Every finding on record at Harmony Pointe Care Center

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for three (#91, #96 and #301) of three residents outside of the secured unit and all residents on the secured unit out of 45 sample residents. Specifically, the facility failed to: -Ensure Resident #91, Resident #96 and Resident #301 were provided with meaningful activities that promoted their mental and psychosocial well-being; and, -Ensure residents on the secure unit were provided with meaningful activities that promoted their mental and psychosocial well-being. Findings include: I. Facility policy and procedure The Activities Schedule policy, revised on 3/14/23, was provided by the nursing home administrator (NHA) on 9/27/24 at 5:07 p.m. The policy read in pertinent part, The community will provide daily activities that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies and the culture of the participants and community. Daily activities include community-sponsored group and individualized activities, in addition to assistance with independent daily activities. Activities will be designed to meet and support the participant's physical, mental, intellectual and psycho-social well-being. Activities will create opportunities for each participant to have a meaningful life by supporting their domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). Activities will be designed to meet participants' best ability to function, incorporating their strengths and abilities. Activities will encourage both independence and community interaction, including the use and support/interaction of volunteers where appropriate. II. Resident #91 A. Resident status Resident #91, age 76, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified cataract (clouding of the clear lens of the eye and sensorineural hearing loss (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain). The 6/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He required supervision with all activities of daily living (ADL). B. Observations On 9/24/24 during a continuous observation, beginning at 2:04 p.m. and ending at 4:27 p.m., Resident #91 was in his room and the following observations were made: At 2:10 p.m., Resident #91 opened his door and peered out of his room. Resident #91 appeared confused. He went back into his room and closed the door. At 4:17 p.m. Resident #91 exited his room and stood in the hallway. An unidentified certified nurse aide (CNA) stopped him and fixed his sleeve. Resident #91 was looking for the dinner menu, which was in the unidentified CNA's hand. The CNA hung the menu back up on the wall. At 4:27 p.m. Resident #91 exited his room and walked down the hallway toward the dining room. -During the above continuous observation, the activities department was conducting group activities of fall crafts and hosting a music group. Resident #91 was not invited to any group activities and did not receive any staff interaction other than when he exited his room and stood in the hallway looking for the dinner menu. On 9/25/24 during a continuous observation, beginning at 1:46 p.m. and ending at 4:10 p.m. Resident #91 was in his room and the following observations were made: At 1:46 p.m. Resident #91 closed his door. At 3:16 p.m. an unidentified nurse brought Resident #91 a labeled snack and then closed his door. -Between 1:46 p.m. and 3:16 p.m. no staff members entered Resident #91's room. At 3:51 p.m. the same unidentified nurse entered Resident #91's room and administered the resident's medications. The nurse left the door open after exiting the resident's room. At 3:52 p.m. Resident #91 was sitting up in bed, staring out the window. At 3:53 p.m. Resident #91 got up and closed his door. -During the above continuous observation, group activities such as games in the lobby, music, and color association were being conducted. Resident #91 was not invited to the group activities. C. Record review The activities care plan, revised on 4/4/24, revealed Resident #91 enjoyed collecting rocks, minerals and jewelry. He enjoyed listening to rock and roll music, painting, sketching and creating art pieces. The interventions included providing a monthly calendar as a reminder of all activities, providing invites and reminders to join group activities and providing independent leisure supplies for the resident. The activities progress note dated 9/3/24 documented that Resident #91 refused the one-to-one activity. -The type of one-to-one activity offered to the resident was not documented. -There was no additional activity documentation available for Resident #91. The September 2024 activities schedule included many activities that were of interest, according to the care plan, to Resident #91, such as music groups, watercolor painting, art with a special host, sip and paint, canvas painting and coloring. -However, observations during the survey revealed Resident #91 was not invited to attend group activities (see observations above). D. Staff interviews The activities director (AD) was interviewed on 9/26/24 at 10:00 a.m. The AD said each resident should be invited to all group activities. She said she was not sure if Resident #91 attended activities. She said she was not sure what type of activities Resident #91 would be interested in or attend. She said Resident #91 was not currently on a one-to-one activity program. The social services director (SSD) and the social services consultant (SSC) were interviewed on 9/26/24 at 11:08 a.m. The SSD said Resident #91 would come down to her office and talk with her and the NHA). She said Resident #91 enjoyed painting. She said she was not aware if Resident #91 was invited to or attended group activities. The NHA and the director of nursing (DON) were interviewed on 9/26/24 at 2:38 p.m. The NHA said each resident should be invited to group activities. He said it was the responsibility of every staff member to invite residents to group activities. The NHA said Resident #91 liked to talk about his service in the military. He said staff probably did not check on Resident #91 since he was ambulatory and felt like the resident was self-sufficient. He said even though Resident #91 was ambulatory and did not require a lot of assistance with ADLs, he still deserved social interaction throughout the day. The NHA said he would meet with the facility staff to ensure Resident #91 was invited to group activities and he was provided with social interaction throughout the day. He said he would identify other residents that might have the same concern and he would update their comprehensive care plans. 50853 III. Resident #96 A. Resident status Resident #96, age 82, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included Alzheimer's disease, unspecified dementia with anxiety, hypertension and liver disease. The 7/29/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required substantial to maximal assistance with transfers and personal hygiene. She used a wheelchair for mobility and depended on staff to propel the wheelchair. B. Observations On 9/23/24 the following observations were made: At 11:00 a.m. Resident #96 was sitting at the counter at the nurses station in the 300 hall. She had an Ensure supplement in front of her but she did not have any activity materials in front of her. At 12:00 p.m. Resident #96 was eating lunch at the nurses station. At 1:17 p.m. Resident #96 was sitting at the nurses station. A live music activity had started in the main lounge down the hall from the nurses station at 1:00 p.m. Resident #96 could hear the music from the nurses station and she was moving to the music and smiling. -Resident #96 was not assisted by staff to attend the music program in the lounge. At 2:42 p.m. Resident #96 was sitting at the nurses station. There were no activity materials in front of her. She did not have a drink or a snack. At 3:38 p.m. Resident #96 was sitting at the nurses station with an empty water cup in front of her. The activity calendar indicated a canvas painting activity had started at 3:30 p.m. -Resident #96 was not assisted to attend the painting activity. On 9/24/24 the following observations were made: At 9:29 a.m. Resident #96 was lying in bed. She was awake and moving around. The activity calendar indicated there was a daily gathering activity scheduled at 9:30 a.m. and rosary prayers at 10:00 a.m. -Resident #91 was not assisted to attend either activity. At 11:57 a.m. Resident #96 was sitting in her wheelchair in her room. There were no meaningful activities provided for the resident to engage in and there was no music playing in the resident's room. A certified nurse aide brought her out to the nurses station and put her lunch on the counter in front of her. On 9/24/24 during a continuous observation, beginning at 1:53 p.m. and ending at 5:37 p.m., the following observations were made: At 1:53 p.m. Resident #96 was sitting behind the nurses station. A Bingo activity was scheduled to begin at 2:00 p.m. -Resident #96 was not invited to attend Bingo. At 2:06 p.m. Resident #96 remained sitting behind the nurses station touching and twisting another resident's oxygen tubing who was sitting next to her. No activity supplies were provided to her. At 2:15 p.m. Resident #96 remained behind the nurses station. An unidentified CNA was charting at the computer near Resident #96. The CNA talked briefly to the resident but did not