were assessed for ADL level of assistance and care needs and the information was compared to the existing care plan. All discrepancies and conflicting documentation were clarified or corrected to reflect each resident's assessed care assistance needs. This was completed on 2/28/24. C. Systematic changes The facility' s quality assurance performance improvement committee developed a plan of improvement on 2/28/24. The plan included: A root cause analysis of the incident was conducted and it was determined that CNA #1 was not following facility policy for reviewing and following Resident #1' s comprehensive care plan, which led directly to the resident falling off the bed while in the care of a facility staff member causing the resident a significant injury (see above). Staff education was completed with all nurses and CNAs on 2/28/24 and completed with new staff and staff upon their assigned work shift by 2/28/24. Following the provision of staff education, each staff member was required to show a return demonstration that they understood and were capable of accessing resident care plans. This was completed with every staff member by 4/30/24. Observations and interviews during the survey revealed staff were consistently following the care plan interventions of the residents included in the survey process on 11/14/24. An interview with the director of nursing (DON) confirmed the corrective actions, and therefore the facility's substantial compliance, by 2/28/24, at the time of the survey was conducted on 11/14/24. D. Monitoring The DON/designee was tasked with ensuring each resident was assessed for appropriate care needs upon admission, quarterly, and with each change in condition and that the resident' s care plan was updated accordingly. Needs for care plan revision out of sequence (when a change of condition occurred) were to be brought to the attention of the DON and other members of leadership and discussed with the interdisciplinary team ( IDT) and then documented in the resident' s record. II. Facility policy and procedure The Fall Management policy and procedure, revised on 4/7/24, was provided by the DON on 11/14/24 at 3:01 p.m. It read in pertinent part, The facility will assess the resident upon admission/readmission, quarterly, with change of condition and will identify appropriate interventions to minimize the risk of injury-related falls. The resident environment remains as free of accident hazards as is possible. Each resident shall receive adequate supervision and assistance to prevent accidents. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and was discharged to the hospital on 11/1/24. According to the November 2024 computerized physician orders (CPO), diagnoses included a fracture to the left femur (hip), a history of stroke, muscle weakness and Alzheimer' s disease. The 9/16/24 minimum data set (MDS) assessment revealed Resident #1 had short-term and long-term memory impairment, severely impaired daily decision-making skills and continuous symptoms of inattention, per staff assessment. The resident had difficulty focusing attention on tasks, was easily distractible and had difficulty keeping track of what she was told. The resident was dependent on two staff members to complete activities of daily living (ADL), including performing toileting hygiene, shower/bathing, and personal hygiene transferring and repositioning in bed. B. Record review Resident #1' s comprehensive care plan documented the resident had an ADL performance deficit due to Alzheimer's disease, dementia, hemiplegia/hemiparesis (weakness) to the right side and a history of stroke. Interventions included providing assistance of two staff members to turn and reposition the resident (initiated 12/11/2020) and providing assistance of two staff members for incontinence care (initiated 12/11/2020). A progress note, dated 2/27/24 at 2:00 p.m., documented the nurse heard a loud noise and screaming for help from a CNA and Resident #1' s roommate. The nurse went to the room to check on the resident. Resident #1 was found lying on the floor. CNA #1 said she was changing Resident #1 and she fell out of bed. CNA #1 said the resident landed on her right side. Resident #1 was assessed and found to have a hematoma (raised area due to swelling) on her forehead, a laceration on her nose, bruising to her chin, a skin tear to her left lower leg shin area, and a skin tear to her left elbow. The resident had rapid respirations, a very high blood pressure and was complaining of pain to her left hip and forehead. Emergency medical services (EMS) was called and the resident was taken to the hospital for assessment and medical treatment. C. Incident investigation The facility fall investigation report, dated 2/27/24, revealed Resident #1 fell out of bed on 2/27/24 at approximately 2:00 p.m. while being assisted by only one CNA (CNA #1). As a part of the investigation, the facility conducted a root cause analysis of the incident and determined CNA #1 was not following the resident' s care plan. When interviewed, CNA #1 was unaware of the resident's care assistance needs, including that the resident was to receive ADL assistance performed by two staff members for proper support and safety. CNA #1' s interview statement documented that she entered Resident #1' s room to assist her with toileting hygiene. CNA #1 said she started to provide care for Resident #1 by wiping her genitalia in the front and then turning the resident on her right side to wipe and cleanse her buttocks. After wiping the resident' s buttocks, the resident slid off the side of the bed to the floor. CNA #1 said the resident did not roll forward but slid off the bed while maintaining a side-lying position landing on her side. CNA #1 told the investigator that she had cared for Resident #1 for the past four years and she thought she was following the resident' s care plan and following interventions for the resident' s current level of care. CNA #1 admitted that she had not reviewed the resident' s care plan recently and believed Resident #1' s care could be provided by one staff member without assistance. -However, the resident' s care plan interventions indicated intervention for the need for two staff members to provide bed mobility assistance had been in place since 12/11/2020. A nurse practitioner exam note, dated 3/11/24 at 11:19 a.m., revealed the resident had been in the hospital since 2/27/24 receiving medical treatment after she fell out of bed during ADL care while in the facility. The note revealed Resident #1 returned that day (3/11/24) after being hospitalized for surgical repair to the left hip after falling out of bed while staff provided care. The note documented that the resident also had ecchymosis (bruising from broken blood vessels to the skin or mucous membranes) on the face resulting from trauma and a hematoma in the middle of the forehead. The resident was able to move all four extremities with decreased movement to both lower legs. A progress note dated, 3/12/24 at 2:03 p.m., revealed the resident moaned in pain when repositioned and was prescribed Tylenol three times a day for the pain. III. Staff interviews The DON and the nursing home administrator (NHA) were interviewed together on 11/14/24 at 3:30 p.m. The DON said CNA #1 had not followed the facility' s policy or the resident' s care plan and that lead to the resident being injured. The DON said CNA #1 was counseled and educated on facility expectations to check each resident' s care plan each shift to be aware of any changes and care needs.

Based on record review and interviews, the facility failed to ensure treatment and services being provided met professional standards of quality for one (#12) of five residents reviewed for unnecessary medications out of 35 sample residents. Specifically, the facility failed to ensure that Resident #12 was administered the correct dose of insulin according to the physician ordered parameters. Findings include: I. Facility policy and procedures The Administration of Medications policy, revised 5/6/22, was provided by the director of nursing (DON) on 2/5/24 at 11:53 a.m. The policy revealed, The facility would ensure medications were administered safely/appropriately per physician order, to address residents' diagnoses and signs and symptoms. Nursing staff were to check the MAR (medication administration record) and the doctor's order before medicating. If there was any doubt about the dose on the MAR or if there was a question on the drug; nursing staff were to stop and verify all information before administering. High alert medications included insulin for all formulations and strengths. II. Resident #12 A. Resident status Resident #12, over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included morbid obesity, dementia, Alzheimer's disease, diabetes mellitus II and long term (current) use of insulin. The 11/22/23 minimum data set (MDS) assessment revealed the resident had short and long term memory problems with no behaviors. The resident was administered insulin for seven days and injections for seven days. B. Record review A physician's order dated 8/17/23 at 9:38 a.m. revealed to administer Novolog solution 100 unit/milliliter, inject seven units subcutaneously with meals and hold for a blood sugar level of less than 150 related to type two diabetes mellitus. The care plan for diabetes mellitus was revised on 7/27/22. The pertinent interventions were for staff to obtain blood sugar checks as ordered, and administer medication as ordered. Staff were to observe and report as needed (PRN) any signs or symptoms of hypoglycemia (low blood sugar levels): sweating, tremor, tachycardia (increased heart rate), pallor (white in color), nervousness, confusion, slurred speech, lack of coordination and/or a staggered gait. Staff were also to observe and report PRN any signs or symptoms of hyperglycemia (elevated blood sugar levels), increased thirst or appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul (rapid deep breathing at a consistent pace) breathing, acetone breath (smells fruity), stupor, and/or coma. The November 2023 medication administration record (MAR) revealed the resident was administered insulin with a blood sugar level below 150 on 11/12/23. The December 2023 MAR revealed the resident was administered insulin twice on 12/18/23 and 12/20/23 with a blood sugar level below 150. The January 2024 MAR revealed the resident was administered insulin three times on 1/1/24, 2/7/24 and 2/29/24 with a blood sugar level below 150. IV. Staff interviews The nursing home administrator (NHA), the DON and licensed practical nurse (LPN) #1 and the regional director of clinical services (RDCS) were interviewed on 2/5/24 at 10:16 a.m. They said the resident was administered insulin multiple times outside the parameters established by the resident's physician. They said the nursing staff had not followed the physician's order and they should have. The DON was interviewed on 2/6/24 at 9:16 a.m. She said the six dates on the resident's MARs revealed the resident was administered insulin, when the resident had a blood sugar level below 150. She said nursing staff should follow physician orders and they did not. She said by not following the physician ordered parameters, the resident might have developed low blood sugar levels. She said low blood sugar levels might result in detrimental adverse outcomes for the resident. LPN #1 was interviewed on 2/6/24 at 11:41 a.m. She said the six dates on the resident's MARs revealed the resident was administered insulin, when it should not have been administered. She said nurses should follow physician orders. She said by giving the insulin contrary to the parameters, the resident might have experienced low blood sugar levels. She said low blood sugar levels might have caused the resident to experience shock, become comatose or have an increase in symptoms related to their comorbidities. LPN #2 was interviewed on 2/6/24 at 12:20 p.m. She said the six dates the insulin was given it should not have been given due to the orders. She said nurses should follow physician orders and parameters. She said nurses should never administer insulin outside the physician parameters. She said by administering the insulin, the resident might have experienced a low blood sugar level, which could have resulted in the resident having lethargy (tiredness), sweats, unable to communicate, a decrease in their baseline response times and possibly shock. She said some residents are more brittle (sensitive) regarding the amounts of insulin they could receive in relation to their blood sugar levels.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#45) out of 35 sample residents. Specifically, the facility failed to ensure that Resident #45 did not keep inhaler medications at the bedside. Findings include: I. Facility policy and procedure The Self Administration of Medications policy and procedure, reviewed 11/28/16, was provided by the director of nursing (DON) on 2/5/24 at 4:39 p.m. It revealed in pertinent part, Facility, in conjunction with the Interdisciplinary Care Team (IDT), should assess and determine, with respect to each resident, whether self administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. Facility should ensure that orders for self administration list the specific medication(s) the resident may self administer. Facility should document in the resident's care plan whether the resident or facility staff is responsible for the storage of the resident's medications. If the resident is responsible for the storage of his/her medications, the facility should provide a secured compartment for storage of such medication in accordance with facility policy, applicable law, the state operations manual (SOM). The medication storage compartments should be located in the resident's room so that another resident is not able to access the medications. II. Resident #45 A. Resident status Resident #45, age 74, was admitted on [DATE] and readmitted [DATE]. According to the February 2024 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and type II diabetes mellitus (DM). The 1/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was independent with eating, personal hygiene, bed mobility, toileting and transfers. B. Observations and resident interview Resident #45 was interviewed 1/31/24 at 11:34 a.m. She said nursing staff had been leaving her inhalers for her to use at her bedside. She said she was no longer taking the Atrovent. There were two Fluticasone inhalers were observed on top of Resident #45's bedside table and one Atrovent inhaler was observed on top of the recliner arm. On 2/5/24 at 11:00 a.m. one Atrovent inhaler was observed on top of Resident #45's recliner arm. C. Record review The cognition care plan, initiated 12/12/23, revealed the resident had impaired cognitive ability and impaired thought process related to forgetfulness. Interventions included allowing extra time to respond to questions and instruction and cue, reorient and supervise as needed. -A review of Resident #45's comprehensive care plan failed to reveal the resident had a medication self administration assessment to be able to administer her own medications and inhalers. The February 2024 CPO did not reveal documentation of a medication self administration assessment. The February 2024 CPO documented an order for Flovent (Fluticasone) inhaler two puffs twice a day, ordered 1/18/24. The February 2024 CPO documented an order for Atrovent inhaler one puff every six hours as needed for shortness of breath, ordered 10/19/23 and discontinued 1/18/24. -A comprehensive review of the February 2024 CPO failed to reveal a physician order to self administer inhalers. III. Staff interviews Registered nurse (RN) #1 was interviewed on 2/5/24 at 2:30 p.m. She said there were no residents currently able to self administer medications or inhalers. She said a medication self administration assessment and physician order were required before a resident was able to self administer any medication. She said Resident #45 did not have a self administration assessment or a physician order to safely administer her own inhalers. She said Resident #45 should not have her inhalers at her bedside table unsecured and unsupervised to be self administered. The DON was interviewed on 2/6/25 at 11:30 a.m. She said for residents to have medications at bedside and self administer should have a medication administration assessment and a physician order to be able to safely administer medications. She said Resident #45 did not have a self medication administration assessment or a physician order. She said Resident #45 should not have her inhaler medications at her bedside unsecured and unsupervised.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one out of six hallways. Specifically, the facility failed to: -Ensure residents' rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure clean technique was followed during wound care; and, -Ensure scissors were cleaned and disinfected according to standards of practice. Findings include: I. Housekeeping A. Professional reference Centers for Disease Control. (5/4/23). Environment Cleaning Procedures. https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118 retrieved on 2/8/24. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas. Include identified high touch surfaces and items in checklists and other job aids to facilitate completing cleaning procedures. B. Manufacturer's recommendations According to the Diversey Oxivir Cleaner Disinfectant manufacturer guidelines, reviewed 2023, was provided by the housekeeping supervisor (HSKS) on 2/6/24 at 1:15 p.m. included the following recommendations, Kills hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) in one minute. Apply product by coarse trigger spray to hard, non porous inanimate surfaces. All surfaces must remain visibly wet for one minute. According to the Diversey Virex Cleaner Disinfectant manufacturer guidelines, reviewed 2023, was provided by the HSKS on 2/6/25 at 1:15 p.m. included the following recommendations, Spray area until it is covered with the solution. Allow the product to penetrate and remain wet for three minutes for all bacteria, five minutes for Tuberculosis (TB), one minute for HBV and HIV and 30 seconds for Norovirus. C. Facility policy and procedure The Daily Room Cleaning policy and procedure, revised 7/19/23, was provided by the HSKS on 2/6/24 at 1:15 p.m. It read in pertinent part, Using a damp rag with hospital grade Environmental Protection Agency (EPA) registered disinfectant list N and water damp dust the room starting with the resident's area (overbed table, and phone) and move to the rest of the items in the room. This includes windowsills, door frames, shelves, walls and doors. D. Observations Housekeeper (HSK) #1 cleaned resident room [ROOM NUMBER]B on 2/6/24 at 11:08 a.m. HSK #1 sprayed a wash cloth with Virex and briefly wiped the top of the bedside table. She dropped the washcloth on the floor, picked the rag up and continued wiping the top of the dresser cabinets. The surfaces were not visibly wet. -She failed to ensure the surfaces remained wet for the three minute surface disinfectant time. She failed to change gloves and obtain a new rag after dropping the rag on a dirty area and before proceeding to a clean area. HSK #1 removed gloves, emptied trash and swept the room. -She failed to perform hand hygiene after removing gloves. She failed to clean high touch surface areas in the room including, call light, light switches and door handles. HSK #1 obtained a wet mop head from a housekeeping cart without wearing gloves and proceeded to mop the room starting from the far side and working her way to the door. She then removed the soiled wet mop head and disposed of the wet mop head in the receptacle on the housekeeping cart. She then pushed the housekeeping cart to the janitor room. -She failed to wear gloves or perform hand hygiene after handling the soiled wet mop head and touching clean items on the housekeeping cart. E. Staff interviews HSK #1 was interviewed on 2/6/24 at 11:26 a.m. She said she used Virex to clean the resident room and it was the same thing as the Clorox bleach. She said the dwell (surface disinfectant) time was 15 minutes. She said to clean a room low surfaces needed to be wiped before high surfaces. She said call lights, light switches and door handles should be wiped down when the room was cleaned. The HSKS was interviewed on 2/6/24 at 11:30 a.m. She said the facility approved cleaner and disinfectant to clean the rooms was Oxivir or Clorox bleach. She said Oxivir had a one minute surface disinfectant time. She said high areas needed to be cleaned first then low areas. She said once low areas were cleaned high areas should not be cleaned without changing the rag and gloves. She said dirty areas should not be cleaned before clean areas. She said high touch surfaces should be cleaned daily. II. Wound care A. Observations Licensed practical nurse (LPN) #1 was observed providing wound care to Resident #43's heel wound on 2/6/24 at 8:00 a.m. LPN #1 obtained Resident #43's designated scissors and cut off her soiled left heel dressing. She laid down scissors on the clean work surface for clean supplies. -She failed to clean scissors before laying scissors on her clean field. LPN #1 opened a clean alginate dressing and cut dressing to size with the used scissors. -She failed to clean the contaminated scissors before cutting the clean dressing. LPN #1 cleaned the scissors at the end of the dressing change with hand soap and water, placed scissors in a bag and returned them to the resident's designated wound care supplies. -She failed to sanitize and disinfect the scissors after use. B. Staff interviews LPN #1 was interviewed on 2/6/24 at 8:45 a.m. She said scissors should be cleaned after touching something dirty. She said she used soap and water. She said if scissors came in contact with something potentially contaminated with blood or body fluid it should be cleaned with the designated Sani cloth germicidal wipes. She said Resident #43's scissors had touched a dirty dressing and should not be placed on a clean field or used to cut a clean dressing. The DON was interviewed on 2/6/24 at 8:45 a.m. She said scissors. after being used on a dirty dressing. should be cleaned with the EPA approved disinfectant before being placed on a clean supply work surface, before being used on clean supplies and after dressing changes were completed. She said this was to ensure that microorganisms did not contaminate clean supplies and were introduced into a wound.