offer her a snack, drink or activity supplies. At 2:24 p.m. Resident #96 was speaking in Spanish to herself. A radio near her was playing country music. At 2:32 p.m. a CNA pushed Resident #96 in her wheelchair to her room. There were no other activities scheduled on the activity calendar for the afternoon. At 2:37 p.m. the CNA left Resident #96's room. The resident was lying in bed. -There was no music playing in the resident's room. At 3:39 p.m. Resident #96 remained in bed. -There was no music playing in the resident's room. At 4:59 p.m. Resident #96 remained in bed. She was awake and moving her legs. -There was no music playing in the resident's room. At 5:37 p.m. Resident #96 remained in bed. -There was no music playing in the resident's room. On 9/25/24 during a continuous observation, beginning at 8:59 a.m. and ending at 12:19 p.m. At 8:59 a.m. Resident #96 was lying in bed. She was awake. -There was no music playing in the resident's room. At 9:16 a.m. the activities assistant (AA) went into room [ROOM NUMBER], across the hall from Resident #96. She was passing out the daily chronicle. At 9:17 a.m. the AA walked to the door of Resident #96's room but registered nurse (RN) #3 was entering the room with medication for the resident. The AA did not go into the resident's room. At 9:20 a.m. the AA walked back down the hall and passed by Resident #96's room without stopping. There was a soup making activity scheduled at 10:00 a.m., however, Resident #96 was not invited to the activity. At 10:25 a.m. CNA #6 brought Resident #96 out of her room in her wheelchair and placed her behind the nurses station at the counter. At 10:55 a.m. Resident #96 continued sitting at the nurses station. No staff were interacting with her and the resident did not have any meaningful activities in front of her. At 11:07 a.m. CNA #5 was charting behind the nurses station next to Resident #96 but did not interact with her. Resident #96 was not provided with any activity supplies. At 12:04 p.m. Resident #96 was sitting at the nurses station with her eyes closed. She did not have any meaningful activities in front of her. -At 12:14 p.m. room trays were delivered to the 300 hall. Resident #96 was sitting behind the nurses station. Another resident, who was sitting beside her, was fiddling with his oxygen tubing. The director of rehabilitation (DOR) addressed the other resident and offered to provide something for him to fiddle with. The DOR left and returned with a jar of beads and other items for him. -The DOR did not address Resident #96 or offer her any activity supplies. At 12:19 p.m. lunch was delivered to Resident #96 and placed on the nurses station counter in front of her. On 9/25/24, the following additional observations were made: At 1:26 p.m. Resident #96 was sitting at the nurses station with her eyes closed. She did not have any meaningful activities in front of her. At 1:36 p.m. CNA #5 took Resident #96 to her room. When CNA #5 left the room, the resident was lying in bed. A music program was scheduled to begin at 2:00 p.m., however, Resident #96 was not able to attend because CNA #5 had put her in bed. At 2:45 p.m. Resident #96 was in bed. A live music activity was scheduled to begin at 3:00 p.m., however, staff did not get the resident out of bed so she could attend the program. At 4:50 p.m. Resident #96 was sitting at the nurses station. An unidentified CNA was sitting behind her charting but the CNA was not interacting with the resident. On 9/26/24 at 8:55 a.m. Resident #96 was in bed, awake. A daily gathering activity was scheduled to begin at 9:30 a.m., however, staff did not get the resident out of bed so she could attend the activity. At 10:56 a.m. Resident #96 was sitting at the nurses station by herself, talking to herself. There were no activity supplies provided to her. At 12:57 p.m. Resident #96 was sitting at the nurses station with a full lunch plate in front of her. She was not eating and staff were not present. At 1:03 p.m. Resident #96 dropped her full plate of food on the floor. C. Record review The activities care plan, initiated 5/3/24 and updated 8/2/24, indicated Resident #96 identified her religion as Catholic. She enjoyed playing bingo, spending time outdoors, being social, dancing, listening to music, and cooking. Interventions included activities staff inviting and encouraging her to attend activities and activities staff offering independent leisure supplies. The care plan indicated Resident #96 used a manual wheelchair and activities staff would provide assistance to and from activities. Review of Resident #96's activity documentation on 9/24/24 and 9/25/24 revealed the following: On 9/24/24 at 2:29 p.m. the activity documentation indicated Resident #96 refused creative, cognitive and therapeutic activities. -However, continuous observation on 9/24/24 from 1:53 p.m. to 5:37 p.m. revealed the resident was sitting at the nurses station and lying in bed. She was not approached by activities staff to attend activities during that time (see observations above). On 9/25/24 at 10:48 a.m. the activity documentation indicated Resident #96 refused to attend a group activity and was active with independent leisure. -However, continuous observation on 9/25/24 from 8:59 a.m. to 12:19 p.m. revealed activity staff did not enter her room on the morning of 9/25/24 to invite her to activities or observe her participating in independent leisure activities. Resident #96 was still in bed at that time (see observations above). IV. Resident #301 A. Resident status Resident #301, age 88, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included fracture of left femur (the large bone in upper leg), unspecified dementia, muscle weakness, dysphagia (difficulty swallowing), hypertension (high blood pressure) and anxiety disorder. The 9/16/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She required partial to moderate assistance with transfers and personal hygiene. She used a wheelchair for mobility and depended on staff to propel the wheelchair. B. Observations On 9/23/24 at 1:20 p.m. Resident #301 was sitting at the counter at the nurses station on the 300 hall eating ice cream. At 3:37 p.m. Resident #301 was sitting at the nurses station with an empty Ensure supplement carton. -She did not have any meaningful activities in front of her. At 4:15 p.m. Resident #301 was sitting at the nurses station. She had no meaningful activities in front of her. She did not attend the music program that was held in the common area. On 9/24/24 at 9:28 a.m. Resident #301 was in bed with her eyes closed. At 11:05 a.m. Resident #301 was in bed, awake. -There was no music playing in the resident's room. On 9/24/24 during a continuous observation, beginning at 1:53 p.m. and ending at 3:40 p.m., the following observations were made: At 1:53 p.m. Resident #301 was sitting behind the nurses station, slumped over in her wheelchair. Bingo was scheduled to begin at 2:00 p.m. -She did not have any meaningful activities in front of her and staff did not invite her to attend Bingo. At 2:13 p.m. CNA #5 took Resident #301 into a bathroom near the nurses station. At 2:16 p.m. CNA #5 brought the resident back to the nurses station and left her at the counter. -CNA #5 did not provide Resident #301 with any meaningful activities. At 2:25 p.m. Resident #301 had three packages of hand wipes and seemed to be reading the labels. CNA #5 moved her over so a male resident could sit at the nurses desk. At 2:32 p.m. CNA #5 took Resident #301 into her room. At 2:36 p.m. CNA #5 left the resident's room after putting Resident #301 in bed. -There was no music playing in the resident's room. At 3:40 p.m. Resident #301 continued lying in bed. -There was no music playing in the resident's room. On 9/24/24 the following additional observations were made: At 4:32 p.m. Resident #301 was sitting at the nurses station with a cup of coffee. At 5:00 p.m. the resident continued sitting at the nurses station. She had no meaningful activities in front of her. At 5:35 p.m. Resident #301 was sitting at the nurses station. Room trays had not been delivered and the resident continued to have no meaningful activities in front of her. On 9/25/24 during a continuous observation, beginning at 8:59 a.m. and ending at 10:25 a.m., the following observations were made: At 8:59 a.m. Resident #301 was in bed with her eyes closed. -There was no music playing in the resident's room. At 9:16 a.m. the AA went into room [ROOM NUMBER], across the hall from Resident #301. She was passing out the daily chronicle. At 9:17 a.m. the AA walked to the door of Resident #301's room but registered nurse (RN) #3 was entering the room with medication. The AA did not go into the room. At 9:20 a.m. the AA walked back down the hall and passed by Resident #301's room without stopping. There was a soup making activity scheduled at 10:00 a.m., however, Resident #301 was not invited to the activity. At 10:05 a.m. an unknown staff person entered Resident #301's room. At 10:09 a.m. the staff person came out into hall and told CNA #5 that Resident #301 did not want to get up. CNA #5 said she would help and entered the resident room. At 10:25 a.m. CNA #5 brought Resident #301 out of her room in her wheelchair and pushed her down the hall toward the dining room and common area. On 9/25/24, the following additional observations were made: At 2:01 p.m. Resident #301 was sitting in the dining room at a table with two other residents. Resident #301 was looking at meal tray cards for other residents. A music program was starting in the common area. At 2:31 p.m. Resident #301 remained sitting in the dining room at the same table with another resident. She was still looking at meal tray cards for other residents. Staff had not assisted her to the music program. At 3:21 p.m. Resident #301 was sitting at the nurses station with an empty glass in front of her and no meaningful activities. At 3:59 p.m. Resident #301 was sitting at the nurses station. There were no meaningful activities on the counter in front of her. At 4:50 p.m. Resident #301 was sitting at the nurses station. She was messing with the shirt of a male resident sitting next to her, trying to tie it on his wheelchair brake handle. A CNA behind her intervened and told her she could not tie the other resident's shirt on the brake handle. -The CNA did not provide Resident #301 with any activity supplies or move her away from the other resident. On 9/26/24 at 8:54 a.m. Resident #301 was in bed with her eyes closed. A daily gathering activity was scheduled at 9:30 a.m., however, staff did not get the resident out of bed so she could attend the activity. At 11:38 a.m. Resident #301 remained in bed and was awake. -There was no music playing in the resident's room. C. Record review The activities care plan, initiated 9/18/24 and updated 9/20/24, indicated Resident #301 enjoyed watching her favorite television programs throughout the day, keeping up with the news, listening to music, playing bingo on occasion, and exercising on occasion. Care plan interventions included staff reminding and encouraging her to attend group activities of her interest and choice and providing assistance to and from activities. Review of Resident #301's activity documentation on 9/24/24 revealed the following: On 9/24/24 at 2:29 p.m. the activity documentation indicated Resident #301 refused creative, cognitive and therapeutic activities. -However, continuous observation on 9/24/24 from 1:53 p.m. to 5:35 p.m. revealed the resident was sitting at the nurses station and lying in bed. She was not approached by activities staff to attend activities during that time (see observations above). V. Staff interviews CNA #5 was interviewed on 9/25/24 at 2:50 p.m. CNA #5 said the activity staff invited residents to activities. She said the CNAs and nurses reminded them. CNA #5 said Resident #96 did not attend activities because she tried to wheel away or got up and walked unsafely. CNA #5 said there was an activity box at the nurses station they could give to residents. She said sometimes she brought Spanish music for Resident #96 to listen to. CNA #5 said resident #301 did not go to many activities. She said the resident did not stay focused and activity staff brought her right back. The AD was interviewed on 9/26/24 at 2:23 p.m. The AD said activity preferences should be in the residents' care plans. She said staff should invite residents to activities daily. The AD said Resident #96 had attended a couple of group activities and she asked the activity staff to bring her to groups. She said staff could offer Resident #96 a busy apron or some coloring when she was sitting at the nurses station. The AD said she was planning to start offering one-to-one visits with Resident #96 because she spoke Spanish. The AD said it was important for residents to have some meaningful activity daily. She said if staff were documenting a resident refused an activity she would have expected them to invite them personally. The NHA was interviewed on 9/26/24 at 2:38 p.m. The NHA said staff should be offering activity supplies for residents who were sitting at the nurses station. He said the residents' electronic medical records (EMR) needed to reflect residents' preferences and staff should document what they were doing and trying for activities for residents. The NHA said residents should be provided meaningful activities even when sitting at the nurses station. The NHA said all staff should invite residents to activities, not just the activity staff. The NHA said if activity staff documented a resident refused an activity then they should have asked them, not just document it was refused. The NHA said the facility would be changing their approach to activities, involving the interdisciplinary team (IDT) and creating a realistic activity calendar. 47960 VI. Secure unit residents A. Observations On 9/25/24 at 4:15 p.m. four residents in the secure unit were hovering by the medication cart, two residents were sitting at dining room tables and two residents were walking around the dining room. A resident picked up the nurse's computer from the table behind her. The resident was looking at the nurse's papers. -There were no other staff members in the dining room and eight residents in the area were without meaningful activity stimulation. Four residents were sitting in the living room by the exit doors without meaningful activity stimulation. On 9/26/24 at 9:19 a.m., the AA wheeled one resident from the dining room to the living room to read the daily news. -Nine residents remained in the dining room without meaningful activity stimulation and only two of the residents were able to self-propel their wheelchairs. On 9/26/24 at 9:35 a.m. the AA was sitting in the living room holding the remote control for the television. There were five residents in the room with her while she was finding something on the television to watch. On 9/26/24 at 9:41 a.m. Resident #43 was in her wheelchair in the hallway. She said, What are we doing today? A whole lot of nothing? Well that's new. Resident #43 continued to wheel down the hallway. -No staff members acknowledged Resident #43. B. Staff interviews The AA was interviewed on 9/26/24 at 9:35 a.m. The AA said she had only been in the activities department since the middle of August 2024. She said the residents on the secured unit liked to listen to music and watch television. She said sometimes the residents went outside if they felt like it but she identified the wrong location for outdoor time with the residents on the secure unit. The AD was interviewed on 9/26/24 at 10:00 a.m. The AD said she had only been working in her role for a couple of months. The AD said she created the activity calendar. She said she tried to oversee the activities in the secure unit at least once per day and it was her expectation that residents would go outside three to four times a week. The AD said the activities department was short staffed and currently had one position open but she said she encouraged her activities staff to rotate through the facility and follow the activity calendar as best as they could. She said when the residents on the secure unit were engaged in activities it helped with their mood and when residents were bored, their behaviors could increase.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of five medication carts and one of three medication storage rooms. Specifically, the facility failed to ensure expired medications were removed from the medication carts and medication storage rooms. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 9/30/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Observations On 9/25/24 at 2:58 p.m. medication cart #1 on the Sunshine Peak hall was observed with certified nurse aide with medication authority (CNA-Med) #1. The following item was found: -One bottle of atropine (involuntary nervous system blocker medication)10 milligrams (mg)/milliliter (ml) oral suspension with an expiration date of 3/8/24. On 9/25/24 at 3:26 pm the medication cart on Red Cloud Peak hall was observed with registered nurse (RN) #2. The following items were found: -One bottle of calcium with vitamin D 10 micrograms (mcg) with an expiration date of August 2024. -One bottle of abacavir and lamivudine (epzicom) (human immunodeficiency virus medication) 600 mg/300 mg tabs with an expiration date of 5/31/24. On 9/26/24 at 10:16 a.m. the station three medication room was observed with the director of nursing (DON). The following items were found: -One container of daptomycin (an antibiotic) 500 mg/50 ml compounded intravenous (IV) solution with an expiration date of 9/16/24. -Two boxes of Dermaprep liquid barrier skin preparation (forms a protective coating on the skin) with an expiration date of 5/17/24. III. Staff interviews CNA-Med #1 was interviewed on 9/25/24 at 3:00 p.m. CNA-Med#1 said the atropine medication should have been removed from the cart when it expired. RN #2 was interviewed on 9/25/24 at 3:30 p.m. RN #2 said the calcium with vitamin D that was in the Red Cloud Peak medication cart was just delivered today. She said the expiration date should have been checked prior to placing the medication in the cart. She said the night shift usually checked the expiration dates. RN #2 removed the expired medications from the cart and said she would dispose of them. The DON was interviewed on 9/26/24 at 10:20 a.m. The DON said the nurses checked the medication carts daily for expired medications. He said there should not be expired medications in the carts or storage rooms.