Based on interviews, observations and record review, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure resident food was palatable in temperature. Findings include: I. Professional references The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 10/16/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, The food shall have an initial temperature of 41 F or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control. II. Facility policy and procedure The Food Temperature Control policy, revised December 2021, was provided by the nursing home administrator (NHA) on 10/5/23. It revealed in pertinent part, 1. Food temperatures are checked at the compilation of the cooking process and before being placed on the serving line; if issues are identified, they are corrected, or the food is discarded. 2. Food temperatures are recorded prior to meal service on the Food Temperature Record Log. 3. If the food temperatures are unsatisfactory, the problem areas are corrected before serving the food items. 4. Hot foods are held at a minimum of 135 F or per state requirements. 5. Cold foods are held at or below 41 F or per state requirements. III. Residents interviews Three alert and oriented residents were interviewed on 10/5/23 between 11:34 a.m. and 3:30 p.m. Resident #1 stated that she ate in her room and the food was warm to cold when it arrived. Resident #3 stated that she frequently ate in her room and the food was frequently delayed and always arrived at the semi-warm temperature. Resident #5 stated he ate in his room and the food was delivered to him in semi warm to completely cold temperatures. He said the scrambled eggs in the morning were so cold like they were held in the refrigerator. IV. Observations Dinner observations were completed on 10/5/23 between 3:30 p.m. and 5:00 p.m. The assembly of the meal trays for the first two warm boxes started at 3:45 p.m. and was completed at 4:25 p.m. when hot boxes left the kitchen. The time frame of the assembly indicated that the first tray that was placed in the hot box was held in the box for 40-45 minutes before it was served to residents. The cold foods temperatures were as following: -Crab salad was 45.5 F. The crab salad was held on ice but was not corrected prior to serving. The holding temperatures of the salad bar foods that were held on a separate cooling table, were not checked prior to serving dinner. The salad bar contained highly perishable foods such as ham salad, eggs, tomatoes, cucumbers, cheese, onions, peppers and cottage cheese (per the facility policy to monitor temperatures). V. Record review The holding temperature log was reviewed on 10/5/23 at 1:30 p.m. in the presence of the dietary manager (DM). The logs contained the initial temperature of the food prior to serving. The holding temperature log for the salad bar was reviewed on 10/5/23 at 5:30 p.m. in the presence of the DM. The log was completely blank and was not completed for October 2023. VI. Staff interviews The DM was initially interviewed on 10/5/23 at 1:30 p.m. She said prior to serving, all hot and cold foods were checked for proper holding temperature and temperatures were documented on the temperature log. She said temperature was taken only once, prior to serving the meal. The chef was interviewed on 10/5/23 at 4:30 p.m. He said holding temperatures were taken prior to serving meals to ensure they were appropriate. He said sometimes temperature was checked after but it was never documented. Regarding the crab salad that was measured at the above recommended holding temperature, he said it was recently prepared and it did not cool down. The DM was interviewed a second time on 10/5/23 at 5:35 p.m. She said all cold foods should be held and served at or below 41 F. She said all food items for the salad bar table should be checked prior the meal was served. She said she did not know why staff did not check or document a salad bar holding temperatures for October 2023. The NHA was interviewed on 10/5/23 at 5:55 p.m. He said dietary staff should follow facility policy regarding holding temperatures. He said the assembly of the meal trays should be more efficient in order to minimize the time that trays were left in the hot box and all residents should receive their meals at the appropriate temperature.

Based on observation, record review and interviews the facility failed to ensure that professional standards of practice were followed for two (#1 and #2) of three residents sample residents. Specifically, the facility to ensure: -Treatments were administered by nursing staff prior to signing it was administered on the treatment administration record (TAR); and, -The nursing staff who administered the treatment signed the TAR as being administered. Finding include: I. Facility policy and procedure The Administration of medication policy, dated 2/13/23, received from the director of nursing (DON) on 4/13/23 at 12:16 p.m. revealed in pertinent part the facility will ensure medications were administered safely and appropriately per physician order to address residents diagnosis and signs and symptoms. Right documentation, make sure to write the time and any remarks on the chart correctly. II. Resident #1 A. Resident #1 status Resident #1, age over 65, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included wound to pressure injuries to coccyx (buttock area) and left hip, dementia (impaired ability to remember), chronic kidney disease (blood filtration insufficiency), hypertension (high blood pressure) and asthma (disease affecting the lungs). The 1/30/23 minimum data set (MDS) assessment revealed the resident had a cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required one person's physical assistance with bed mobility, transfers, dressing, eating and personal hygiene. B. Observations On 4/13/23 at 10:07 a.m. the director of nursing (DON) and licensed practical nurse (LPN) #1 were observed providing wound care to Resident #1. Resident #1 was laying in bed on her right side supported with pillows. LPN #1 collected supplies for dressing change while DON set up Resident #1's bed to gain access to wounds. The left hip dressing was removed and had a date of 4/12/23 written on the dressing. LPN #1 removed a dressing to the coccyx which was labeled with the date 4/12/23. LPN #1 completed dressing change according to the physician orders and added date and initials to new dressing. B. Record review According to the April 2023 CPO treatment orders for the coccyx and left hip were: -Wound to coccyx: Cleanse with wound cleanser, pat dry, apply skin prep (skin barrier protectant) to peri wound (around the outside of wound bed), apply Medi-Honey (specialized wound ointmentment), gently pack with alginate (specialized wound dressing), cover with foam dressing every day shift and as needed for dressing compromise. Ordered on 4/11/23. -Left hip wound: cleanse with normal saline, pat dry, skin prep peri wound, apply medi-honey, cover with foam dressing. One time every other day and as needed changes if dressing was compromised. Ordered on 4/4/23. Review of the TAR on 4/13/23 at 8:40 a.m. revealed both the coccyx and the left hip were signed out by registered nurse (RN) #1. The DON provided a medication administration audit report on 4/13/23 at 12:16 p.m. This revealed a timestamp signature of nurses completing treatment. Resident #1's coccyx and left hip treatments were signed out on 4/13/23 at 6:17 a.m. by RN #1. -However, the dressing changes were completed during the observation on 4/13/23 at 10:07 a.m. (see above). III. Resident #2 A. Resident status Resident #2, younger than 65, was admitted on [DATE]. According to the April 2023 CPO, the diagnoses included non pressure ulceration of the buttock, type two diabetes (insulin deficiency), dementia and hypertension. The 3/30/23 MDS assessment revealed the resident had moderate impaired cognition with a BIMS score of 12 out of 15. She required two-person assistance with transfers, one person assistance with bed mobility, dressing, personal hygiene and eating. B. Observation On 4/13/23 at 9:45 a.m. the DON and LPN #1 entered the Resident #2's room to perform a dressing change. Supplies were collected and the resident was positioned for care. LPN #1 removed dressing to coccyx which had no date or nurse initials. LPN #1 completed dressing change per the physician order placing 4/13/23 date and initials on dressing. C. Record review According to the April 2023 CPO treatment orders for coccyx were: -Bilateral buttocks: cleanse with normal saline, pat dry, skin prep peri wound, cover wound bed with hydrofera blue (specialized wound dressing), and cover with mepore (border dressing cover). Change every day and evening shift and as needed changes if dressing is compromised. Review of the TAR on 4/13/23 at 8:43 a.m. revealed the dressing change was signed out by RN #1. The DON provided a medication administration audit report on 4/13/23 at 12:16 p.m. This revealed a timestamp signature of RN #1 completing treatment. RN #1 signed out treatment completed at 6:17 a.m. -However, the dressing was changed on 4/13/23 at 9:45 a.m. (see above). IV. Staff interviews LPN #1 was interviewed on 4/13/23 at 9:45 a.m. LPN #1 acknowledged there was no date on dressing removed from Resident #2 bilateral buttock wounds. LPN #1 was interviewed on 4/13/23 at 10:07 a.m. during dressing change for Resident #1. LPN #1 acknowledged the date on Resident #1's dressing was 4/12/23 for both the left hip and the coccyx. RN #1 was interviewed on 4/13/23 at 10:40 a.m. RN #1 reviewed the treatment administration record and confirmed she signed out the treatment for Resident #1 and #2 even though she did not provide the dressing change. RN #1 said someone had to sign it out. RN #1 said LPN #1 performed the dressing change for Resident #1 and #2 today. RN #1 said sometimes the hospice nurse would complete the dressing change and they did not have access to the facility's charting system so staff nurses still have to sign them out as being complete. RN #1 said she did not add a progress note to the resident's chart when another party completed the dressing changes. The DON and LPN #1 were interviewed on 4/13/23 at 11:20 a.m. The DON said treatments were to be signed out by the nurse who completed the treatment after it was completed. LPN #1 said the floor nurse was to add a progress note in the resident's chart to indicate if the hospice nurse completed the dressing change.

Based on observations, interviews, and record review, the facility failed to ensure one (#36) of four residents reviewed for nutrition out of 40 sample residents received the care and services necessary to meet their nutritional needs to maintain their highest level of physical well being. Resident #36 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Dietary interventions included snacks in the evening, two proteins during meals, 2% milk served with meals, and fortified foods when possible. Since admission on 2/10/22 it was documented that Resident #36 was losing weight with variable meal intakes. A nutritional supplement was added on 3/23/22 and discontinued on 4/28/22 due to the resident's preference. The resident continued to lose weight and on 6/16/22 other interventions were put in place including additional proteins at meals, 2% milk served with meals, and fortified foods when possible. The 8/15/22 quarterly nutrition assessment documented that the resident had a significant weight loss of 15.8% over the past 180 days (since admission) and this was an unplanned weight change. No additional interventions were put into place. On 8/20/22 orders were placed for the resident to not be weighed for comfort. Meal intakes continued to be variable, interviews and observations during the survey indicated the resident said she did not like the food served and was not provided with milk (cross-reference F803 for menus). The care plan did not include nutritional interventions and just addressed weight fluctuations despite the resident's significant weight loss. Findings include: I. Facility policy The Hydration and Nutrition policy, revised 7/14/21, was provided by the director of nursing (DON) on 10/18/22 at 3:33 p.m. It read, in pertinent part, Adequate nutrition and hydration are essential for overall function. Each resident receives a sufficient amount of food and fluids to maintain acceptable parameters of nutritional and hydration status. A minimum of three meals are provided each day. If a meal or particular food is refused, the resident is offered a substitute of a similar nutritive value. Snacks are given between meals and at bedtime according to the resident desire and/or need. An ongoing assessment of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse. II. Resident status Resident #36, age 86, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/15/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. It indicated the resident required set up assistance for eating. It indicated the resident did not have difficulty swallowing. It indicated the resident had weight loss and was not on a physician prescribed weight loss regimen. The section related to dental status was incomplete. III. Resident interview Resident #36 was interviewed on 10/11/22 at 10:20 a.m. She said the food at the facility was not good. She said she had complained about the food to the staff but she was unsure who and they did not do anything. She said she did not try to get a different meal if she did not like what was served. She said she was independent with eating and preferred to eat in her room. She said she had lost about 25 pounds since admission and was not on any supplemental nutrition. She said she usually ate about 50% of her meals. Resident #36 was interviewed again on 10/12/22 at 1:00 p.m. She said she ordered a cobb salad for lunch and it was good. The resident had eaten 50% of her salad and no milk was on her tray. The resident had two drinks. Resident #36 was interviewed again on 10/13/22 at 9:05 a.m. She said breakfast was good that morning and she had eaten about 50%. She said no milk was served with breakfast but she did not like milk. The resident had eaten 50% of her breakfast and no milk was on her tray. IV. Record review Weights since admission revealed the following: -On 2/10/22 the resident weighed 173.4 pounds; -On 2/12/22 the resident weighed 173.6 pounds; -On 2/13/22 the resident weighed 173.3 pounds; -On 2/18/22 the resident weighed 170.0 pounds; -On 2/24/22 the resident weighed 168.7 pounds; -On 3/4/22 the resident weighed 165.1 pounds; -On 3/15/22 the resident weighed 162.4 pounds; -On 3/26/22 the resident weighed 159.8 pounds; -On 4/3/22 the resident weighed 160.1 pounds; -On 5/1/22 the resident weighed 157.1 pounds; -On 6/6/22 the resident weighed 156.8 pounds; -On 6/12/22 the resident weighed 155.1 pounds; -On 6/26/22 the resident weighed 155.1 pounds; -On 7/1/22 the resident weighed 155.6 pounds; -On 7/25/22 the resident weighed 151.7 pounds; -On 8/1/22 the resident weighed 149.8 pounds, a 23.6 pound weight loss over six months, which was 13.6%. The nutrition care plan, revised 6/1/22, indicated Resident #36 was at risk for weight fluctuations related to current health status. Interventions included assistance with meals as needed, education with resident and family on storage and preparation of outside food, education with resident and family on potential weight fluctuations, and encouraging and providing diet order. -No interventions or food preferences were included in the care plan until 10/13/22 (during survey). The updated nutrition care plan, initiated 10/13/22 (during the survey), indicated Resident #36 was at risk for poor nutrition related to being a selective eater, history of weight loss, and declining nutritional interventions. Interventions included encouraging fluids between meals, offering choices and honoring preferences, offering snacks in between meals, and providing tray set up. The October 2022 CPO revealed the following: -Evening snack at bedtime for nutrition support and document percentage consumed, ordered 7/27/22; and, -Resident on palliative care, do not weigh for quality of life, ordered 8/20/22. The initial nutritional assessment was completed on 2/14/22. It indicated Resident #36 was on a regular diet with regular texture and thin liquids. It indicated the resident was not on nutritional supplements. It indicated the resident's intake for breakfast and lunch was 76-100% and dinner was 51-75%. It indicated the resident had her own teeth, had no difficulty swallowing, and required set up assistance with meals. It indicated the resident's current intake was meeting their estimated protein and caloric needs. It indicated no nutritional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/9/22 a nutrition progress note indicated Resident #36 had a 3% weight loss over three weeks and 2Cal Med Pass two times a day was ordered as a supplement. The 4/28/22 a nutrition progress note indicated Resident #36 did not like the 2Cal Med Pass and the order was discontinued. -However, there were no other nutritional supplements offered to the resident or her dietary preferences obtained when she had 3% weight loss. The 5/5/22 a nutrition progress note indicated Resident #36 had a 5% weight loss over ten weeks. It indicated weight continued to trend downward with variable intakes of 25-75%. It indicated no nutritional interventions. The quarterly nutritional assessment was completed on 5/19/22. It indicated Resident #36 continued on a regular diet with regular texture and thin liquids. It indicated no significant weight loss and intakes ranged from 25-100%. It indicated the resident's protein and caloric needs were not being met. It indicated no nutritional interventions were in place due to the resident's dislike for oral nutrition supplements. The 6/16/22 nutrition progress note indicated Resident #36 had weight fluctuations and was down 5% over 12 weeks. It indicated two protein items and 8 ounces 2% milk were added to the tray card. The 6/24/22 a nutrition progress note indicated Resident #36 verbalized she did not want to eat because nothing sounded or looked good to her. It indicated Resident #36 did not like oral nutrition supplements and was not willing to try. It indicated the resident was agreeable to have two protein items and 8 ounces of milk at meals. The 7/28/22 a nutrition progress note indicated Resident #36 had 10% weight loss over 21 weeks. It indicated the addition of an evening snack as a supplement. The quarterly nutritional assessment was completed on 8/15/22. It indicated Resident #36 continued on a regular diet with regular texture and thin liquids. It indicated the resident's weight at admission was 173.4 pounds and current weight was 149.8 pounds. It indicated the resident had a significant weight loss of 15.8% decrease over the past 180 days and this was not a planned weight change. The assessment indicated two protein items, 2% milk, and fortified foods, if possible, would be served at all meals. It indicated an evening snack was initiated as a supplement. The summary of the assessment indicated no change in nutrition intervention and indicated the resident did not like oral nutrition supplements. The 8/15/22 nutrition progress note indicated Resident #36 refused to be weighed. It indicated the resident was on palliative care. It indicated the family was to bring in outside fast food and snacks to increase oral intake. The 9/15/22 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It noted the resident had lost 24 pounds since admission and a hospice consultation was discussed with the resident and family. The 9/22/22 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated the resident reported decreased appetite. The meal intake records from 9/18/22 to 10/17/22 indicated the resident's intake was variable and typically between 25-75%. -A request was made for meal percentage intakes since admission but these were not provided. The snack intakes from the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . July and August 2022 had 0% intake of snacks documented. The September 2022 intake had ten days of 100% intake and two days of 20-25% documented. The October 2022 intake had one day of 100% documented. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V. Interviews The registered dietitian consultant (RDC) and licensed practical nurse (LPN) #1 were interviewed on 10/13/22 at 3:27 p.m. The RDC said Resident #36 had weight loss prior to the do not weigh order. She said the do not weigh order was in place for comfort and the family preferred it. She said the resident did not take any nutritional supplements. She said the resident was able to choose her preferred meals and frequently ordered a salad or her family would often bring in food. She said the resident consumed more when family was present. She said the dietary staff could fortify foods such as sauce or gravy and it would be given depending on what the resident ordered and what was on the meal service line. She said the weight loss was expected. She said the resident did not have weight loss interventions because the resident declined the interventions. She said interventions should be included in the care plan such as food preferences, snacks, assessment of chewing and swallowing as needed, and accepting food and fluids as described. She said the resident's care plan should have more interventions than it currently had due to the resident's health status. She said it was expected the resident's weight would decline due to the lack of interventions and the resident not being willing to accept interventions. -However, the interventions were not routinely offered, her dietary preferences were not obtained nor were her complaints addressed regarding the food. LPN #1 said snacks were available to the resident but she did not typically eat them. LPN #1 said the resident did not eat more if staff was present. She said the resident did not complain of the food taste or texture and she could order whatever she wanted. She said her intake was usually 50%. Registered nurse (RN) #1 was interviewed on 10/17/22 at 1:34 p.m. She said Resident #36 ate about 50% of her food during meals. She said the resident did not ask for a different entree if she did not like what was served since she ordered her meals. She said she had not heard the resident complain about the taste or texture of the food. Certified nurse aide (CNA) #2 was interviewed on 10/17/22 at 3:11 p.m. She said the CNAs took the residents' orders before meals to determine if they wanted the main entree or something from the alternative menu. She said snacks were available to the residents but they were only given if the resident requested it. She said the snacks available were string cheese, yogurt, or a peanut butter and jelly sandwich. She was unsure if Resident #36 ever requested a snack. The DON was interviewed on 10/17/22 at 6:56 p.m. She said she was part of resident at risk meetings as well as interdisciplinary team meetings. She said these meetings were weekly. She said the facility's registered dietitian was out on medical leave and the RDC was filling in as needed but was not attending the weekly meetings. She said Resident #36 had an order of do not weigh. She said the last weight that was taken indicated the resident was losing weight. She said Resident #36 did not like supplements. She said the family would bring in snacks or fast food to increase intake and she was unsure if the resident verbalized a dislike of the food at the facility. She said the facility would fortify foods and give milk when possible. She said if milk was on the meal ticket she would expect it to be given. She said she did not see in the resident's chart where a snack would be provided in the evening.

Based on interviews and record review, the facility failed to ensure one (#17) of two out of 40 sample residents was treated with dignity and respect and cared for in an environment that promoted her quality of life. Specifically, the facility failed to ensure Resident #17 did not suffer from emotional distress by registered nurse (RN) #4. The facility failed to provide Resident #17 an environment free to share her concerns without fear of humiliation, retaliation or intimidation. The facility's failure caused continued emotional distress experienced by the Resident #17. Findings include: I. Resident #17 A. Resident status Resident #17, age 78, was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/29/22 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision with activities of daily living. It indicated the resident did not have any signs or symptoms of depression. The resident did not reject any care during the assessment period. B. Resident interviews Resident #17 was interviewed 10/11/22 at 10:32 a.m. She said about two to three months ago that RN #4 was short with her and embarrassed her in front of other staff members. She said she approached the unit manager, licensed practical nurse (LPN) #1 to make a doctor appointment for the next day regarding a procedure to remove eyelashes on her left eye because the unit manager for her unit was not at work. She said her eyelashes grow inwards and she was experiencing a lot of pain in the left eye. She said RN #4 approached her in the hallway and chewed me out and said that I didn't need to bother anyone else and I had to wait until my unit manager returned to make the appointment. Resident #17 said she approached the unit manager, licensed practical nurse (LPN) #2, upon her return to the facility, about the incident and told her that I felt like I was at fault and wanted to apologize to RN #4. LPN #2 told Resident #17 that she did not have to apologize. Resident #17 said she continued to feel badly and approached RN #4 the next day to apologize. RN #4 told the resident that she had been chewed out by LPN #2 regarding the incident. Afterwards, Resident #17 said that RN #4 was very cold towards her and would only come in to give her medications and leave. She said RN #4 would not speak with her. During the interview, Resident #17 became emotional and had tears in her eyes when speaking of the encounter with RN #4. Resident #17 said, They were supposed to investigate it and write up a report and they never did that. Resident #17 said RN #4 was no longer employed at the facility because she followed a member of the administrative team to another facility. She and there has been a positive change since she has been gone in the attitudes of the CNAs (certified nurse aides) and residents. C. Record review The mood care plan, initiated on 11/11/18, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -It did not include any person-centered approaches to manage the resident's depression. The impaired visual function care plan, initiated on 10/10/18 and revised on 1/22/2020, documented the resident's vision was severely impaired to the left eye and had right eye [CONDITION(S)] related to [CONDITION(S)], [NAME] disease of the eye and corneal ulceration of left eye (from misalignment of eyelashes as they rub against the eyeball). The interventions included consulting with an eye practitioner as required, explaining activities/sounds in the environment as needed and explaining care and services. II. Additional resident interview Resident #28, who was cognitively intact according to the facility assessment, was interviewed 10/17/22 at 10:30 a.m. Resident #28 said that RN #4 was a good nurse but she was abrupt with many residents and her attitude was someone who was not very happy with her job. She said RN #4 had an air about her where she felt RN #4 thought she was better than the residents and other staff members. III. Staff Interviews LPN #2 was interviewed on 10/13/22 at 5:00 p.m. LPN #2 said she was the unit manager of the unit where Resident #17 resided. She said that RN #4 butted heads with a lot of residents and was no longer employed at the facility. She said she followed the former NHA to another facility. LPN #2 said, in early July 2022, she had to take a day off of work. She said when she returned, Resident #17 said she went to LPN #1 to make an appointment for her to remove the eyelashes for her left eye, because she was experiencing pain. She said Resident #17 told her RN #4 accosted (approached aggressively) her in the hall and told Resident #17 that she did not need to bother anyone about her appointment and that she needed to speak with LPN #2 when she returned to work. LPN #2 said Resident #17 felt bad and wanted to smooth things over with RN #4. She said Resident #17 wanted to write an apology note to RN #4. LPN #2 told Resident #17 apologies were not necessary and that she should not feel bad about asking for the appointment. Resident #17 wrote the note and left it for RN #4 on the medication cart. She said she saw RN #4 take the note, unopened, to Resident #17's room. She said Resident #17 told her she found the note she had written RN #4 in her nightstand, unopened. LPN #2 said it was the ultimate (expletive) to someone who was just trying to offer an apology. LPN #2 said Resident #17 continued to feel badly and was emotional about the incident. LPN #2 said she reported this incident, in writing, to the former nursing home administrator (NHA) along with many other complaints from family, staff and residents regarding RN #4. LPN #2 said the former NHA was always smoothing things over and making excuses for RN #4. LPN #2 said the complaint was not addressed and felt the grievance, along with all the other grievances about RN #4, probably ended up in the shredder. LPN #2 said the former NHA and RN #4 were now employed at another facility. The NHA was interviewed on 10/17/22 at 8:15 a.m. He said he was unable to find an investigation regarding the incident between Resident #17 and RN #4. He said he interviewed Resident #17 that day (10/17/22) and she was very tearful and upset when recounting the incident regarding RN #4. He said he was not the NHA at the facility when this event occurred. LPN #2 was interviewed on 10/17/22 at 2:30 p.m. She said the issue regarding Resident #17 not feeling like RN #4 had been giving her the antidepressant medication (which had happened the weekend before the incident, see the former NHA interview below) and the issue with making the appointment were two separate instances. She said she was not aware of the incident with the medications. She said Resident #17 had come to her, the day she returned to work, and told her about the incident with RN #4. She said she immediately informed the former NHA that same day. LPN #6 was interviewed on 10/17/22 at 2:35 p.m. She said any allegations of abuse should be reported immediately to the unit manager, the director of nursing (DON), supervisor on duty and the executive director. She said the types of abuse reported were physical, mental, verbal and neglect. The NHA and former nursing home administrator (FNHA) were interviewed on 10/17/22 at 11:00 a.m. The FNHA said she had completed an investigation regarding Resident #17 reporting RN #4 had not been giving her the antidepressant medication she was prescribed, which was the weekend before the incident with RN #4. She said she had conducted an investigation and resolved the concern with the resident by ensuring the medications were shown to the resident prior to being crushed and mixed with applesauce. She said LPN #2 had not reported the incident between Resident #17 and RN #4 to her, however she was able to recount the entire event between Resident #17 and RN #4. She said that event had not been included in the investigation she completed about the medication concern.

Based on interviews and record review, the facility failed to ensure one (#17) of two out of 40 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #17 did not suffer from emotional abuse by registered nurse (RN) #4. The facility failed to provide Resident #17 an environment free to share her concerns without fear of humiliation, retaliation or intimidation. The facility's failure caused continued emotional distress experienced by the Resident #17. Findings include: I. Facility policy and procedure The Reporting Alleged Abuse policy and procedure, revised February 2017, was provided by the nursing home administrator on 10/10/22 at 8:30 a.m. It revealed, in pertinent part, This facility does not condone resident abuse and/or neglect by anyone. This includes but is not limited to: staff members, other residents, consultants, volunteers, staff from other agencies serving out residents, family members, the responsible party, sponsors, friends, or other individuals. All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease and depression. The 7/29/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision with activities of daily living. It indicated the resident did not have any signs or symptoms of depression. The resident did not reject any care during the assessment period. B. Resident interviews Resident #17 was interviewed 10/11/22 at 10:32 a.m. She said about two to three months ago that RN #4 was short with her and embarrassed her in front of other staff members. She said she approached the unit manager, licensed practical nurse (LPN) #1 to make a doctor appointment for the next day regarding a procedure to remove eyelashes on her left eye because the unit manager for her unit was not at work. She said her eyelashes grow inwards and she was experiencing a lot of pain in the left eye. She said RN #4 approached her in the hallway and chewed me out and said that I didn't need to bother anyone else and I had to wait until my unit manager returned to make the appointment. Resident #17 said she approached the unit manager, licensed practical nurse (LPN) #2, upon her return to the facility, about the incident and told her that I felt like I was at fault and wanted to apologize to RN #4. LPN #2 told Resident #17 that she did not have to apologize. Resident #17 said she continued to feel badly and approached RN #4 the next day to apologize. RN #4 told the resident that she had been chewed out by LPN #2 regarding the incident. Afterwards, Resident #17 said that RN #4 was very cold towards her and would only come in to give her medications and leave. She said RN #4 would not speak with her. During the interview, Resident #17 became emotional and had tears in her eyes when speaking of the encounter with RN #4. Resident #17 said, They were supposed to investigate it and write up a report and they never did that. Resident #17 said RN #4 was no longer employed at the facility because she followed a member of the administrative team to another facility. She and there has been a positive change since she has been gone in the attitudes of the CNAs (certified nurse aides) and residents. C. Record review The mood care plan, initiated on 11/11/18, documented the resident had a diagnosis of depression. It indicated the resident had a history of feeling tearful, hopeless and socially isolating. The interventions included administering antidepressant medications as ordered, completing the PHQ-9 (patient health questionnaire for depression) quarterly and as needed, providing the resident time to discuss concerns, feelings and thoughts as needed. -It did not include any person-centered approaches to manage the resident's depression. The impaired visual function care plan, initiated on 10/10/18 and revised on 1/22/2020, documented the resident's vision was severely impaired to the left eye and had right eye blindness related to macular degeneration, [NAME] disease of the eye and corneal ulceration of left eye (from misalignment of eyelashes as they rub against the eyeball). The interventions included consulting with an eye practitioner as required, explaining activities/sounds in the environment as needed and explaining care and services. III. Additional resident interview Resident #28, who was cognitively intact according to the facility assessment, was interviewed 10/17/22 at 10:30 a.m. Resident #28 said that RN #4 was a good nurse but she was abrupt with many residents and her attitude was someone who was not very happy with her job. She said RN #4 had an air about her where she felt RN #4 thought she was better than the residents and other staff members. IV. Staff Interviews LPN #2 was interviewed on 10/13/22 at 5:00 p.m. LPN #2 said she was the unit manager of the unit where Resident #17 resided. She said that RN #4 butted heads with a lot of residents and was no longer employed at the facility. She said she followed the former NHA to another facility. LPN #2 said, in early July 2022, she had to take a day off of work. She said when she returned, Resident #17 said she went to LPN #1 to make an appointment for her to remove the eyelashes for her left eye, because she was experiencing pain. She said Resident #17 told her RN #4 accosted (approached aggressively) her in the hall and told Resident #17 that she did not need to bother anyone about her appointment and that she needed to speak with LPN #2 when she returned to work. LPN #2 said Resident #17 felt bad and wanted to smooth things over with RN #4. She said Resident #17 wanted to write an apology note to RN #4. LPN #2 told Resident #17 apologies were not necessary and that she should not feel bad about asking for the appointment. Resident #17 wrote the note and left it for RN #4 on the medication cart. She said she saw RN #4 take the note, unopened, to Resident #17's room. She said Resident #17 told her she found the note she had written RN #4 in her nightstand, unopened. LPN #2 said it was the ultimate (expletive) to someone who was just trying to offer an apology. LPN #2 said Resident #17 continued to feel badly and was emotional about the incident. LPN #2 said she reported this incident, in writing, to the former nursing home administrator (NHA) along with many other complaints from family, staff and residents regarding RN #4. LPN #2 said the former NHA was always smoothing things over and making excuses for RN #4. LPN #2 said the complaint was not addressed and felt the grievance, along with all the other grievances about RN #4, probably ended up in the shredder. LPN #2 said the former NHA and RN #4 were now employed at another facility. The NHA was interviewed on 10/17/22 at 8:15 a.m. He said he was unable to find an investigation regarding the incident between Resident #17 and RN #4. He said he interviewed Resident #17 that day (10/17/22) and she was very tearful and upset when recounting the incident regarding RN #4. He said he was not the NHA at the facility when this event occurred. LPN #2 was interviewed on 10/17/22 at 2:30 p.m. She said the issue regarding Resident #17 not feeling like RN #4 had been giving her the antidepressant medication (which had happened the weekend before the incident, see the former NHA interview below) and the issue with making the appointment were two separate instances. She said she was not aware of the incident with the medications. She said Resident #17 had come to her, the day she returned to work, and told her about the incident with RN #4. She said she immediately informed the former NHA that same day. LPN #6 was interviewed on 10/17/22 at 2:35 p.m. She said any allegations of abuse should be reported immediately to the unit manager, the director of nursing (DON), supervisor on duty and the executive director. She said the types of abuse reported were physical, mental, verbal and neglect. The NHA and former nursing home administrator (FNHA) were interviewed on 10/17/22 at 11:00 a.m. The FNHA said she had completed an investigation regarding Resident #17 reporting RN #4 had not been giving her the antidepressant medication she was prescribed, which was the weekend before the incident with RN #4. She said she had conducted an investigation and resolved the concern with the resident by ensuring the medications were shown to the resident prior to being crushed and mixed with applesauce. She said LPN #2 had not reported the incident between Resident #17 and RN #4 to her, however she was able to recount the entire event between Resident #17 and RN #4. She said that event had not been included in the investigation she completed about the medication concern.