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections throughout the facility. Specifically, the facility failed to: -Ensure housekeeping staff disinfected high touch surfaces (call lights, door handles and light switches) in resident rooms; -Ensure areas were cleaned from clean areas to dirty areas; -Ensure hand hygiene was performed appropriately during the cleaning of resident's rooms; -Ensure linen was transported and stored appropriately; -Ensure equipment used for multiple residents was cleaned regularly; and, -Ensure residents did not share cutlery and food items. Findings include: I. Ensure professional standards of infection control were followed when cleaning resident rooms A. Professional reference According to The Centers for Disease Control (CDC) Environment Cleaning Procedures (3/19/24), retrieved on 9/30/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, 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; and, -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. According to the CDC Hand Sanitizer Guidelines and Recommendations (3/12/24), was retrieved on 9/20/24 from https://www.cdc.gov/clean-hands/about/hand-sanitizer.html Apply the gel product to the palm of one hand (read the label to learn the correct amount), cover all surfaces of hands and rub your hands and fingers together until they are dry. This should take around 20 seconds. B. Facility policy and procedure The Hand Washing and Hand Hygiene policy, dated 2019, was provided by the NHA on 9/27/24 at 5:07p.m. It read in pertinent part; Using Alcohol-Based Hand Rubs: apply a generous amount of product to the palm of hand and rub hands together. Cover all surfaces of hands and fingers until hands are dry. C. Observations During a continuous observation on 9/25/23, beginning at 9:00 a.m. and ending at 9:26 a.m. the following was observed: Housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER], a double occupancy room. HSK #1 performed applied hand sanitizer foam, rubbed his hands together for less than 10 seconds and then applied gloves to his visibly wet hands. HSK #1 had difficulty donning (putting on) the gloves because his hands were not completely dry. HSK #1 entered room [ROOM NUMBER] and emptied all of the trash. HSK #1 removed his gloves, sanitized his hands and donned clean gloves. He sprayed Clorox urine remover on the toilet and toilet room floor, said he would leave the solution on for at least five minutes and he would clean this last (However, HSK #1 did not clean the toilet last). HSK #1 sprayed Oxivir cleaning solution on the sink, over bed tables, window sill and other furniture. HSK #1 said he would let this set for at least one minute. HSK #1 removed his gloves, performed hand hygiene and donned clean gloves. He said the bathroom chemicals had been sitting for over five minutes and he cleaned the toilet and toilet room. HSK #1 wiped the toilet tank, sharps container, windowsill, heat register, shelf and toilet. He removed his gloves and performed hand hygiene. He donned new gloves and mopped the bathroom floor. HSK #1 performed hand hygiene, donned gloves and obtained two clean towels. He set one clean towel on the commode lid on side one of the room and wiped furniture and the windowsill on side two (by the window). He performed hand hygiene and changed gloves, then wiped down furniture on side one using the rag that was laying on the commode. HSK #1 performed hand hygiene, donned clean gloves and mopped the floors. HSK #1 removed his gloves, used hand sanitizer and moved his cart to the next room. He donned gloves and entered room [ROOM NUMBER] and began gathering trash. -Each time HSK #1 used hand sanitizer, he rubbed it into his hands for less than 10 seconds and applied gloves to visibly wet hands. -HSK #1 did not clean the call lights, door handles or light switches. D. Staff interviews HSK #1 was interviewed on 9/26/24 at 9:26 a.m. HSK #1 said he usually cleaned the bathroom first to get it out of the way. The housekeeping/laundry supervisor (HLS) was interviewed on 9/26/24 at 3:54 p.m. The HLS said hand sanitizer should be rubbed into hands for 30 seconds or until hands were dry. The HLS said clean towels should not be set down on dirty surfaces prior to use because they could become contaminated. She said the bathroom should be cleaned last. She said if the sink was not in the same room as the toilet, it should be cleaned before the toilet. The HLS said high touch surfaces such as the bedside table, night stand, call light and door knobs should be cleaned every day. The infection preventionist (IP) was interviewed on 9/26/24 at 3:40 p.m. The IP said resident rooms should be cleaned in order of cleanest surfaces to dirtiest. She said the bathroom and toilet should be cleaned last because it is considered the dirtiest area She said a clean towel should not be put on top of a used commode and then used to clean the room. The IP said this would be a concern for infection because the commode was considered dirty. II. Ensure linen was transported and stored appropriately A. Facility policy and procedure The Linen policy, dated 2022, was provided by the NHA on 9/27/24 at 5:07p.m. It read in pertinent part, Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. B. Observations On 9/24/24 at 9:23 a.m. a linen cart containing clean linens was observed uncovered on the 200 hall. On 9/24/24 at 2:43 p.m. an unidentified certified nurse aide (CNA) pushed a linen cart down the 300 hall. There were folded gowns and bed pads on top of the cart and not covered. On 9/25/24 at 10:33 a.m. an unidentified laundry aide unloaded a linen cart off of the dumbwaiter (a small elevator used to transport linen). There were clean personal linens on hangers in the cart and it was not covered. C. Staff interviews The HLS was interviewed on 9/26/24 at 3:54 p.m. The HLS said when clean linen was transported it should be covered to prevent contamination. The IP was interviewed on 9/26/24 at 3:40 p.m. The IP said clean linen should be covered when transported in the hallways. III. Ensure equipment used for multiple residents was cleaned regularly A. Professional reference According to The Centers for Disease Control (CDC) Environment Cleaning Procedures (3/19/24),was retrieved on 9/30/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, Best practices for selection and care of noncritical patient care equipment: Clean all equipment using the methods and products available at the facility. All equipment should include detailed written instructions for cleaning and disinfection from the manufacturer, including pictorial instructions if disassembly is required. Train the staff responsible for cleaning equipment on procedures before the equipment is placed into use. Shared equipment should be cleaned before and after each use. B. Facility policy and procedure The Cleaning and Disinfecting Environmental Surfaces policy, dated 2019, was provided by the nursing home administrator (NHA) on 9/27/24 at 5:07p.m. It read in pertinent part; Environmental surfaces will be cleaned and disinfected according to current Center for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) blood borne pathogens standard. Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled. C. Observations On 9/25/24 at 2:43 p.m. a sit to stand mechanical lift was taken into a resident room on the 200 hall. The platform base, where the resident's place their feet, was full of debris,crumbs, a pepper packet and dirt. On 9/25/24 at 3:55 p.m. dirty towels were laying on top of a sit to stand lift that was stored in the 200 hall. D. Staff interviews The director of nursing (DON) was interviewed on 9/26/24 at 3:46 p.m. The DON said mechanical lifts should be cleaned daily by the night shift staff. He said dirty towels should be put in the laundry bin not laid on top of equipment in the hall. 47960 IV. Failure to ensure Resident #71 and Resident #95 did not share utensils and plates of food A. Observations A continuous observation on 9/23/24, beginning at 11:15 a.m. and ending at 12:15 p.m. The following was observed: At 11:49 a.m. Resident #95 carried her lunch plate to the staff to place in the dirty dish bin. Resident #95 returned to the dining table, sat down where Resident #71 had been sitting and began using Resident #71's utensils to eat the food that remained on Resident #71 plate. -The staff in the dining room did not provide redirection to Resident #95 when she began using Resident #71's utensils. A continuous observation on 9/25/24, beginning at 9:35 a.m. and ending at 12:49 p.m. the following was observed: At 12:06 p.m. Resident #95 took a roll off of Resident #71's plate and placed it on her plate. At 12:07 p.m. Resident #95 moved her plate with her utensils to the center of the table. At 12:08 p.m. Resident #71 moved Resident #95's plate in front of him. Resident #71 began eating the food on Resident #95's plate with Resident #71's utensils. -The staff in the dining room did not provide redirection to Resident #95 when she began using Resident #71's utensils and eating off of his plate. B. Staff interviews CNA #1 was interviewed on 9/25/24 at 12:26 p.m. CNA #1 said the residents should not share plates and utensils. She said all of the staff on the unit were responsible for watching the residents during meal times. She said sharing plates and utensils could lead to the spread of viruses between residents. The DON was interviewed on 9/26/24 at 12:32 p.m. The DON said residents should not share plates of food or utensils because it could lead to the spread of infection or viruses between residents.

Based on interviews, record review and observations the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, palatable in taste, texture and temperature. Specifically the facility failed to ensure the resident food was palatable in taste, texture and temperature. Findings include: I. Facility policy and procedure The Meal Preparation for Nutritive Value and Palatability policy and procedures, revised April 2023, was received from the nursing home administrator (NHA) on 9/27/24 at 5:07 p.m. It read in pertinent part, Food is prepared by methods that conserve nutritive value, flavor, and appearance. Food and drink that is palatable, attractive, and at a safe and appetizing temperature. Food is not prepared too far in advance of meal service. Food is prepared using acceptable standards of cooking. Hot food is not on the steam table ready to serve until 30 minutes prior to serving residents. Meal service is timed for tray/cart delivery within reasonable time limits to preserve temperature and quality of food. II. Resident interviews Resident #70 was interviewed on 9/23/24 at 1:35 p.m. She said she ate two sandwiches a day because the food was always served cold. Resident #24 was interviewed on 9/23/24 at 3:23 p.m. Resident #24 said the food served was cold all of the time. She said the food did not taste good most of the time. Resident #203 was interviewed on 9/23/24 at 4:05 p.m. She said the food served was always cold. Resident #18 was interviewed on 9/24/24 at 9:31 a.m. She said the room trays were sometimes cold. She said sometimes the certified nurse aides (CNA) were behind and were not able to get the trays out right away. Resident #251 was interviewed on 9/24/24 at 11:47 a.m. She said she only ate turkey and peanut butter and jelly sandwiches recently, because she did not like the food. She said the food had no flavor to it and was not prepared well. She said overall the food was not good. Resident #49 was interviewed on 9/24/24 at 12:15 p.m. He said the hot food was not served hot. He said he did not like the choices the facility had on the menu. He said most of the time he ordered take out food. III. Observations During a continuous observation on 9/26/24, beginning at 10:25 a.m. and ending 12:27 p.m., the following was observed during the lunch meal preparation and service in the main kitchen. -At 10:59 a.m. the cook (CK) #1 began preparing the resident's plates for the restorative unit. CK #1 put the food on a styrofoam plate, covered the plate in plastic wrap and placed it on the counter. An unidentified CNA then put the plate on an uninsulated rolling cart. -At 11:09 a.m. the last plate was placed on the rolling cart and the cart was taken to the restorative unit for room trays. -At 11:09 a.m. CK#1 began preparing the resident's plates for the secured unit. CK #1 placed the food on a plate, covered the plate in plastic wrap and placed it on the counter. An unidentified CNA placed the plate on a rolling cart. -At 11:22 a.m. the last plate was placed on the rolling cart and the cart was taken to the secured unit for room trays. -At 11:22 a.m. CK #1 plated the first plate for the dining room. The food was served on a styrofoam plate. -At 11:36 a.m. CK #1 began plating up the plates for the first hallway trays for the 200 hallway. CK #1 placed the food on the styrofoam plates, covered them in saran wrap and placed them on the counter. An unidentified CNA placed the plates on a tray and placed them on a multiple tier cart that was open. -At 11:58 a.m. CK #1 plated the last plate, covered it with plastic wrap and placed it on the counter. An unidentified CNA placed the plate on the tray and placed it on the uninsulated cart. The unidentified CNA delivered the room trays to the 200 hallway. -At 12:02 p.m. CK #1 began preparing the plates for the 300 hallway. CK #1 placed the food on the styrofoam plates, covered them in plastic wrap and placed them on the counter. An unidentified CNA placed the plates on an uninsulated cart. -At 12:13 p.m. CK #1 prepared the last plate, covered it in plastic wrap and placed it on the counter. An unidentified CNA placed the on the uninsulated cart and delivered the plates to the 300 hallway. -At 12:13 p.m. CK #1 began plating the first plate for the 400 hallway. CK #1 placed the food on the styrofoam plates, covered the plates in plastic wrap and placed them on the counter. An unidentified CNA placed the plates on an uninsulated cart for the 400 hallway. -At 12:25 p.m. CK #1 prepared the last plate, covered it up in plastic wrap and placed it on the counter. An unidentified CNA placed the plate on an uninsulated cart and exited the dining room at 12:27 p.m. to deliver the trays to the 400 hallway. A test tray for a regular diet was evaluated by five surveyors immediately after the last resident had been served their room tray for lunch on 9/26/24 at 12:42 p.m. The regular diet test tray consisted of lemon herb chicken, oven roasted parmesan potatoes, green beans, a dinner roll and strawberry shortcake fluff. -The lemon herb chicken was dry. -The oven roasted parmesan potatoes were 115.7 degrees F. The potatoes were bland and dry. -The green beans were 119 degrees F. The green beans were bland. -The dinner roll was soggy. IV. Record review The food committee meeting minute notes were received from the dietary manager on 9/17/24 at 1:15 p.m. The food committee minute notes from 8/14/24 documented in pertinent part, The residents said some days they were served vegetables and some days they were not served vegetables. -There was no documentation indicating a resolution to the concerns regarding vegetables brought up in the food committee. V. Staff interviews The dietary manager (DM) was interviewed on 9/26/24 at 1:34 p.m. The DM said he was aware of the concerns about the food being served cold. He said only one side of the plate warmer was working and the other side was currently broken. He said one side of the plate warmer had not been working for a while. He said he informed the NHA that he was waiting for the plate warmer to be repaired. He said the kitchen staff were trying to get the room trays out to the residents quicker. He said the facility did not have any hot boxes to transport the room trays in. The DM said maintenance had shut the water off in the morning, so he had to use styrofoam plates to serve lunch. The DM said the food committee was held monthly. He said there were not a lot of residents who attended the meeting. He said the residents who attended the monthly meeting had never complained about the food. He said if more residents attended the meetings and voiced their concerns then he could address the concerns. The DM said he had never run out of food. He said the cooks had been preparing extra food because the census had been going up. He said he did not work on the weekends so he was not aware of any concerns about the food running out and alternatives being served. The DM said the alternative menu was posted outside the dining room. He said the alternative menu was always available for the residents to order off of. He said the last time it was updated was last year. He said the main menu was rotated every six months. He said the menu was in the summer/spring season and would soon be changing over to the fall/winter menu. The NHA was interviewed on 9/26/24 at 1:45 p.m. The NHA said he was aware of the concerns from the residents about the food being cold. He said the common complaint he had heard from the residents was that the vegetables were too hard or too soft. He said he had encouraged those residents to eat their meals in the dining room. He said that the facility did not have any hot boxes to transport the room trays. He said he had ordered a plate warmer and was waiting for it to arrive. He said he did not know when he ordered the plate warmer. He said once the plate warmer was repaired that it should help fix the cold plate problem. The NHA said all the meals were served on the regular plates. He said he did not know why lunch was served on the styrofoam plates. The NHA said he had encouraged all the residents to attend the food committee meeting that was held once a month. He said he had told the residents to attend so that they could voice their concerns.