Based on observations, record review and interview, the facility failed to provide the necessary treatment and services to prevent the development of pressure injuries for one (#42) of two residents reviewed for pressure injury out of 40 sample residents. Resident #42 was identified by the facility as a high risk for developing pressure injuries upon his admission to the facility. On 9/13/22, the resident developed a pressure injury to the right trochanter (hip). The facility failed to ensure an initial assessment of the pressure injury was completed upon the residents admission, The physician was not notified timely and a treatment order was not put into place until 9/26/22; 13 days after the pressure injury was identified. A treatment note dated 9/27/22, by the wound physician, documented the resident had a stage 3 facility acquired pressure injury to her right hip. The facility failed to take sufficient steps to promote wound healing and prevent further skin breakdown. Additionally, the facility failed to ensure that repositioning and incontinence care were provided to the resident in a timely manner. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2018, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 10/27/22, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Ulcer Prevention policy and procedure, last reviewed April 2022, was provided by the nursing home administrator (NHA) on 10/18/22 at 3:41 p.m. It revealed, in pertinent part, To provide associates and licensed nurses procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPUAP (national pressure injury advisory panel) and WOCN (wound, [CONDITION(S)], continence nurses society). Based on the comprehensive assessment of a resident the facility must ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. A skin assessment/inspection occurs on admission/readmission. Skin observations also occur throughout point of care provided by CNA's (certified nurse aide) during ADL (activities of daily care) care (bathing, dressing, incontinent care, etc.). Any changes or open areas are reported to the nurse. A risk assessment tool, Braden scale or Norton scale, determines the residents risk for pressure injury development. The scores documented on the tool and placed in the resident's medical records using the appropriate form. Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include but are not limited to: impaired/decreased mobility and decreased functional ability, comorbid conditions, cognitive impairment, exposure of skin to urinary and fecal incontinence, and the history of healed injury. A skin assessment/inspection should be performed weekly by a licensed nurse. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. Upon admission and throughout stay at a minimum a pressure redistribution surface is in use with turning and repositioning as needed with ADL care/assistance incontinent care if needed to include skin barriers application as needed, preventative wheelchair cushion is indicated, etc. Skin inspections with particular attention to bony prominences, skin cleansing with appropriate cleanser at time of swelling and routine intervals, treat dry skin with moisturizers, minimize skin exposure to incontinence using devices ( i.e. briefs) and skin barriers, minimize injury due to shear and friction through proper positioning, transfers and turning schedules, improve residents mobility in activity when potential exists(restorative). Measures to protect the resident against adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: reposition at least every two to four hours (per NPIAP standards) as consistent with overall patient goal in medical condition; utilize positioning devices to keep bony prominences from direct contact; ensure proper body alignment when side-lying; heel protection/suspension if indicated; maintain HOB (head of bed) at the lowest degree of elevation consistent with medication conditions;, a pressure redistribution mattress service is placed under the resident; when positioned in a wheelchair, the resident is to be placed on a pressure reduction device and repositioned; when positioned in a wheelchair, consideration is given to postural alignment, distribution weight, balance, and stability. The Documentation and Assessment of Wounds policy and procedure, reviewed April 2022, was provided by the NHA on 10/18/22 at 3:41 p.m. It revealed, in pertinent part, To guide the associates and licensed nurse in the assessment of the wounds to include pressure ulcer/injuries, venous, arterial, diabetic, dehisced surgical wounds, and other (not otherwise specified). Based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. A wound assessment/documentation is required to occur at a minimum weekly. Nurses performing the treatment would perform an prn (as needed) assessment/documentation if noted change has occurred i.e. wound has healed/resolved, appears infected, or appears to have declined. It may not be practical for the weekly assessment to occur on the 7th day deadline due to dressing not required to be changed on due date, wound round or MD (medical doctor) schedule changes, follow-up appointments, or resident's refusal. For those purposes would obtain wound assessment/documentation prior to if able or within the calendar week to maintain assessment and documentation compliance. Documentation is located in the EHR (electronic health record) progress notes, wound observation tool and/or skin integrity data collection tools. Additional documentation from MD office visits or wound clinic notes may be located in the hard copy medical record. III. Failure to provide the necessary treatment and service to prevent the development of pressure injuries for Resident #42 A. Resident #42's status Resident #42, age 72, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 8/16/22 minimum data set (MDS) assessment, the resident had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. The resident required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. The MDS documented the resident was incontinent of bowel and bladder and did not have any unhealed pressure ulcers. The resident was on hospice care. B. Observations On 10/12/22, during a continuous observation, beginning at 2:06 p.m. and ended at 3:18 p.m., Resident #42 was observed laying in the supine position (laying on his back) with his feet directly onto the mattress. -At 2:55 p.m. Resident #42 remained in the same position. -At 3:18 p.m. Resident #42 was laying in bed, awake. He attempted to sit up in bed but was unable to reposition himself. On 10/13/22, during a continuous observation, beginning at 8:30 a.m. and ended at 1:25 p.m. Resident #42 was observed sitting in the day room, in front of the television, in a Broda chair. -At 8:48 a.m. the resident was observed eating breakfast in the day room, in the Broda chair. -At 9:10 a.m. Resident #42 remained in the day room, in the Broda chair. -At 9:34 a.m. licensed practical nurse (LPN) #2 and LPN #5 took Resident #42 to his room and helped him to bed by standing the resident and doing a pivot transfer. They placed a pillow behind his head and positioned him supine. The resident's feet were placed directly on the mattress. Certified nurse aide (CNA) #4 came into the resident's room, put his oxygen on, lowered the bed and positioned the resident at 45% angle. -At 9:45 a.m. CNA#4 brought the resident a blanket and put it on him. The resident's feet remained directly on the bed. -At 10:08 a.m. the Resident #42 remained in the same position. -At 11:05 a.m. LPN #5 checked to ensure dressing was on his pressure ulcer. She did not check the resident's incontinence brief or offer to reposition the resident. -At 11:18 a.m. hospice agency staff went in but left because the resident was asleep. The hospice agency staff did not provide the resident care. -At 12:14 p.m. Resident #42 remained in the same position. -At 12:22 p.m. CNA #4 closed the resident's door. She did not enter the resident's room. -At 12:34 p.m. LPN #5 entered the resident's room and gave the resident his medication. She did not offer or provide repositioning to the resident. -At 12:35 p.m. CNA #4 brought the resident his lunch tray, set it on the overbed table and assisted him with eating. -At 12:52 p.m. CNA#4 was finished assisting the resident with his lunch. CNA #4 lowered Resident #42's bed and kept the resident at a 45 degree angle. CNA #4 did not offer to reposition the resident or provide incontinence care. -At 1:17 p.m. Resident #42 remained in the same position. -At 1:25 p.m. CNA #4 entered the resident's room and provided Resident #42 with incontinence care. CNA#4 said the resident was incontinant with urine and the brief was wet. The soiled brief was observed in a trash bag. The brief was heavy, sopping wet, and the moisture could be felt with a gloved hand. CNA #4 said she had not provided Resident #42 incontinence care since the resident was transferred to the Broda chair for breakfast. After providing incontinence care, CNA#4 did not float the resident's heels. The resident was still laying in the supine position. Cross-reference F677: the facility failed to provide incontinence care and repositioning timely for Resident #42. C. Record review The cognition care plan, revised 10/5/22, documented the resident had impaired cognitive skills related to dementia, had trouble word findings and had short-term and long-term memory loss. The activities of daily living (ADL) care plan, revised on 10/11/22, documented the resident had a self-care deficit related to a [CONDITION(S)] ([CONDITION(S)]) with subsequent impaired mobility. It indicated the resident required one person assistance with bed mobility and totally dependent upon staff for personal hygiene and toileting. The interventions included providing the resident with body pillows for positioning while in bed, encouraging the resident to participate in ADLs as he was able, floating the resident's heels while in bed, repositioning the resident in bed as tolerated, placing the resident's call light on the left side of the resident due to visual impairments. The skin integrity care plan, revised on 10/10/22, revealed Resident #42 was at risk for an alteration in his skin integrity due to impaired mobility, incontinence and a right hand contracture. The interventions included placing an arm rest pad on the left side for skin integrity, applying lotion to the resident's bilateral upper and lower extremities daily, cleaning and drying the resident's skin after each incontinent episode with barrier ointment being applied, completing the Braden scale assessment quarterly or as indicated, checking for proper positioning when the resident was up in the Broda chair, following wound care orders, a pressure reducing mattress to the bed and cushion for the wheelchair and weekly skin checks. The skin impairment care plan, revised on 10/11/22, documented the resident had a stage three pressure injury to the right trochanter (any of two bony protuberances by which muscles are attached to the upper part of the thigh bone). The interventions included assessing the location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/6/22 Braden assessment documented the resident was at a high risk for pressure ulcers with a score of 11 out of 23. A lower score indicates more risk. III. Failure to assess, notify the physician and put a treatment in place timely upon the identification of a pressure injury A. Record review The 9/13/22 weekly skin integrity data collection documented the resident's skin was intact, however the 9/13/22 nursing progress note documented the resident had an open area to the right hip, was improving in size and condition, and it did not have any signs and symptoms of infection. It indicated the nurse applied skin prep to the open area. The September 2022 medication administration record (MAR) and the treatment administration record (TAR) did not reveal documentation of a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound physician note dated 9/27/22 documented that resident had a stage three pressure ulcer located on the right hip, that was acquired at the facility. The 9/27/22 weekly skin integrity data collection documented the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] The 9/27/22 wound observation tool assessment documented Resident #42 acquired a stage three pressure injury to the right trochanter on 9/21/22. It revealed the wound was unchanged with 20 % (percent) slough (part of the [CONDITION(S)] process consisting of [MEDICATION(S)], white blood cells, bacteria and debris, along with dead tissue and other proteinaceous material) The wound observation document revealed the wound was 2 cm (centimeters) length x 1.7 cm width x 0.2 cm depth. The treatment order was to apply [MEDICATION(S)] with a foam dressing every day. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound physician note dated 10/4/22 documented that resident had a stage three pressure ulcer located on the right hip. The wound physician used an anesthetic instrument 2% [MEDICATION(S)] intervention used as an anesthetic to numb sensation of pain. Also in place was an alternating pressure mattress. A wound physician note dated 10/11/22 documented that resident had a stage three pressure ulcer located on the right hip, the progress was better, complexity was high. Preventive measures care in place, offloading heels and plan in care. -The physician did not give any other details for preventative measures. B. Observations -On 10/13/22 at 11:00 a.m. LPN #2 was observed providing a treatment to Resident #42's stage three pressure injury to the right trochanter. -LPN #2 removed the treatment dressing and a small amount of light yellow purulent (pus) drainage was observed on the dressing. The wound edges appeared pink and the wound bed was difficult to visualize due to residual slough and drainage in the wound. -The measurements were: 0.5 cm length x 0.3 cm width x 0.1 cm depth. IV. Staff interviews LPN #4 was interviewed on 10/17/22 at 1:30 p.m. LPN #4 said Resident #42 had a pressure ulcer to the right hip that was being monitored daily. LPN #2 said Resident #42 was a high risk for developing pressure injuries and should be repositioned every two hours. When a new wound was identified, the registered nurse (RN) should be notified to perform an assessment and physician to obtain treatment orders. The director of nursing (DON) was interviewed on 10/17/22 at 7:00 p.m. The DON said that skin observations should be conducted every day during ADL care. She said any indication of skin breakdown should be reported to the nurse and an assessment should be completed. She said the physician should notify the physician to obtain a treatment order as soon as a wound was identified. She said she and the unit manager observed all wounds in the facility with the wound physician every Tuesday. She said the wound physician would assess the wound, provide treatments and document any changes to the treatment orders. The DON said any skin breakdown observed should be reported to the physician and a treatment should be put in place immediately. The DON said Resident #42 required assistance from staff for bed mobility and repositioning. She said repositioning should be provided or offered to Resident #42 approximately every two to three hours. She acknowledged the MAR and TAR did not reveal a treatment had been put into place until 9/26/22, 13 days after the nurse documented the wound to the right hip.