Based on observations and interviews the facility failed to ensure that residents personal funds accounts were managed adequately for the facility and accessible to the residents. Specifically, the facility failed to ensure residents were able to access their personal funds accounts on the weekend. Findings include: I. Resident interviews Resident #27 was interviewed on 9/23/24 at 11:48 a.m. Resident #27 said she could only access her personal funds account when the lady in the front office was in the facility. Resident #27 said she could not get money from her personal funds account on the weekends. Resident #16 was interviewed on 9/26/24 at 11:32 a.m. Resident #16 said residents could not get money from their personal funds account on the weekends. Resident #16 said if residents wanted money for the weekend, they had to ask for the money on Friday. II. Observations -On 9/23/24, 9/24/24 and 9/25/24 there was not a sign posted in the facility regarding resident banking hours. On 9/26/24 at 1:40 p.m. a sign was posted on the wall next to the business office. The sign indicated resident banking hours were Monday through Friday from 10:30 a.m. to 11:00 a.m. At the very bottom of the sign, in very small print, it indicated money could be accessed in emergencies by contacting the nursing supervisor on duty. III. Staff interviews The business office manager (BOM) was interviewed on 9/25/24 at 2:18 p.m. The BOM said resident banking hours were from 10:30 a.m. to 11:00 a.m. Monday through Friday but the residents could access their personal needs money any time she was in the office. The BOM said there was also a lock box where personal funds account money was kept for emergencies. The BOM said the nursing supervisor on duty on the weekends could access the lock box, however, she said the lock box was broken and the facility needed a new one. The BOM said she used to have a sign by her door with posted banking hours but it fell down and broke. The BOM said the sign indicated residents could contact the nursing supervisor on duty if they needed money for emergencies. She said the sign fell down around the first of August and the frame needed to be repaired. Registered nurse (RN) #2 was interviewed on 9/26/24 at 10:38 a.m. RN #2 said she did work some weekends. She said she did not know if residents could access personal funds account money on weekends. RN #2 said activities staff usually had ways to get things residents needed. RN#2 said she could message her supervisor if a resident needed something. The BOM was interviewed again on 9/26/24 at 10:45 a.m. The BOM said the lock box used to be kept in one of the medication carts and was accessible to the nursing supervisor on duty on weekends. The BOM said the facility needed to get a new lock box because batteries corroded the old one. She said it had been a few months since the box was broken and money had not been available for residents to access on weekends. The social services consultant (SSC) was interviewed on 9/26/24 at 1:40 p.m. The SSC read the sign posted by the business office and said the sign indicated personal funds accounts were accessible Monday through Friday from 10:30 a.m. to 11:00 a.m. She said it did not appear residents could access money on weekends. She said the very small print at the bottom of the sign indicated money could be accessed in emergencies through the nursing supervisor. The SSC said she could barely read the small print and the facility would update the sign with a larger print. The nursing home administrator (NHA) was interviewed on 9/26/24 at 2:38 p.m. The NHA said residents should be able to access their personal funds accounts on the weekend. The NHA said he was not informed until this week (during the survey) that the lock box was broken. He said he told staff to replace it.

Based on observations, record review and interviews, the facility failed to provide a clean, comfortable and homelike environment for one (#91) of one resident out of 45 sample residents and resident rooms on four of four hallways. Specifically, the facility the facility failed to: -Ensure a homelike environment was created for Resident #91 by personalizing his room; -Ensure resident rooms and bathrooms on four of four hallways received necessary maintenance repairs; and, -Ensure hallways and dining rooms received necessary maintenance repairs. Findings include: I. Facility policy and procedure The Homelike Environment policy and procedure, revised February 2021, was provided by the nursing home administrator (NHA) on 9/27/24 at 5:01 p.m. It revealed in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment, comfortable (minimum glare) yet adequate (suitable to the task) lighting, inviting colors and decor, personalized furniture and room arrangements, clean bed and bath linens that are in good condition, pleasant, neutral scents, plants and flowers, where appropriate, comfortable and safe temperatures (71 degrees Fahrenheit (F) to 81 degrees F) and comfortable sound levels. II. Failure to personalize Resident #91's room A. Resident status Resident #91, age 76, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified cataract (clouding of the clear lens of the eye and sensorineural hearing loss (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain). The 6/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of three out of 15. He required supervision with all activities of daily living (ADLs). The assessment indicated it was somewhat important for him to have books, newspapers and magazines to read, to be able to listen to music he enjoyed, to do his favorite activities, to be able to go outside and very important to be around animals. B. Observations On 9/23/24 at 3:15 p.m. Resident #91 was in his room sitting on his bed. His call light was laying on the floor between the bed and the wall, inaccessible, with his bed pushed up against the wall. When the call light was pulled from the floor the push button was not connected, therefore the call light was not functional. The A side of the room's call light was strung up over the top of what appeared to be a television wall mount and out of reach of Resident #91. Resident #91 did not have a roommate. Resident #91's room was bare with nothing on the walls. The chest of drawers was missing a drawer, there were no towels near the sink, and there was not a trash bag in his trash receptacle. A small box (approximately 12 inches by 8 inches) was observed to be full of what appeared to be the resident's belongings on the floor, next to the chest of drawers. The bedside table had his dirty black tennis shoes sitting on top of it with the television remote inside his shoe. C. Record review The activities care plan, revised on 4/4/24, documented Resident #91 used to collect rocks, minerals and jewelry. It revealed that he used to show off his canvas paintings and jewelry to staff members. It further revealed that he loved dogs and used to own terriers throughout his life. The 3/22/24 activity assessment documented Resident #91's preferences included having books, magazines and newspapers to read, being able to listen to music, doing his favorite activities, going outside and being around animals. D. Staff interviews Certified nurse assistant (CNA) #4 was interviewed on 9/26/24 at 9:10 a.m CNA #4 said the walls in Resident #91's room were bare with no decorations. She said Resident #91 liked to put things in boxes. -However based on the observation above, Resident #91 only had a very small box of belongings in the room. CNA #4 said the housekeeping and the activities departments were responsible for helping residents personalize their rooms. CNA #4 said Resident #91's call light was on the floor between the bed and the wall and it should be on the bed and accessible to Resident #91. The activities director (AD) was interviewed on 9/26/24 at 10:00 a.m. The AD said she could not remember if Resident #91 had anything on the walls in his room. She said she recalled a box with paintings in it, but she could not remember if the resident had any other personal items. She said Resident #91's room was dark. The AD said she had printed a picture of Resident #91's family and gave it to social services to hang up in his room. She said she could not remember when that had occurred, or if social services had hung up the picture. The AD said she did not know which department was responsible for assisting in the personalization of resident rooms. The social services director (SSD) and the social services consultant (SSC) were interviewed on 9/26/24 at 11:08 a.m. The SSD said Resident #91 was into painting and that he had some pictures on the wall, but she said she had not been in his room recently. She said the social services assistant had hung pictures up in Resident #91's room. She said she was not aware there was nothing on the walls in Resident #91's room. She said she was not aware which department's responsibility it was to assist the resident in personalizing his room. The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 9/26/24 at 2:38 p.m. The NHA said the facility took an interdisciplinary team (IDT) approach to personalizing resident rooms. He said there was not one department assigned to assist residents in the personalization of their rooms. He said the facility would provide donated items and talk to family members to send or bring in the resident's personal effects. The NHA said he was unaware the walls in Resident #91's room were bare, had a broken chest of drawers, did not have any towels at the sink and did not have a trash bag in the receptacle. He said he would meet with the IDT to ensure Resident #91's room was fixed and he was provided the supplies he required to ensure his room was personalized. 48114 III. Failure to ensure resident rooms, hallways and dining rooms received necessary maintenance repairs A. Observations and resident interviews On 9/25/24 at 8:54 a.m. the door frame to the entrance of room [ROOM NUMBER] was observed to be chipped. The toilet in the bathroom of room [ROOM NUMBER] did not flush and there was no string on the call light by the toilet. The resident who resided in room [ROOM NUMBER] said she had to reach down inside of the tank and pull the chain in order for the toilet to flush. On 9/25/24 at 8:52 a.m., across from room [ROOM NUMBER], the baseboards were observed to be missing on both sides of the entrance way into the physical therapy room. On 9/25/24 at 8:47 a.m. the window blinds to room [ROOM NUMBER] were observed to be broken off and missing. The resident who resided in room [ROOM NUMBER] said he reported the broken blinds to the maintenance department and was told there was an order to replace all the blinds in the facility. He said he did not like how the light came through the broken blinds and he would like for them to be replaced. He said the light could be bothersome to him. On 9/25/24 at 8:46 a.m. the light fixture outside of room [ROOM NUMBER] was observed to be cracked and falling off the ceiling. On 9/25/24 at 8:56 a.m. the 400 hallway was observed to have carpet with several stains on it. On 9/25/24 at 8:57 a.m. the entrance room [ROOM NUMBER] was observed to have three tiles that were broken off and missing. In the center of the room there was a small hole in the floor tiles that it was chipping away. There was a big crack which extended from the hole that affected six other floor tiles. The bathroom in room [ROOM NUMBER], around the base of the toilet, was observed to be missing one tile. The resident who resided in room [ROOM NUMBER] said the hole in the tile often made her wheelchair wheels get stuck. She said if the facility would fix the tile it would be nice. On 9/25/24 at 9:03 a.m. the call light alert box over the entrance to room [ROOM NUMBER] was observed to be coming off the ceiling. On 9/25/24 at 9:10 a.m. room [ROOM NUMBER] was observed to have one curtain hanging from the left side of the window and no curtain on the right side of the window. On 9/25/24 at 9:15 a.m. the heater vent along the two walls by the four windows in the secure unit dining room was observed to be completely off the wall and on the floor. Two walls in the dining room by the dining room tables were chipped and needed to be repainted. On 9/25/24 at 9:21 a.m. the four plug outlet attached to the wall next to bed #2 in room [ROOM NUMBER] was observed to be coming off the wall. One of the standing four dresser drawers in the room had one drawer that was missing. On 9/25/24 at 9:18 a.m. room [ROOM NUMBER]'s window blinds were observed to be broken off and missing. On 9/25/24 at 9:25 a.m.the ceiling where the privacy curtain rod was hanging in room [ROOM NUMBER] was observed to be removed and the drywall was peeling off. The resident who resided in room [ROOM NUMBER] said the ceiling had been peeling off for a long time. He said it bothered him that it was not fixed. B. Staff interviews An environmental tour was conducted on 9/25/24 at 9:41 a.m. with the maintenance director (MTD) and the above concerns were observed. The MTD said when staff saw something that needed to be fixed or repaired they would send him a text message. He said the facility had an electronic work system to track needed repairs. He said he did not use the system because he wanted to know right away what repairs needed to be done. He said he did not sit by the computer all day and that staff texting him was the best way to reach him. He said all the nurses stations had his phone number and staff knew how to reach him with any problems or concerns. He said he tried not to use the electronic work system. The MTD said he walked through the building at least twice a day every day. He said he did the first walk through first thing in the morning and then he did another walk through in the afternoon around 2:00 p.m. He said he walked through the building by himself as he was the only maintenance person in the building. He said the NHA did his own walk through of the building. The MTD said if he found any issues during the building inspection, he would let the NHA and DON know. He said if he could not fix something right away he would let the NHA know. He said if there was a nursing concern he would let the DON know. The MTD said work orders could take a while to get approved depending on how much it cost to fix the issue. He said anything that cost over 2500 dollars had to be approved by the NHA. He said the approval process could take one week or months. The NHA was interviewed on 9/25/24 at 10:18 a.m. The NHA said he did his own walk through the building once a day. He said the IDT, which consisted of all the department heads (the SSD, the DON, the assistant director of nursing (ADON), the dietary manager (DM), the rehabilitation director, the medical provider (MD) and the MTD) met every morning and did environmental rounds. He said depending on the issues they saw during environmental rounds that needed to be fixed, he would take notes and address the problem or issues right away. The NHA said the MTD was the only person who looked over the building for repairs and maintenance. He said he could reach out to the other communities to help out if needed. He said he was aware of the issues and concerns of the building and was working on getting the building repaired.

Based on record review and interviews, the facility failed to ensure one (#34) of five out of 45 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to: -Ensure the unapproved off label use of an antipsychotic medication (Seroquel) was not used for insomnia,for Resident #34; -Ensure the gradual dose reduction (GDR) recommendations were followed up on for Resident #34; and, -Ensure a consent was obtained for the use of the antipsychotic medication (Seroquel) for Resident #34. Findings include: I. Resident #34 A. Resident status Resident #34, age 65, was initially admitted on [DATE], discharged to an assisted living facility on 12/19/23 and readmitted on [DATE]. According to the September 2024 computerized physician orders (CPO), the diagnoses included multiple sclerosis (an autoimmune condition that affects the brain and spinal cord central nervous system) and insomnia (difficulty sleeping). The 6/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He was dependent upon staff for assistance with oral hygiene, toileting, bathing, lower body dressing and personal hygiene. The MDS documented Resident #34 was prescribed an antipsychotic medication. B. Record review The September 2024 CPO documented Resident #34 was prescribed Quetiapine Fumarate (Seroquel) 50 milligrams (mg), give one tablet by mouth at bedtime for insomnia ordered on 8/19/24 The use of antipsychotic medication care plan, initiated on 1/5/24, documented Resident #34's use of an antipsychotic medication for insomnia. The interventions included administering psychotropic medications as ordered by physician, monitoring for side effects and effectiveness, completing an abnormal involuntary movement scale (AIMS) assessment quarterly or as needed, monitoring behaviors identified for the antipsychotic medication, discussing with the medical doctor (MD), power of attorney (POA) and family regarding the ongoing need for use of the medication, reviewing behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, reviewing medications with the interdisciplinary team (IDT) quarterly and as indicated and attempting a GDR when clinically indicated. The 4/25/24 psych-pharm management progress note documented the resident was prescribed Quetiapine Fumarate 50 mg for insomnia and Trazodone HCI (anti-depressant) 50 mg for sleep as needed. The recommendations included to track the resident's hours of sleep for the use of the Trazodone and consider a GDR of Trazodone next quarter. -The psych-pharm meeting did not address Resident #34's unapproved and off label use of the Seroquel medication. The 7/25/24 psych-pharm management progress note documented Resident #34 was prescribed Quetiapine Fumarate (Seroquel) 50 mg one time per day for insomnia. The recommendations included reducing the Seroquel to 25 mg. -However, according to the September 2024 medication administration record (MAR) Resident #34 was still prescribed 50 mg of Seroquel one time per day. The facility did not follow through on the recommendations to reduce the Seroquel from 50 mg to 25 mg on 7/25/24. A review of Resident #34's medical record did not reveal documentation that the facility had obtained consent prior to the administration of the Seroquel. C. Staff interviews The social services consultant (SSC) was interviewed on 9/26/24 at 5:29 p.m. The SSC said the use of Seroquel for insomnia was an unapproved off-label use of the medication. She said there was no clinical justification for use of Seroquel for insomnia. The SSC said she did not know why Resident #34 was prescribed two medications for insomnia. She said was unable to find documentation to indicate a medical justification for the unapproved off label use of the Seroquel for insomnia. The SSC said the GDR recommendations were made during the monthly psych-pharm meetings. She said a GDR recommendation should be followed up on within seven days. She acknowledged the GDR recommendation had not been followed up on since Resident #34 was still prescribed Seroquel 50 mg one time per day instead of 25 mg on time per day. II. Facility follow-up After the survey process (9/23/24 - 9/26/24), the facility provided documentation on 9/27/24, that the resident's primary care physician (PCP) was contacted regarding the unapproved off label use of Seroquel for Resident #34. The physician responded to discontinue the Seroquel. The facility provided a consent dated 11/10/23 for the use of Seroquel, however Resident #34 had a planned discharge from the facility to an assisted living community (December 2023). This consent was from his previous admission to the facility.