Based on interviews, observations and record review, the facility failed to ensure two (#42 and #20) of three residents reviewed for activities of daily living of 40 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to: -Ensure that Resident #42 received incontinence care timely; and, -Ensure that Resident #42 and #20 received repositioning timely. Findings include: I. Professional reference A. [NAME], T.V. et al. Review of the Current Management of Pressure Ulcers. Advances Wound Care. 2018 [DATE]; 7(2): 57-67. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 40/ retrieved on 10/21/22. Nursing home patients have a pressure ulcer prevalence of 11% and are most likely to develop pressure ulcer over the sacrum or heels. Nursing home patients were also found to have contractures at a prevalence of 55%. Contractures are caused by decreased elasticity of the tissue surrounding major joints, and the resulting lack of full mobility in the affected extremities significantly the risk of pressure ulcer formation. B. Pechlivanoglou, P. et al. TURNing high risk patients: An economic evaluation of repositioning frequency in long term care. Journal of the American Geriatrics Society. 2018 July; 66(7): 1409-1414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 29/ retrieved on 10/22/22. According to current US (United States) practice guidelines, nursing home residents should be repositioned as frequently as required by their condition. Practice guidelines in Canada and the US recommend that patients at high risk of pressure ulcers be repositioned every two hours. II. Facility policy and procedure The Activity of Daily Living policy and procedure, reviewed on 7/17/21, was provided by the nursing home administrator (NHA) on 10/18/22 at 3:34 p.m. It documented, in pertinent part, Purpose: to ensure facilities identify and provide needed care and services that are resident centered, in accordance with residents preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. For bed/wheelchair mobility the following procedures will be followed: assist residents with bed/wheelchair repositioning as necessary to promote good body alignment and prevent skin breakdown. Explain the importance of changing positions to prevent skin breakdown to the resident. Utilize appropriate safety measures and any necessary equipment to maintain resident safety. After providing assistance, ensure the resident is safe and comfortable and place the call light within reach. III. Resident #42 A. Resident status Resident #42, age 72, was admitted on [DATE]. According to the computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 8/16/22 minimum data set (MDS) assessment, the resident had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident was incontinent of bowel and bladder. B. Observations On 10/13/22, during a continuous observation, beginning at 8:30 a.m. and ended at 1:25 p.m. Resident #42 was observed sitting in the day room, in front of the television, in a Broda chair. -At 8:48 a.m. the resident was observed eating breakfast in the day room. -At 9:10 a.m. Resident #42 remained in the day room, in the Broda chair. -At 9:34 a.m. licensed practical nurse (LPN) #2 and LPN #5 took Resident #42 to his room and helped him to bed by standing the resident and doing a pivot transfer. They placed a pillow behind his head and positioned him supine (lying on his back, facing upward). Certified nurse aide (CNA) #4 came into the resident's room, put his oxygen on, lowered the bed and raised the head of the bed to a 45 degree angle. -At 9:45 a.m. CNA#4 brought the resident a blanket and put it on him. -At 10:08 a.m. the Resident #42 remained in the same position. -At 11:05 a.m. LPN #5 checked to ensure dressing was on his pressure ulcer. She did not check the resident's incontinence brief or offer to reposition the resident. -At 11:18 a.m. hospice agency staff went in but left quickly because the resident was asleep. The hospice agency staff did not provide the resident care. -At 12:14 p.m. Resident #42 remained in the same position. -At 12:22 p.m. CNA #4 closed the resident's door. She did not enter the resident's room. -At 12:34 p.m. LPN #5 entered the resident's room and gave the resident his medication. She did not offer or provide repositioning to the resident. -At 12:35 p.m. CNA #4 brought the resident his lunch tray, set it on the overbed table and assisted him with eating. -At 12:52 p.m. CNA #4 was finished assisting the resident with his lunch. CNA #4 lowered Resident #42's bed and kept the resident at a 45 degree angle. CNA #4 did not offer to reposition the resident or provide incontinence care. -At 1:17 p.m. Resident #42 remained in the same position. -At 1:25 p.m. CNA #4 entered the resident's room and provided Resident #42 with incontinence care. CNA #4 said the resident was incontinent of urine and the brief was wet. The soiled brief was observed in a trash bag. The brief was heavy, sopping wet, and the moisture could be felt through the bag with a gloved hand. CNA #4 said she had not provided Resident #42 incontinence care since the resident was transferred to the Broda chair for breakfast. After providing incontinence care, the resident was positioned back to the supine position. C. Record review The activities of daily living (ADL) care plan, revised on 10/11/22, documented the resident had a self-care deficit related to a [CONDITION(S)] ([CONDITION(S)]) with subsequent impaired mobility. It indicated the resident required one person assistance with bed mobility and totally dependent upon staff for personal hygiene and toileting. The interventions included providing the resident with body pillows for positioning while in bed, encouraging the resident to participate in ADLs as he was able, floating the resident's heels while in bed, repositioning the resident in bed as tolerated, placing the resident's call light on the left side of the resident due to visual impairments. D. Staff interview CNA #4 was interviewed on 10/17/22 at 12:25 p.m. She said residents should be offered incontinence care and repositioning every two hours. She said Resident #42 was incontinent and total assistance with repositioning and incontinence care. She said Resident #42 was not able to communicate that he needed incontinence care. Licensed practical nurse (LPN) #5 was interviewed on 10/17/22 at 1:30 p.m. She said Resident #42 was incontinent and needed to be checked and changed every two hours. She said because the resident had a pressure ulcer, he should be repositioned every two hours. The director of nursing (DON) was interviewed on 10/17/22 at 7:00 p.m. She said that residents that needed assistance with incontinence care need to be checked and changed every two to three hours. She said that residents who were at high risk for developing pressure ulcers and required total assistance with repositioning should be repositioned or offerred repositioning every two to three hours. IV. Resident #20 A. Resident status Resident #20, age 83, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/27/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene and extensive assistance of two people for transfers. B. Observations During a continuous observation on 10/12/22, beginning at 9:25 a.m. and ended at 2:30 p.m., Resident #20 was observed eating breakfast using her right hand. Resident was positioned on her back with bilateral legs tipped to the right side. -At 10:10 a.m. an unidentified certified nursing assistant (CNA) was observed taking blood pressure on the resident's left arm. Resident #20 remained on her back in the same position. -At 11:50 a.m. an unidentified staff member was observed delivering the lunch meal tray to the resident. -At 2:30 p.m. an unidentified CNA entered the resident's room. She did not offer to reposition the resident. During a continuous observation on 10/13/22, beginning at 9:00 a.m. and ended at 2:00 p.m., Resident #20 was observed eating breakfast in her room. She was lying on the bed, positioned on her back. -At 1:30 p.m., registered nurse (RN) #2 entered Resident #20's room to complete a skin assessment. During the skin assessment, unidentified crumbs were observed on linens underneath the resident, pillows were observed placed between the resident's knees and feet. The resident's legs were positioned to the right. Pillows were not placed behind the resident's back. Prior to the skin assessment at 1:30 p.m., facility staff had not entered Resident #20's room and offered the resident repositioning in over four hours. C. Record review The comprehensive care plan included the resident was at risk for skin impairment related to decreased mobility, bilateral foot drop, incontinence, cognitive impairment, severe contracture to bilateral knees, skin fragile and prone to bruising (initiated 6/18/18, revised 5/6/19). The interventions included rearranging bed to encourage repositioning (initiated 2/19/19), encouraging the resident to get up in the Broda chair as much as she would allow (initiated 2/26/2020), placing body pillow between the resident's legs, feet, buttocks, and bilateral knees (initiated 8/14/19), an air mattress with bolsters (initiated 8/15/18) and assisting the resident with frequent position changes as tolerated (initiated 8/15/18). The alteration in ADL self-care performance care plan documented the resident required assistance with ADLs related to dementia, limited range of motion, musculoskeletal impairment and bilateral contractures (initiated 7/5/18). It indicated the resident was totally dependent of one to two staff members with bed mobility and repositioning. D. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 10/17/22 at 2:35 p.m. She said Resident #20 was unable to reposition without nursing staff assistance. CNA #5 was interviewed on 10/17/22 at 2:40 p.m. She said Resident #20 was fully dependent and required two people for rolling or changing position. He said that the resident should be repositioned every one to two hours.

Based on observations, record review, and interviews the facility failed to ensure menus were followed to meet the residents' nutritional needs on two of two units. Specifically, the facility failed to follow the menu. Menu items were omitted without substitutions being made of the same nutritional value. Findings include: I. Facility policy and procedure The Menu, Substitution, and Alternative policy and procedure, 4/15/22, was sent via email on 10/18/22 at 3:34 p.m. by the director of nursing (DON). It revealed in pertinent part, Menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Residents with known dislikes of food and beverage items, who express a refusal of the food served or request a different meal choice are offered a substitute of similar nutritive value. Menus are reviewed for nutritional adequacy, approved and signed by the Registered Dietitian prior to beginning a new cycle. The Director of Food and Nutrition Services signs and dates the menus as used.Menus are served as written, unless changed due to an unpopular item on the menu, an item that could not be procured or a special meal. The Director of Food and Nutrition Services/Registered Dietitian documents the substitution on the extended menu and the Menu Substitution Record. Only the Director of Food and Nutrition Services, designee or the Registered Dietitian substitute menu items. Menus meet the nutritional needs of residents in accordance with established national guidelines. The Director of Food and Nutrition Services or Registered Dietitian ensures a planned menu alternate that is nutritionally equivalent is available on the menu. Each resident's preferences are followed to the extent nutritionally and medically desirable in order to promote food acceptance. II. Record review The facility's menus and nutritive values for week one and two were provided by the dietary manager (DM) on 10/10/22 at 12:46 p.m. The weekly menu cycle was Sunday through Saturday. Each breakfast menu included a beverage of choice and milk. Each dinner menu included a beverage of choice and milk. -Week one had milk listed on the menu calendar for every breakfast and dinner. -Week two had milk listed on the menu calendar for every breakfast and dinner. Milk was documented to be eight ounces for a regular diet, four ounces of whole milk for liberal renal diet, and skim milk for cardiac diets. III. Observations and interviews On 10/12/22 at 5:10 p.m.-5:30 p.m. in the dining room residents were not offered milk which was on the dinner menu. The dietary cook (DC) was interviewed on 10/12/22 at 5:12 p.m. The DC said if residents wanted milk they could have it but the resident must ask for it. She said the kitchen did not offer milk substitutes like cheese sticks or cottage cheese with the meals. The following residents were interviewed on 10/12/22 between 5:15-5:30 p.m. during the dinner meal in the dining room about being offered milk. Resident #7 said They do not offer me milk and I do not ask for it. I have two sodas. Resident #21 said I did not ask for milk. The staff did not offer me a substitute like cheese sticks or yogurt. Resident #193 said I am not offered milk with meals and I do not ask for it. Resident #57 said I only get water. I am not offered milk with meals. I would take a glass of milk if they offered whole milk but they only serve 2% milk. On 10/13/22 between 8:20 a.m.-8:25 a.m. the following residents were interviewed who receive room trays with meals in their rooms. Resident #13 said It says milk on the menu but I drink two sodas at night. The staff have never offered me a cheese stick of cottage cheese as a substitute. I don ' t think they do that here. Resident #76 said We do not get milk or substitutes offered with our meals. Observations on 10/13/22 at 8:05 a.m. during the breakfast meal in the dining room revealed the residents were not served or offered milk. IV. Staff interviews The dietary manager (DM) was interviewed on 10/17/22 at 9:25 a.m. She said everything that was on the menu should be served with each meal. She said if residents did not like milk when it was on the menu they could have cottage cheese or a cheese stick instead. She said she was unaware alternatives to milk were not being offered with the meals. She said she did not know if milk was on the menu for protein or dairy needs. She said she was unaware some residents were drinking only soda and not being offered milk. The registered dietitian consultant (RDC) was interviewed on 10/17/22 at 2:23 p.m. She said the facility did not need to offer a dairy substitute because the staff knew their residents. She said she would not offer other vegetables if a resident refused. She said she did not agree that if milk was on the menu other dairy items should be offered. She said the milk was on the menu for dairy needs. She provided the facility a la carte menu which revealed yogurt, cottage cheese, pudding and ice cream were available. The facility had the items in the kitchen but they were not offered for substitutes with meals which had milk on the menu. V. Facility follow-up On 10/18/22 at 1:01 p.m. the RD emailed additional information concerning milk being offered. She wrote the company spent $3,493.00 on milk products. She wrote concerning the dietary staff that they know the residents very well, including those who will or will not accept milk or a dairy equivalent. She wrote the regulation did not construe to limit the resident's right to make personal dietary choices. The facility failed to offer milk or offer any milk substitutes when milk was on the menu two times per day. How much the facility spent on dairy products was not the observation or an indication of offers. The information provided that the dietary staff knew each resident making them qualified to not offer milk or a milk substitute was not the observation. Also limiting the resident's right to make personal dietary choices was not the observation but rather being offered and then the resident could make personal dietary choice was the observation.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure two (#18 and #42) of six residents reviewed with limited mobility reviewed for range of motion (ROM) received appropriate services, equipment, and assistance to maintain maximal mobility and services to prevent further decrease in ROM, out of 40 sample residents reviewed. Specifically, the facility failed to provide: -Resident #18 contracture management services to maintain or prevent decline to his range of motion for contractures in his left elbow, left wrist, and left hand. He was not being offered or provided items for his left hand for his contracture. (carrots or rolled towel). He had not been evaluated for contracture devices since 2020. -Resident #42 had contracture management services for contractures to his right upper extremity. Findings include: I. Facility policy and procedure The Range of Motion and Exercise policy, revised 10/11/21, was sent via email on 10/19/22 at 11:54 a.m. by the director of nursing (DON). It revealed in pertinent part, The facility will provide Range-of-Motion Exercises in accordance with professional standards of practice as outlined by Lippincott through the procedure. Passive range-of-motion (ROM) exercises refer to movement of a joint through partial or complete range of activity with the assistance of a health care provider. Full ROM involves flexion, extension, abduction, adduction, and rotation of the affected joint. Indications for ROM exercises include patients with temporary or permanent loss of mobility, sensation, or consciousness. These exercises have been shown to improve or maintain joint mobility, strength, and endurance and prepare the patient for ambulation. When included as a key component of care, ROM exercises can enhance patient outcomes, improve gas exchange, reduce rates of ventilator-associated pneumonia, shorten the duration of mechanical ventilation, reduce the risk of contractures and enhance long-term functional ability. II. Resident #18 A. Resident status Resident #18, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/27/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. He required total dependence on staff for bathing. The resident did not reject care from staff. A seven day look back revealed the resident did not receive physical therapy, occupational therapy, and was not on a program with restorative nursing. -According to the director of nursing (DON) he had not received a restorative nursing evaluation since 2020, see interview below. B. Observations and interview On 10/10/22 at 3:52 p.m. Resident #18 was observed lying in bed, he used his right hand to hold his left wrist and hand next to his chest. He was not wearing any hand or elbow contracture devices. Resident #18 said he had terrible contractures in his left hand and left wrist. He said sometimes he put a rolled up tissue in his left hand to help make my contracture not hurt. He said his contractures did not get any better over time. He said the staff did not give or offer him anything to put in his hand or for his wrist. He said he had never heard of any device that was soft to put in his hand. He said sometimes he rolled up a corner of a blanket to hold in his palm to avoid his hand feeling bad. He said he would not refuse any items for his contractures if the staff provided something for him. On 10/11/22 at 10:00 a.m. Resident #18 was lying on his bed sleeping. His right hand held his left wrist close to his chest. His left hand was holding the corner material of his beige blanket. On 10/12/22 at 9:19 a.m. Resident #18 was lying on his bed. His left hand was bent over and his fingertips almost touched his left wrist. He did not have any contracture devices on his left hand. Resident #18 said sometimes his wrist and hand hurt, and sometimes it did not. He said he could push his soft beige blanket into his left palm to relieve any pressure he felt at times. At 3:36 p.m. the resident was in his wheelchair in his room. His right hand cradled his left wrist and hand to his chest. He did not have any contracture devices in his left hand. On 10/13/22 at 8:30 a.m. the resident was in his wheelchair in the dining room. He had his arms crossed across his chest with his right hand holding his left wrist while a staff member assisted him with eating. He did not have any devices for contractures in his left hand. On 10/17/22 at 11:00 a.m. Resident #18 was lying on his bed. His right wrist was holding his left wrist and left hand close to his chest. He did not have any contracture devices in his left hand. C. Record review The 10/2/18 comprehensive care plan, revised on 10/5/22, revealed the resident had limited physical mobility with contractures. He had contractures to his bilateral knees, left hand, left elbow and left wrist that were all present upon his admission. The goal was he would remain free of complications related to immobility through the next review date. The intervention was to cleanse his inner left hand contracture with soap and water, and dry completely daily. His multiple contractures to his wrist was one of the reasons he was a fall risk. -There were no current nursing or therapy notes which regarded that the resident was evaluated to maintain or prevent further worsening of his contractures. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 10/17/22 at 8:30 a.m. She said Resident #18 always used his right hand to hold his bent over left hand and held it close to his body. She said he did not wear a brace, or a sling, or anything in his hand. The director of rehab (DOR) was interviewed on 10/17/22 at 5:15 p.m. She said the last contracture evaluation Resident #18 had been in 2020. She said she remembered Resident #18 refused to wear any splinting. She said he had been on restorative before but when a resident refused help from restorative three times, they would be dropped from the program. She said we could offer him contracture management and restorative services for range of motion (ROM) exercises. She said every resident was reviewed for contractures every three months which included a staff member looking visually at their contracture. She said she had a spreadsheet that listed the residents in the facility who had contractures. She said it was important to have preventative measures in place so that contractures did not worsen. She said the facility needed to do better on his daily plan of care. She said she did not know if Resident #18 ' s contracture had worsened since his last evaluation which was a few years ago. She said she would look in the medical records to see if since 2020 any preventative measures for contractures and interventions were put in place for Resident #18. She said if she found pertinent information she would send it via email. -No follow-up email was sent regarding Resident #18 ' s contractures or interventions. The director of nursing (DON) was interviewed on 10/17/22 at 5:26 p.m. She said she was responsible for restorative nursing. She said she assigned a nurse to the program and the facility had only one restorative certified nurse aide (RCNA). She said the RCNA a few times a week was taken off of her restorative work to be a certified nurse aide (CNA) on the floor to help out when there was a staffing need. She said Resident #18 was encouraged to attend the activity departments exercise program. She said she did not know how often he attended an exercise program. She said he was evaluated for transfers in 2021. She said there were no preventative measures for his contractures indicated in his care plan. She said she knew a few years ago he did a restorative program but then refused. She said she did not know how long ago it was since he had been offered again to have a restorative program. She said the facility could offer him devices to help his contractures. She said she did not have any documentation that he was offered any measures for his left wrist and hand in the last six months. Licensed practical nurse (LPN) #1 was interviewed on 10/17/22 at 5:30 p.m. She said she was responsible for restorative nursing with the DON. She said the facility had one RCNA for the entire building who sometimes was required to work on the floor and did not perform restorative duties. She said she was aware Resident #18 had left wrist and left hand contractures and that he did not have any devices for his hands. She said she would help get him evaluated for devices right away. D. Facility follow-up On 10/19/22 at 5:29 p.m. director of rehab (DOR) emailed a occupational therapy evaluation and plan of treatment on 10/18/22 (after survey) for Resident #18. III. Resident #42 A. Resident status Resident #42, age 72, was admitted on [DATE]. According to the October 2022 CPO, the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 8/16/22 MDS assessment, the resident had short-term and long-term memory impairment with severe impairment in making decisions about tasks of daily life. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. The resident received restorative therapy. B. Observations On 10/12/22 at 2:06 p.m. Resident #42 was observed in his room. The resident ' s fingers were touching his palms and his wrist on his right hand and his arms were on his chest. He was lying supine (on his back). The resident did not have a splint of preventative measures in place for his contractures. -At 3:18 p.m. Resident #42 was laying in the same position. He did not have any preventative measures in place for his contractures. On 10/13/22 at 8:30 a.m. Resident #42 was observed sitting in the day room in his Broda chair, in front of the television. The resident did not have any preventative measures in place for his contractures. -At 9:45 a.m. certified nurse aide (CNA) #4 brought a blanket and put it on the residents feet. She did not offer the resident any preventative measures for his contracture. -At 1:17 p.m. the resident was observed in his room, lying supine in the bed. The resident did not have any preventative measures in place for his contractures. C. Record review The limited range of motion care plan, initiated 8/23/22, revealed that the resident had contractures to the right wrist, right elbow, right shoulder, right hand and left ankle. The interventions included observing and reporting any signs of immobility, contractures forming or worsening, thrombus formation or skin-breakdown; providing supportive care and assistance with mobility as needed; and providing active and passive range of motion. It indicated the resident required total assistance for passive stretching of the bilateral ankles. The October 2022 CPO documented a restorative nursing range of motion program for the resident. -However, it did not include any instructions regarding which areas, how many days per week or minutes during each session. According to the October 2022 restorative nursing range of motion program documentation the resident participated in total assistance of the bilateral left ankle on six out of 14 occasions. -It did not indicate if any other range of motion was provided for the resident ' s other contractions. D. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 10/17/22 at 1:30 p.m. She said the nurses or CNAs provided active range of motion (ROM) with Resident #42. She said the ROM was not documented in the resident ' s medical record. She said the facility staff communicated verbally that the ROM was completed for the resident. The director of rehabilitation (DOR) was interviewed on 10/17/22 at 5:15 p.m She said the facility offered daily restorative therapy for residents with contractions. She said that only the restorative nurse performed range of motion on the resident under the restorative program plan. She said Resident #42 had a brace but threw it last time he was at therapy and it was still in the therapy room. She said they have tried a rolled up towel in the past and he refused. -However, the DOR was unable to provide documentation of the resident's refusal of the splints and preventative measures such as the rolled towel during and after the survey process.

Based on observations, record review, and staff interviews, the facility failed to provide an ongoing program to support residents in their chosen activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#84 and #71) of four out of 40 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #84 and Resident #71. Findings include: I. Facility policy and procedure The Therapeutic Activities Program policy and procedure, revised 4/1/22, was provided by the nursing home administrator (NHA) on 10/18/22 at 3:34 p.m. It documented, in the pertinent part, The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activity program. This includes completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing. Directing the activity program includes scheduling of activities, both individuals and groups implementing and/or directing/delegating the implementation of the programs, monitoring the response and or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary. The facility should implement an ongoing resident centered activities program that incorporates the residents interest, hobbies and cultural preferences which is integral to maintaining and/or improving resident's physical, mental and psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (Security, autonomy, growth, connectedness, identity, joy and meaning). Procedure program scheduling: it is important for residents to have a choice about which activities they participate in, whether they are part of a formal activities program or self-directed. Additionally, a resident's needs and choices for how he or she spends time, both inside and outside the facility, should also be supported and accommodated, to the extent possible, including making transportation arrangements. Program types: Individual or independent programming ensures that all residents who are unable or unwilling to participate in group programs have consistent, goal oriented and individualized recreation opportunities. All residents have a need for engagement and meaningful activities. Residents who prefer not to participate in group programs and/or independently involved in recreation pursuits will be identified through an assessment process. Individual interventions will be developed based on each resident's assessed needs. The individual program will be provided according to a consistent schedule identifying specific days of the week and the timeframe in which the program will occur. Each resident's individual program will include interventions that meet the resident's assessed social, emotional, physical, spiritual and cognitive functioning needs. These approaches will reflect the resident's lifestyle and interests and will be incorporated into the interdisciplinary care plan. Group programming ensures each resident the opportunity for active participation in group programming designed to accommodate his or her social and or cognitive abilities to promote quality of life. The resident population will be assessed according to each resident's present cognitive capability, physical functioning, and endurance as it relates to his or her social functioning to determine the level of programming in which each resident would best function. Independent recreation participation will be documented in the progress notes to reflect planned approaches and progress towards goals. The current participation record will be maintained daily, organized and accessible to recreation service staff. All participation records are maintained as part of the medical record for three months and then submitted to medical records. II. Resident # 71 A. Resident status Resident #71, age [AGE] years old, was admitted on [DATE]. According to October 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/16/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance of one person with bed mobility, toileting and personal hygiene and supervision with transfers. The 8/16/22 MDS assessment documented reading and keeping up with the news was very important to the resident and going outside to enjoy the weather and doing his preferred activities was somewhat important. B. Observations On 10/12/22, during a continuous observation beginning at 9:15 a.m. and ended at 3:16 p.m., Resident #71 was observed sitting in his wheelchair, in his room with no meaningful activities. -At 9:27 a.m. the resident was in his chair with his food on the table, but he was not eating. -At 9:34 a.m. certified nurse aide (CNA) #4 entered the resident's room and asked him if he needed his glasses. CNA #4 gave the resident his glasses and then left the room. -At 10:00 a.m. activity staff were observed asking other residents if they wanted to attend the exercise group activity. They did not enter Resident #71's room to invite him. -At 10:20 a.m. Resident #71 was observed sleeping in his wheelchair. -At 10:45 a.m. Resident #71 remained sitting in the wheelchair in his room. The activity staff were observed walking through the hallway and were asking some residents if they wanted to participate in the crafting group activity. The activity staff did not go into Resident #71's room to ask him if he wanted to participate in the group activity. -At 12:04 p.m. the resident's family member entered the resident's room to visit with him and left the facility at 1:04 p.m. -At 2:22 p.m. Resident #71 was observed sitting in his room, in his wheelchair. -At 3:16 p.m. the activity staff were observed walking throughout the hallway asking some residents if they wanted to attend a group activity of making candy bags. The activity staff did not go into Resident #71's room or ask the resident if he would like to participate in the group activity. On 10/13/22, during a continuous observation beginning at 9:03 a.m. and ended at 12:20 p.m., an activity staff member was observed entering Resident #71's room to drop off the Daily Chronicle. -At 9:14 a.m. the resident was in his room, sitting in the wheelchair. The television was not turned on and the resident did not have any meaningful activity while in his room. An unidentified CNA entered the resident's room. She did not speak to the resident and then exited the room. -At 9:36 a.m. an unidentified CNA entered Resident #71's room and changed the bedding. Upon exiting the room, the CNA shut the door. Activity staff were observed walking throughout the hallway asking some residents if they wanted to attend the group activity which was exercising. Activity staff did not go into Resident #71's room or ask the resident if he would like to participate in the group activity. -At 11:14 a.m. the resident propelled himself in his wheelchair out of his room and into the hallway. -At 11:27 a.m. the resident's family member entered the nursing unit and wheeled the resident back to his room to visit. C. Record review The activity care plan, dated on 8/23/22, documented that Resident #71 enjoyed the paper daily, music, time with his family, socializing and watching television, but needed assistance with channel selection. The interventions included encouraging communication with his family, encouraging the resident to spend time outside of his room interacting with peers and staff members, spending time with visitors in the common areas to increase time out of his room and endurance, and encouraging participation in activities by assisting him to and from activities. It indicated the resident required reminders for group activity times and locations. The 8/29/22 activity progress note documented that the resident had a subscription to the newspaper and received it daily. It indicated he was observed watching television, sleeping, socializing with employees and people watching. The resident had little to no interest in attending group activities at this time, however last quarter the resident participated in happy hour, sweet shop, calendar review, holiday events, and order in lunch group activities/events. The 9/14/22 activities evaluation documented that the following activities were somewhat important to the resident: animals and pets, community outings, music, and social parties. It indicated the following activities were very important to the resident: current news, family and friends, movies, reading, sports and television. The August 2022 participation records documented Resident #71 participated in the following activities: current events on 20 occasions, received the newspaper on 23 occasions, reading on 17 occasions, watched television on 15 occasions, went for a wheelchair walk on three occasions and looked outside through the window on 11 occasions. The September 2022 participation record documented the resident participated in five sessions of current events, had five family visits, received mail delivery nine times and newspaper delivered 22 times and socialized on six occasions. The October 2022 participation record documented Resident #71 received mail delivery on three occasions, newspaper delivery on 16 occasions, socialized on three occasions, watched sports on one occasion and watched television on 15 occasions. D. Staff interviews Certified nurses aide (CNA) #4 was interviewed on 10/71/22 at 12:25 p.m. She said that Resident #71 enjoyed watching television. She said he did not leave his room often. The activities director (AD) was interviewed on 10/71/22 at 2:40 p.m. She said Resident #71 liked activities that involved food and would bring him food to his room for the men's lunch. She said that he did not participate in other group activities and the activities staff tried to invite him to activities that revolved around food. She said the resident was not on a one-to-one activity program. She said she did not know why the resident was not invited to the group activities on 10/12/22 and 10/13/22. She said the resident should have been invited and given the opportunity to decline. III. Resident #84 A. Resident Status Resident #84, age 92, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 9/22/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. She required total dependence on staff with walking in the corridor, and locomotion on and off the unit. It was important for her to go outside and get fresh air when the weather was good. B. Observations During daily observations of the resident she was observed in her room lying on her bed. Her bed was the first bed to the right upon entry into the room. Her bed faced the hallway door with her back to a privacy curtain. During observations the angles of her bed varied from flat on her back to a 30 degree angle. Her roommate's bed was next to the window. Each day it was very dark in her room with the privacy curtain drawn which blocked a view of the window. Even if the resident turned herself around 180 degrees she would only see a curtain. On 10/10/22 at 9:30 a.m. the resident was on her bed in a dark room, a privacy curtain drawn to separate the roommates which blocked the window, and the resident was looking at her computer tablet. On 10/11/22 at 10:15 a.m. the resident was on her bed in a dark room, a privacy curtain drawn to separate the roommates, which blocked the window, and the resident was looking at her computer tablet. On 10/12/22 at 10:20 a.m. the resident was on her bed in a dark room, a privacy curtain drawn to separate the roommates, which blocked the window, and the resident was looking at her computer tablet. At 2:00 p.m. the privacy curtain was pulled back to the wall, the window was visible and there was sunlight throughout the room. The resident had her back to the window, her bed was up at a 30 degree angle, and she had her computer tablet. She did not face the window. On 10/13/22 at 10:20 a.m. and 4:00 p.m. the resident was on her bed in a dark room, a privacy curtain drawn to separate the roommates which blocked the window, and the resident was looking at her computer tablet. On 10/17/22 at 8:20 a.m., 11:30 a.m. and 2:22 p.m. the resident was on her bed in a dark room, a privacy curtain drawn to separate the roommates which blocked the window, and the resident was looking at her computer tablet. C. Resident interview Resident #84 was interviewed on 10/10/22 at 9:30 a.m. She said she requested the facility move her to a room which had a bed by the window. She said that being in bed all day next to the wall in a dark room was depressing. She said she had depression and it was relieved at times by going outside, and also being able to look out a window. She said she asked someone to take her outside in a wheelchair this week because it was perfect fall weather. She said she had not been out of her bed for about two weeks and that was depressing to her. Resident #84 was interviewed again on 10/12/22 at 10:20 a.m. She said she could not see behind the privacy curtain that separated her area from her roommates. She said she needed staff help to get out of her bed. She said she could not see out the window but she said a staff member told her she was on a list for a room with a bed by the window. She said she did not know when that would happen but hoped it would be soon. She said she asked again to go outside in a wheelchair and was told someone would take her outside today or tomorrow. Resident #84 was interviewed again on 10/13/22 at 4:00 p.m. She said no staff took her outside yesterday or today. D. Record review Care Plan The comprehensive care plan, 9/16/22, identified the resident had seasonal depression and enjoyed sunshine. On 10/5/22 it was identified to offer to take the resident outside. The resident required one staff member to provide moderate to maximum assistance to move between surfaces and utilize a wheelchair. Assessment The 9/22/22 MDS admission assessment revealed it was important for the resident to have reading materials, visit with pets, and to go outside to get fresh air when the weather was good. The 9/25/22 activities assessment revealed the resident enjoyed the outdoors. The resident's preferred way to be outdoors was to look out the window from her bed. The 10/4/22 psychosocial note written by the social service director (SSD) revealed, the social worker discussed with the resident her voicing she had seasonal depression, and asking staff to offer to take her outside/out of her room. Activity Participation The activity participation records were provided by the SSD on 10/17/22 at 2:27 p.m. It was revealed, -September 2022 the resident was only offered activities twice since her admission on 9/15/22. She was offered the two activities both on the same day 9/28/22. She declined the offer to a garden group, and to order lunch in. She was not offered any other activities in the month, including the category of patio time. -October 2022 the resident was offered activities three times (during the survey). On 10/11/22 she declined the offer categorized as travelog. On 10/12/22 she declined two activity offers, crafts, and trivia. She was not offered any other activities in the 17 days of the month, including the category of patio time. E. Staff interviews The SSD was interviewed on 10/17/22 at 1:56 p.m. She said she had offered to take the resident outside and so had the staff. She said she did not know which staff offered to take her outside. She said she had written down in her progress notes that she offered to take the resident outside. She said primarily it was the activity department's job to take the resident outside. She said she would provide her progress notes of the outside invites. -No progress notes of outside invites were provided by the SSD. The nursing home administrator (NHA) was interviewed on 10/17/22 at 2:05 p.m. He said the resident was on a list to get moved to a room with a bed by the window. He said the facility was redoing floors in a few rooms. He said when that project was finished the resident would then be offered to move to a room with a bed by the window. The activity director was interviewed on 10/17/22 at 2:40 p.m. She said Resident #84 liked to go outdoors and liked to look out the window. She said on the activity participation record there was a section called patio time which meant to take a resident outdoors. She said she did not have any documentation or proof that the resident was offered activities or declined any other activities other than what was on the activity log since she was admitted . The AD said she only had documentation that the resident declined invites twice in September 2022 and three times in October 2022. She said the resident was not provided one-to-one visits from the activity department. She said in the future she could ask the resident what specific days she would like to go outside and take her on those days. She said the resident liked looking through her window to view the outside as one of her activities of choice. She said she had not been in the resident's room in about a month. She said she was unaware her roommate was next to the window and that Resident #84's privacy curtain was often pulled. She was also unaware the resident's back was to the window. She said she needed to be helped by staff into her wheelchair in order to go outside. She said she could not say if her department offered to take her outside and said she had no other documentation. She said she would fix the situation right away.

Based on interviews and record review, the facility failed to ensure two (#76 and #17) of three out of 40 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to: -Respond timely to a grievance filed by Resident #76. The resident had a certified nurse aide (CNA) #3 help with the completion of a grievance form. CNA #3 placed the grievance form in her personal bag and placed it in her car instead of turning the grievance form into facility management. CNA #3 left the grievance form in her car until she returned to work six days later, and seven days after the incident, when she gave the grievance form to the social service director (SSD); and, -Respond to a grievance for Resident #17, when she reported her sunglasses missing to staff. Findings include: I. Facility policy and procedure The Grievance Procedures and Concern & Comment Program policy, revised 8/7/21, was sent via email on 10/19/22 at 11:54 a.m. by the director of nursing (DON). It revealed in pertinent part, The Concern & Comment Program is utilized to address the concerns of residents, family members and visitors. The Social Services Director is responsible for the following: Assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights, and accommodation of needs. As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. Immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the Executive Director; and as required by State law. Coordinating orientation and in-service training to ensure that all facility associates know about the facility grievance procedures, the Concern & Comment Program, and their roles in providing responsive customer service to residents and families in grievance resolution. All staff are responsible for the following: Immediately communicating all grievances and concerns expressed by residents, families, and/or visitors to a licensed nurse or department manager. The associate completing the form will take adequate time to record the concern comprehensively or allow the concerned individual to record their comments on the form. Complete information will facilitate appropriate & prompt follow-up. Resolve the concern, if possible. If resolution is not possible at that time, explain to the individual that another staff member will be assigned to investigate the concern and will contact them as soon as possible. All concerns are reported to the Supervisor on duty who will then contact the Executive Director, Director of Nursing, and/or other personnel as needed. Administrative staff are responsible for the following: Reporting grievances and concerns to the Executive Director and Director of Nursing. Routing the Concern & Comment Form to the Social Services Director and/or Executive Director as well as the appropriate department manager to investigate and resolve the concern. The appointed manager will contact the concerned party within 24 hours to share the status of the investigation and resolution. II. Resident #76 A. Resident status Resident #76, age 84, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance with transfers, bed mobility, dressing, toilet use, and personal hygiene. She required limited assistance with walking in her room, and walking in the corridor. B. Resident interview Resident #76 was interviewed on 10/10/22 at 3:18 p.m. She said the facility did not handle grievances well. She said she turned in a grievance form a few days ago. She said a staff member helped her fill it out and took it from her to hand it in for her. She said she did not know who her form was given to. She said when she did complain no one from staff ever came back to tell her what happened with her complaint or how it would be resolved. She said there really was no point filling out the grievance forms when they did not come back to follow-up with her. She said a CNA from an agency was rude and treated her roommate roughly verbally. She said I said loudly when the situation was happening, watch out roomie, she is bigger than you. She said she complained about the situation to the facility CNA and even filled out a grievance form. She said she never heard anything back from the facility about her grievance. She said she did not know if that specific agency CNA was still allowed to work in the facility or not. She said, I hope they don't allow that agency person back in the building. C. Record review The facility grievance logs for six months were provided by the nursing home administrator on 10/12/22 at 2:00 p.m. The grievance from Resident #76 was not on the log sheet of complaints. The facility grievance card for Resident #76 was provided on 10/13/22 at 10:17 a.m. The front and back of the card was filled in but there were no attachments (which were provided on 10/17/22). The facility grievance for Resident #76 was provided again on 10/17/22 at 8:50 a.m. by the director of nursing (DON). The card had two attachments with it. The attachments were written statements from the social service director (SSD) and another from a registered nurse (RN). The grievance card and attachments revealed: -The reported incident took place on 10/7/22 with no time recorded of the event (Friday). The resident had a staff member help her fill out the grievance form on 10/8/22 at 10:45 a.m. (Saturday). (The staff member said she put the grievance card in her personal bag and left the bag with the grievance form in her car until she returned to work on 10/13/22 Thursday, 6 days later, see interviews below). -Resident #76 described her concern: Rude to roommate. Nurses to care for us. Resident #76 wrote that she provided this information to the staff member CNA #3. Resident #76 wrote CNA #3 was not able to resolve her concern. -The facility investigation and response on 10/13/22 at 8:00 a.m. revealed the SSD spoke to both residents in the room. -Actions taken to resolve/respond to the concern, was education with staff on reporting timely. -The attachments revealed an interview on 10/13/22 at 8:00 a.m of the SSD and the two roommates. The SSD followed-up on the grievance form with the residents. The other attachment was written by a facility RN. The RN dated her timeline of the event on 10/7/22 (Friday). The RN's signature was on the bottom of her written statement but she did not sign a date when she wrote her timeline for the investigation. The RN's timeline did not include that CNA #3 spoke to her about the grievance card. The RN's timeline was a review of conversations with the two residents on 10/7/22. No grievance card was filled out by the RN on 10/7/22. The RN's timeline did not include any conversation with CNA #3 about the grievance. D. Staff interviews The SSD was interviewed on 10/17/22 at 1:08 p.m. She said the incident occurred on 10/7/22 and the grievance card was brought to her on 10/13/22. She said she asked the RN who worked that night to write out a statement on 10/14/22. She said we began immediate education of the staff on how to report grievances. She said very soon the facility would have all staff educated on the subject of grievance reporting. She said the RN who wrote a timeline was not in the building today to be interviewed. She said CNA #3 worked on Saturday 10/8/22 and did not return to work until Thursday 10/13/22. She said she did not know where the grievance card was for the week. She said it was brought to her on 10/13/22. She said CNA #3 told her the reason she waited to hand in the grievance card was because the CNA wanted to speak with the SSD personally about the matter when she handed in the grievance card. The NHA was interviewed on 10/17/22 at 1:20 p.m. He said the incident happened on 10/7/22. He said the complaint was written on Saturday 10/8/22. He said CNA #3 did not give the complaint form to the SSD until 10/13/22 on Thursday. He said he did not know if the CNA took the written grievance home with her. He said the CNA had been trained to give the grievance card to management immediately but she did not hand the card in to management. He said he did not interview the agency CNA which the complaint was about. He said he did not interview the agency CNA because the facility had placed her on a list to not allow her to work at the facility. He said he did not feel any follow-up was necessary because it was a customer service issue. He said he did not contact the agency to tell them about the CNA in the grievance. He said he would provide the written documentation that the agency CNA on the grievance form was not allowed back to work in the building. (see below, no proof was provided by the facility) CNA #3 was interviewed on 10/17/22 at 1:39 p.m. She said on Saturday 10/8/22 Resident #76 told her an agency CNA was very rude to the resident's roommate. She said she gave a grievance form for Resident #76 to fill out. She said she told an RN in the building about the situation. She said she put the grievance card in her work bag on 10/8/22 and put it in her car for a week. She said she gave the grievance card to the SSD when she worked again on 10/13/22. She said she was wrong not to give the card to the SSD, or the receptionist, or the manager on duty. She said she had never helped a resident with a written grievance before. She said it was the first time she had ever completed one in the years she worked in the facility. She said she learned from the situation to hand the grievance card in immediately. She said from now on she would turn in a grievance to the manager on duty, or even call the SSD or the DON. E. Facility follow-up The facility did not provide the requested information about the reported agency CNA who was not allowed to work in the facility again. The facility did not provide any documentation during survey or afterwards (exit 10/17/22) of the list of agency staff not allowed to work in the facility again. III. Resident #17 A. Resident status Resident #17, age 78, was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/29/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision with activities of daily living. B. Resident interview Resident #17 was interviewed on 10/11/22 at 10:40 a.m. Resident #17 said that a pair of sunglasses were left by her daughter in law with the receptionist about one month ago. The receptionist had placed her name on the glasses and left them on the counter instead of bringing them directly to her. She said the sunglasses were missing and had never been replaced. She said the resident said staff were aware that the sunglasses were missing. C. Record review The 10/17/22 concern and comment form (completed on 10/17/22, during the survey process, completed by the social services assistant) documented the resident was unable to locate an original pair of sunglasses and had initially declined for glasses to be replaced. It did not include the details of the sunglasses, which were labeled with her name, were not returned to her and had been left at the front desk of the facility. The SSA offered to replace the sunglasses (on 10/17/22) and the resident agreed. The resolution documented that Resident #17 would purchase new sunglasses and submit a receipt for reimbursement. The form was signed by the nursing home administrator (NHA) on 10/17/22. II. Staff Interviews Receptionist #1 was interviewed on 10/13/22 at 4:00 p.m. She said Resident #17's granddaughter had brought in a pair of sunglasses about one month prior. She said she had labeled the sunglasses for the resident and placed them on the counter. She said the sunglasses were on the counter when she left for the evening. She said, the next morning, the sunglasses were gone from the counter. She said she asked Resident #17 if she had the sunglasses, and she said they had not been given back to her. She said she reported the missing sunglasses to the social services assistant (SSA). The social services director (SSD) and SSA were interviewed on 10/17/22 at 3:35 p.m. The SSD said grievances and reports of missing items were documented on a concern and comment form. She said the receptionist logged the forms and then provided them to the appropriate department to investigate. The SSA said Receptionist #1 had reported Resident #17's missing sunglasses. She said she did not document the missing sunglasses on a concern and comment form. She said she had talked to Resident #17 after the sunglasses went missing and she did not want them replaced. She said she did not document the conversation with the resident. She said she completed a concern and comment form and met with Resident #17 that day (10/17/22) and determined the resident wanted the sunglasses replaced. She said she submitted the concern and comment form to the NHA.

Based on observations, interviews and record review, the facility failed to ensure the highest practicable well-being for one (#1) of three sample residents. Specifically, the facility failed to ensure the resident was timely assessed for change in limb length and swelling to the right leg, which had recently been surgically repaired after a fall at the facility. Though the facility had been informed of a change in limb length, no nurse visualized the lower extremities or documented an assessment of the same related to limb length change. The facility waited until the next day (approximately 16 hours) to obtain assessment via x-ray, which resulted in the resident being transferred from bed to chair and the resident receiving therapy services before the dislocation of the surgically repaired hip was confirmed via x-ray. The findings included: Cross reference F323, failure to provide supervision and assistance to prevent falls with injury, for interviews and record review demonstrating a 16-hour delay in coordinating cares for the resident after an x-ray identified an acute [MEDICAL CONDITION] hip. Resident Status: Resident #1, age 94, was admitted on [DATE] and re-admitted on [DATE]. According to the 8/16 computerized physician orders [REDACTED]. The 7/20/16 significant change minimum data set (MDS) comprehensive assessment showed the resident had severe cognitive impairment as evidenced by a brief interview for mental status score of two of 15. The resident did not exhibit behavioral symptoms or rejection of cares during the MDS observation period. -The resident required extensive assistance from two staff for bed mobility, transfers, and toileting. The resident was not steady and was only able to stabilize with human intervention when moving from seated to standing position, moving on and off the toilet, and with surface to surface transfers. The resident had range of motion limitations to one lower extremity. The resident had a catheter for urinary continence and was frequently incontinent of bowel. -The resident had a fall in the month prior to re-admission and had falls in the two to six months prior re-admission. The MDS indicated it could not be determined if the resident had a fracture related to falls in the six months prior to re-admission. Family Interviews: A family member visiting the resident was interviewed on 8/2/16 at 10:29 a.m. The family member said the resident had broken her hip in multiple places after a fall at the facility. The family member said they were concerned about the resident's right leg (which had been surgically repaired after the fall with fracture) because there was new swelling. The family member said the resident's memory interfered with determining the resident's pain. According to the family member, the resident reported knee pain, even though she guarded her right hip after the hip repair surgery. The family member suggested speaking with the resident's power of attorney. A telephone interview was conducted with the resident's power of attorney (POA) on 8/2/16 at 10:40 a.m. A follow-up interview was conducted in person on 8/2/16 at approximately 2:50 p.m. The POA said the family was worried about the resident's right leg because it was swollen and it looked shorter than the left leg. The POA said the family was concerned the resident either dislocated her repaired hip or had a [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) that was the result of stopping her blood thinner injections. The POA said they had reported the concerns with the resident's leg to the nurse caring for the resident. The POA said the family was concerned the facility was not taking the change in condition of the resident's leg seriously. The family member visiting the resident completed a follow-up interview on 8/3/16 at 1:47 p.m. The family member appeared emotional and upset as the resident was being removed from the facility on a gurney accompanied by two ambulance crew. The family member said an x-ray taken earlier that day showed the resident had dislocated the right hip. The family member said the resident had been in pain and was complaining of pain to the knee. The family member attributed this complaint of pain at a seemingly wrong site to the resident's memory problems. The family member said she was not sure if the hip was dislocated because of a hardware problem or if something happened at the facility. The family member expressed worry over the discomfort the resident would experience with returning the hip to its proper position. The family member expressed concern with the resident being of advanced age and requiring another hospital procedure. Observations: The resident was observed on 8/3/16 at 7:32 a.m. The resident was in bed in the same street clothes observed on the previous day. The resident had removed the adductor wedge. The resident was moving her left leg persistently over the right leg. The resident was unable to convey her needs due to language barrier. The right leg, which was visible, looked swollen. The left leg could not be well observed as it was in constant motion. Certified nurse aide (CNA) #3 and CNA #4 arrived to assist the resident. The CNAs reported they were getting the resident up for breakfast. The resident was observed on 8/3/16 at 10:50 a.m. The resident was in bed with the bed in the low position. The adductor wedge had been removed. The resident was persistently moving her left leg. The resident was heard to call out. The resident pointed at the dresser. The call light was turned on to summon assistance. CNA #4 responded to the call light and offered the resident sips of fluid. The resident was observed to be crying. Record Review: A review of the clinical record revealed the swelling of the resident's surgically repaired right leg was first noticed on 8/1/16. The family reported and the physical therapist noted the right leg was shorter than the left on 8/2/16. The resident was not evaluated for the shortened limb until 8/3/16, which revealed a delay in assessment of the change to the right limb. A review of nurses' notes from 7/13/16 to 7/30/16 revealed no notes where the nurse identified the resident's right limb was shorter than the left limb. The 7/13/16 initial nursing data collection tool/assessment did not note a discrepancy in leg length when the resident returned to the facility on [DATE] after surgical repair of the right hip. The 7/14/16 physical therapy evaluation did not show the resident had a difference in lower limb length. The physical therapist (PT) completing the evaluation indicated the resident had to receive therapy in bed and had pain with movement. A 7/22/16 palliative care consult visit reviewed all of the resident's systems. The review did not show the resident had a discrepancy in lower limb length. An 8/1/16 palliative care consult said the resident had increased [MEDICAL CONDITION] in the right leg. An ultrasound of the right leg was ordered. The note indicated 2-plus [MEDICAL CONDITION] was present in the right foot. A nurse's progress note dated 8/2/16 at 9:37 p.m. said in pertinent part that the resident's son was in that evening to visit. The son was concerned about his mother's right hip and that one leg was shorter than the other and is wanting to have an x-ray done to her right hip. An 8/2/16 physical therapy progress note said the resident participated in therapy including standing and taking steps in the parallel bars. The physical therapy note said the resident's right leg was noticeable shorter than the left. An 8/3/16 at 7:00 a.m. telephone order said the resident was to have an x-ray of the right knee and right hip due to pain and swelling. (This order was obtained approximately 16 hours after the POA reported speaking to the facility about concerns with the resident's right leg.) X-ray results with a date of service of 8/3/16 showed the resident was receiving an x-ray for pain and swelling to the right leg. The x-ray result received at 8/3/16 at 12:21 p.m. showed the resident had a superior hip dislocation of the right hip. A telephone order dated 8/3/16 at 1:00 p.m. said the resident was to be sent to the hospital for a dislocated right hip after surgical repair of the same hip. The 8/3/16 Situation Background Assessment Recommendation (SBAR) form documented the following: -The resident began having swelling of the lower right extremity on 8/1/16. The situation was made better by pain medication. -The resident had decreased mobility compared to baseline. -The SBAR did not record if the resident had pain, pain intensity or how the pain was addressed. -The SBAR said the resident's right leg was approximately two inches shorter than the left leg. An 8/3/16 provider note showed the resident had an x-ray that showed a dislocated right hip. The note said the resident's right leg was observed to be shortened upon examination. Review of the 8/16 MAR indicated [REDACTED]. The Tylenol was given as scheduled 8/1/16 through discharge on 8/3/16 at 1:30 p.m. As needed orders for 650 mg of Tylenol every four hours by mouth and [MEDICATION NAME] 200 mg as needed by mouth every four hours were not administered. The 8/16 MAR indicated [REDACTED].) Physician Interview: The resident's physician was interviewed by telephone on 8/3/16 at 3:53 p.m. The physician said he had spoken with the resident's family when he was at the facility on 8/2/16. The physician said he was told by the family that the resident's right leg was shorter than the left. The physician said the family also reported swelling to the right leg. The physician said he did observe the right leg for swelling and ordered a sonogram to be completed to rule out a [MEDICAL CONDITION]. The physician denied observing the resident's left leg or making a comparison of the two legs for discrepancy of length. The physician said he recalled asking staff on 8/2/16 to proceed with an x-ray of the right hip. Staff Interviews: Staff interviews revealed there was a delay in assessing the change in length of the resident's right leg. No nurse visualized and documented the difference in the resident's limb length. The x-ray, requested by the physician and the family on 8/2/16, was not ordered until 8/3/16. In the interceding time, the resident was transferred from bed to chair and had two physical therapy sessions. CNA #3 was interviewed on 8/2/16 at 4:45 p.m. The CNA reported regularly working on the unit where the resident resided. The CNA said the resident was just not comfortable because of her repaired hip. CNA #4 was interviewed on 8/3/16 at 11:34 a.m. The CNA said the resident got up in her wheelchair for breakfast and then was transferred back to bed later in the morning. The CNA was not sure why the resident was crying. On 8/3/16 at 1:50 p.m. licensed practical nurse (LPN) #2 and unit manager (UM) #2 said the resident was being transferred to the hospital for a dislocated right hip. LPN #2 was interviewed on 8/3/16 at 2:34 p.m. The LPN said the resident's family had told her about their concerns with swelling to the resident's leg and that one leg was now longer than the other. The LPN said she reported the family concern's to the UM and to the physician. The LPN said the physician ordered an ultrasound on 8/2/16 and they ordered an x-ray of the hip on 8/3/16. The LPN said she did notice the resident had one leg that looked longer than the other. The LPN did not measure the legs to determine the difference in length. The LPN said the resident had been up for the morning meal and then went back to bed sometime after that. The LPN said the resident had been tearful on 8/3/16. The LPN said she did not think the resident was in pain because she knows the word for pain in the resident's language. UM #2 was interviewed on 8/3/16 at 4:03 p.m. The UM said she assessed the resident's leg for swelling but did not observe the resident's leg for change in length. The UM reviewed the clinical record and was unable to identify an assessment of the change in the resident's lower extremities. The UM said she had been observing the resident's right leg only because it was swollen and the skin was taut and shiny. The UM said authorization for an x-ray of the left hip was obtained on 8/3/16. The UM agreed that the family reported concerns with limb shortening on 8/2/16. An interview with PT #1 was conducted on 8/3/16 at 4:35 p.m. The interview was joined by the director of rehabilitation (DOR) part way through. The PT said she had noticed significant shortening of the right lower limb during treatment on 8/2/16. The PT said the 8/2/16 treatment was the first time she was able to observe the resident standing. The PT said she attributed the limb shortening to a combination of the surgical repair and the resident's kyphosis (spine curvature). The PT said she had never obtained measurements of the resident's limbs so she would not know if the limb shortening had worsened. The PT reported that on 8/3/16 the resident continued to receive therapy services and had spent 20 minutes transferring on and off the toilet. The PT said she did not observe any trouble with pain during the 8/2 and 8/3/16 therapy treatments. The DOR was interviewed on 8/4/16 at 11:34 a.m. The DOR reviewed the therapy clinical records. The DOR reported that prior to the 8/2/16 PT note, there was nothing documented about a shortened right lower limb. The DOR said the resident had been on therapy case load since her return from the hospital beginning on 7/14/16. The DOR said she would have expected documentation of disparate limb length if it were identified previously. The director of nursing (DON) was interviewed on 8/4/16 at 1:30 p.m. The DON reviewed the resident's clinical record. The DON agreed there was no nursing assessment of the resident's limb length when it was reported that the right leg was shorter by the resident's family on 8/2/16. The DON said she would expect the nurses to look at the resident's legs and document any discrepancy in limb length. The DON said floor nurses did not report the limb length concerns to her on 8/2/16. The DON said the therapy staff did not convey observations of a shorter right leg to her on 8/2/16.

Based on observations, interviews and record review, the facility failed to ensure two (#55 and #18) out of 44 total residents sampled received care and services to meet their highest practicable level of well-being. Specifically, the facility failed to: -Ensure resident #55's wishes for cardiopulmonary resuscitation were honored. Staff failed to begin cardiopulmonary resuscitation (CPR) when the resident was found without a pulse and respirations. (Cross reference F155; resident rights) -Ensure resident #18 consistently received comfortable wheelchair positioning. I. Advance Directives - Resident #55 (Cross-reference F155) Resident #55, age 85, was admitted to the facility on [DATE]. The resident's electronic medical record (EMR) revealed [DIAGNOSES REDACTED]. The resident expired on [DATE]. The [DATE] Minimum Data Set (MDS) assessment showed a brief interview for mental status (BIMS) of six out of 15. The resident's score indicated the resident's cognition was severely impaired. Section J (Health Conditions) did not reveal a condition or chronic disease that would result in a life expectancy of less than six months. Record Review: A review of the resident's Colorado Medical Orders for Scope of Treatment (MOST) form, last reviewed on [DATE], showed if the resident had no pulse and was not breathing, she wanted cardiopulmonary resuscitation (CPR) attempted. The [DATE] care plan conference record revealed a CPR status of Full COR. The discussed status indicated the resident wanted CPR attempted if she was found non-responsive without a pulse and not breathing. The ,[DATE] Medication Administration Record [REDACTED]. The [DATE] physician's note identified the resident had a full cor CPR status. Full cor indicated the resident wanted CPR in the event she had no pulse and was not breathing. A review of the [DATE] telephone orders showed physical therapy and occupational therapy were discontinued due to the resident transitioning to hospice services related to her failure to thrive diagnosis. A review of the resident's care plans failed to show an interim care plan for hospice services. There was no advance directive care plan to indicate the resident's wishes that CPR be attempted in the event she was found non-responsive and without a pulse. The [DATE] progress note was reviewed and revealed at approximately 7:30 a.m., the resident was found on the floor lying flat on her back with her legs out stretched in front of her and arms flat on the floor next to the resident. The resident was found without a pulse, respirations, blood pressure, or a heart rate. The note included the resident was a do not resuscitate (DNR). There was no documentation in the progress note to indicate the facility attempted CPR to honor the wishes of the resident if she was found non-responsive, without a pulse and found not breathing. Interviews: On [DATE] at 2:14 p.m., the unit manager (UM) #2 of the west wing was interviewed. UM #2 stated prior to becoming a UM, she was a floor nurse at the facility. She stated floor nurses were responsible for completing advanced directives with residents upon admission into the facility. -The UM recalled admitting the resident into the facility on [DATE]. The UM reviewed the [DATE] progress note and confirmed the resident was seen non-responsive. The UM stated the resident was assessed and the physician and family was called. The UM reported the resident was DNR which indicated no attempt to perform CPR was conducted. -The UM reviewed the [DATE] MOST form and confirmed the resident's wishes in the event she had no pulse or was found not breathing was to have CPR attempted. The UM stated the purpose of an advance directive was to honor the resident's requests if found non-responsive. On [DATE] at 2:31 p.m., the director of nursing (DON) was interviewed. -The DON stated advance directives allowed residents an opportunity to direct their end of life care. The DON stated advance directives also allowed the facility to provide end of life care according to the wishes and preferences of their residents. -The DON reviewed the MOST form and confirmed the resident wished to have CPR performed if she was found non-responsive. The DON reviewed the [DATE] progress note and acknowledged the documentation showed the resident was DNR which would indicate the facility did not attempt to perform CPR. The DON expressed the facility should have attempted to honor the resident's end of life care preferences. She further acknowledged there was no advance directive care plan available in the resident's medical record. Facility Follow-up: On [DATE] at approximately 4:00 p.m., the DON provided a document from [DATE] completed by a facility consultant identifying a concern with the advance directives for residents of the facility. The document showed the facility was aware of an issue with the MOST forms and were given direction to honor resident care directives, however resident #55's end of life preferences were not honored. II. Positioning - Resident #18 A. Resident Status Resident #18, age under [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The [DATE] quarterly minimum data set (MDS) assessment revealed the resident was rarely or never understood when communicating. The resident had impaired short and long term memory; severely impaired decision making; did not recall the season, location of his room; staff names and faces, and that he was in a nursing home. The resident exhibited continuous signs and symptoms of [MEDICAL CONDITION] including inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION]. The resident did not exhibit [MEDICAL CONDITION], behaviors, rejection of care or wandering. The resident was dependent on two staff for bed mobility and transfers. The resident was dependent on one staff for locomotion on and off the unit; dressing; toileting; eating; personal hygiene; and bathing. The resident had limited range of motion bilaterally to upper and lower extremities. The resident's mobility was through the use of a wheelchair. B. Observations On [DATE] at 10:02 a.m., the resident was seated in the television lounge near the nurse's station on the West unit, where the resident resided. The resident was in a tilt-in-space wheelchair that was reclined. As a result of being reclined, the resident's legs were dangling approximately five to six inches from the ground. On [DATE] at 9:06 a.m., the resident was observed in the television room. His eyes were closed and he was tilted back in his wheelchair. The resident's legs were dangling approximately five to six inches off the ground. On [DATE] at 9:57 a.m., the resident was observed in the television room. The resident was awake and swinging his legs as he was tilted back in his wheelchair. On [DATE] at 3:50 p.m., the resident was awake, sitting in his wheelchair. The resident was tilted back in the chair with his legs dangling approximately five to six inches from the floor. On [DATE] at 10:03 a.m., the resident was observed awake in his room. He was tilted backwards in his wheelchair. His legs were dangling several inches off the floor. On [DATE] at 10:33 a.m., the resident was in his room sitting in his wheelchair, which was tilted backwards. The resident appeared to be sleeping. His legs were dangling several inches off the ground. On [DATE] at 12:56 p.m., the resident was observed in his wheelchair in the hallway beside the door to his room. The resident was tilted back in his wheelchair with his legs dangling. C. Family Interview On [DATE] at 11:37 a.m., the family member was interviewed in the resident's room. The family member immediately adjusted the resident's tilt-in-space wheelchair so that the resident had his feet touching the floor. The family member stated she often found the resident with his legs dangling. The family member said had instructed staff to tilt the wheelchair so the resident's feet could just touch the floor because it was less likely to cause him discomfort. She said the resident could not have foot pedals on his wheelchair due the resident's leg movements; the resident, at times, moved his legs with such frequency and energy that he was injured on the foot pedals. The family member stated the resident had been in the tilt-in-space wheelchair, which she had purchased for him, since he was admitted to the facility. D. Record Review The clinical record did not include a care plan to direct staff as to how the resident was to be positioned when up in his wheelchair. 1. Monthly Summary The [DATE] monthly summary indicated the resident need to be repositioned every two hours. The summary did not indicate the resident should be tilted with his legs dangling when up in his wheelchair. Moreover, it did not indicate he should be positioned so that his feet just touched the floor, as requested by the resident's family member. The [DATE] monthly summary noted the resident needed positioning in bed, used an anti-pressure mattress, used a positioning pillow, and required frequent assistance with repositioning. The summary did not indicated the resident should be tilted with his legs dangling when up in his wheelchair or positioned so that his feet just touched the floor, as requested by the resident's family member. 2. Computerized physician's orders [REDACTED].>The ,[DATE] CPO showed the resident had an order that read reclining wheelchair fyi (for your information). The order did not direct that the resident be left in a reclined position when in the wheelchair. 3. Care Plan A falls care plan dated [DATE] identified the resident was at risk for falls related to weakness, impaired mobility, [MEDICAL CONDITION], [MEDICAL CONDITIONS], and use of antianxiety medication. The goal was for the resident to be free from falls. Approaches included fall risk assessment; falling star program; egress mattress to bed; two person assist for transfer, reclining wheelchair; and monitoring for adverse medication effects. The care plan did not direct staff to recline the resident's wheelchair as a safety measure or to position the resident so that his feet just touched the floor. An antianxiety medication care plan dated [DATE] identified the resident was fidgety and received [MEDICATION NAME]. The goal was for the resident and others to be free from injury related to restlessness through the next review period. The approaches included [MEDICATION NAME] (antianxiety medication) as ordered; frequent position changes; and monitoring/recording episodes of restlessness. The care plan did not direct that the resident should be tilted back in his wheelchair as a safety measure during episodes of restlessness. 4. Rehabilitation Services Multidisciplinary Screening Tool The [DATE] screening noted the resident used a tilt-in-space wheelchair and was total assist for propulsion. The screening did not address use of foot pedals or maintaining the resident in a tilted position to prevent falls. The [DATE] screening noted the resident used a tilt-in-space wheelchair and was total assist for propulsion. The screening did not address use of foot pedals or maintaining the resident in a tilted position to prevent falls. The [DATE] screening noted the resident used a tilt-in-space wheelchair and was total assist for propulsion. The screening did not address use of foot pedals or maintaining the resident in a tilted position to prevent falls. 5. Restorative Assessment The [DATE] restorative nursing assessment indicated the resident had limited range of motion to the bilateral upper and lower extremities. The assessment noted the resident used a tilt-in-space wheelchair. The assessment did not include information about keeping the resident in a tilted position. 6. Treatment Administration Record (TAR) The ,[DATE] TAR did not include a treatment of [REDACTED]. E. Staff Interviews On [DATE] at approximately 10:12 a.m., an interview with certified nurse aide (CNA) #6 revealed the resident did not use foot pedals on his wheelchair. The CNA acknowledged the resident's feet were dangling and she was observed to adjust the tilt of the resident wheelchair so his toes and the balls of his feet touched the floor. The CNA stated that the resident's family had told her that the resident was supposed to be positioned so that his feet barely touched the floor. The CNA stated staff should adjust the tilt of the resident's wheelchair so that his toes were able to touch the floor. On [DATE] at 12:58 p.m., the licensed practical nurse (LPN) #4, who served as the manager for the restorative nursing department, was asked about the resident's positioning in his wheelchair. -The LPN stated that the resident's legs were dangling, which would not be comfortable for the resident. The LPN stated she believed the resident did not use foot pedals on his wheelchair because he would throw his legs around and be injured on the foot pedals. -The LPN stated she believed staff would tilt the resident back for transport and then would fail to return the resident to a position where his feet could touch the floor when they arrived at the intended destination. -The LPN reviewed the resident's chart and the CNA care plan book. The LPN stated there was nothing to direct staff to ensure the resident's feet touched the floor as he sat in his wheelchair. The LPN stated there was no discreet signage on the resident's wheelchair or in his room to remind staff to position the resident so his feet could touch the floor. F. Facility follow up after survey exit 1. Typewritten letter After the survey exit, the facility furnished a typewritten letter dated [DATE] stating the resident was maintained in a reclined position to prevent falls. However, no care plans, assessments or other information was submitted to show that tilting the resident back in his wheelchair was an appropriate or planned approach for fall prevention. 2. Physician letter A handwritten letter by the physician dated [DATE] stated that the physician felt foot pedals were not appropriate for the resident due to the resident body movements. The physician letter did not address tilting the resident in such a manner that his legs were unable to touch the floor, either as a method of fall prevention, a planned intervention, or other purpose to promote the resident's well-being.