Based on record review, observations and interviews, the facility failed to ensure two (#91 and #66) of two residents out of 45 sample residents were kept free from restraints. Resident #91 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and dementia. On 8/31/24 Resident #91 was blocking the entrance to the dining room when another resident became upset and struck Resident #91 on the forehead causing a laceration. Resident #91 became upset and was pacing the hallways looking for the other resident. Due to Resident #91's behaviors, the facility staff physically restrained Resident #91 by placing him in the secured unit for the day, instead of providing him with interventions to calm him down after an altercation in which he was hit by another resident. Resident #91, who had Alzheimer's disease, was unable to advocate for himself while he was being restrained in the secured unit. By placing Resident #91 in the secured unit, in an already aggressive state, he began to initiate behaviors with the residents who resided on the secured unit. Additionally, the facility failed to ensure a table was not used to restrain Resident #66. Findings include: I. Facility policy and procedure The Physical Restraint policy and procedure, dated 9/30/23, was provided by the nursing home administrator (NHA) on 9/27/24 at 5:01 pm. It revealed in pertinent part, Physical restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. II. Resident #91 A. Resident status Resident #91, age 76, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified cataract (clouding of the clear lens of the eye) and sensorineural hearing loss (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain). The 6/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) of three out of 15. He required supervision with all activities of daily living (ADL). The assessment indicated the resident did not exhibit wandering or exit seeking behaviors during the assessment period and did not reside on the secured unit. B. Observations On 9/23/24 at 3:15 p.m. Resident #91 was sitting on his bed. His call light was laying on the floor between the bed and the wall, inaccessible, with his bed pushed up against the wall. The cord attached to the push button was not connected to the wall, therefore the call light was not functional. There was a call light on the other side of the room that was strung up over the top of what appeared to be a television wall mount and out of reach of Resident #91. Resident #91 did not have a roommate. Resident #91's room was bare, with nothing on the walls. The chest of drawers was missing a drawer, there were no towels near the sink and there was not a trash bag in his trash receptacle. A small box was observed (approximately 12 inches by 8 inches) full of what appeared to be his belongings on the floor, next to the chest of drawers. The bedside table had his dirty black tennis shoes sitting on top of it with the television remote inside his shoe. Cross reference F584: the facility failed to ensure a homelike environment was created for Resident #91 by personalizing his room. Cross reference: F679: the facility failed to meet Resident #91's socialization needs by providing him independent activities in his room and inviting him to group activities according to his preferences. C. Record review The behavioral care plan, initiated and revised on 4/2/25, documented Resident #91 had a history of verbally aggressive behavior due to Alzheimer's disease The interventions included anticipating the resident's needs, providing an opportunity for positive interactions and attention, explaining all procedures and providing a program of activities of the resident's interest and accommodating the resident's needs. The verbal aggression care plan initiated on 9/3/24, documented Resident #91 had the potential to become verbally aggressive due to dementia, ineffective coping skills and poor impulse control. The interventions included providing 15-minute checks as needed, administering medications as ordered, evaluating the resident's coping skills and support system, evaluating the resident's understanding of the situation when agitated, intervening before the agitation escalated, guiding the resident away from sources of distress, engaging the resident calmly in conversation and approaching the resident later if the resident had an aggressive response. -The comprehensive care plan did not reveal documentation that indicated the resident was at risk of exit seeking or elopement. The 9/3/24 abuse investigation, documented on 8/31/24, revealed Resident #91 was blocking the entrance to the dining room. A male resident asked Resident #91 to move, however Resident #91 did not want to move. The male resident attempted to move Resident #91 out of the way and Resident #91 grabbed the other resident's wrist. The other male resident was able to remove his wrist from Resident #91's grasp and move past Resident #91. As the other resident was leaving, Resident #91 called him a racial slur. The other resident struck Resident #91 on the forehead leaving a laceration and bruising. The 9/1/24 nursing progress note documented at 10:34 a.m. revealed Resident #91 was observed standing in the hallway. He was looking up and down the hallway looking for someone. Resident #91 said, I know how to take care of myself. He better look out, I will find him. Resident #91 then started pacing the hallway and looking into other residents' rooms. The nurse documented that she spoke with the registered nurse (RN) in the facility and asked if Resident #91 could go to the secured unit. The RN agreed and the certified nurse aide (CNA) walked Resident #91 to the secured unit. The 9/2/24 nursing progress note documented Resident #91 returned to unit 200, where he resided, on 9/1/24 at 10:00 p.m. after being in the secured unit since 10:34 a.m. It revealed Resident #91 returned to the unit where he resided due to starting behaviors with the other residents who resided on the secured unit. -The facility failed to provide documentation of Resident #91's time in the secured unit. -The facility kept Resident #91 in the secured unit for 11 hours and 26 minutes. He did not have a bed to lay down in, nor any of his belongings. -The facility did not contact the physician for an order to place the resident in the secured unit, did not obtain consent from the resident's responsible party and did not complete an assessment to determine appropriateness of his placement in the secured unit. -The facility restrained Resident #91 in the secured unit in an attempt to control his behaviors, however the resident continued to display behaviors while on the secured unit. D. Staff interviews The social services director (SSD) and the social services consultant (SSC) were interviewed together on 9/26/24 at 11:08 a.m. The SSD said she was the one who reported the resident to resident altercation that involved Resident #91. She said Resident #91 called another male resident a racial slur and in response, the other resident struck Resident #91 on the forehead. The SSC said the secured unit was considered a restraint. The SSD said she was not aware Resident #91 had been taken to the secured unit after the altercation. The SSC was interviewed again on 9/26/24 at 2:17 p.m. The SSC said it was inappropriate for the facility staff to put Resident #91 on the secured unit. She said the NHA was not aware Resident #91 had been taken to the secured unit after the resident to resident altercation. The SSC said the facility had initiated immediate education to the facility staff regarding restraints, behavioral interventions and the secured unit. The NHA, the director of nursing (DON) and the clinical consultant (CC) were interviewed on 9/26/24 at 2:38 p.m. The NHA said it was inappropriate for the facility staff to take Resident #91 to the secured unit when he was having behaviors. He said the facility staff should have used interventions to address Resident #91's behavior, not place him on the secured unit. The NHA said residents must meet a certain criteria of exit seeking behavior and consent had to be obtained in order to place a resident on the secured unit. The NHA and the DON said facility staff should have called them so they could have consulted on how to handle Resident #91's behaviors. 47960 III. Resident #66 A. Resident status Resident #66, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included fracture of the right femur (hip), epilepsy (a chronic brain disorder that causes seizures), unsteadiness on feet and neurocognitive disorder with Lewy bodies (dementia with a build-up of proteins in the brain). The 8/6/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. He was dependent on staff for all ADLs. B. Observations During a continuous observation on 9/25/24, beginning at 9:24 a.m. and ending at 12:49 p.m., the following was observed: At 9:24 a.m. Resident #66 was in the dining room. He was seated in his wheelchair at the dining room table with his wheelchair locked. At 10:32 a.m. the resident was assisted to the television room. At 10:35 a.m. Resident #66 was assisted back to the dining room. The resident was positioned at a table with his wheelchair locked. He remained in the same location with his wheels locked through the lunch service and was assisted to his room at 12:49 p.m. -Resident #66 was positioned in front of the table so he was unable to move freely because he was unable to unlock his wheelchair or self-propel. During a continuous observation on 9/26/24, beginning at 9:05 a.m. and ending at 10:00 a.m., the following was observed: At 9:05 a.m. Resident #66 was in the dining room being assisted with his breakfast. The resident finished his breakfast and remained in the same location at the dining room table with his wheels locked until 10:00 a.m. At 12:20 p.m. Resident #66 was in the same location as he had been since the morning and the wheelchair was still locked. -Resident #66 was positioned in front of the table so he was unable to move freely because he was unable to unlock his wheelchair or self-propel. C. Resident interview and observation Resident #66 was interviewed on 9/26/24 at 9:12 a.m. Resident #66 said he was able to unlock his wheelchair, however when the resident was asked to demonstrate how he unlocked the wheels on the wheelchair, he was unable to perform the request and made no attempt to move his arms. D. Record review According to the September 2024 CPO the resident did not have a physician's order for restraints. The fall care plan, dated 9/25/24, revealed the resident was at risk for falls. Interventions included anticipating the residents needs and providing frequent checks to ensure the resident was appropriately positioned in the wheelchair. E. Staff interviews The DON was interviewed on 5/17/23 at 2:31 p.m. The DON said residents should not be pushed against a table with their wheels locked if they were unable to unlock them. RN #1 was interviewed on 9/26/24 at 12:20 p.m. RN #1 said Resident #66 had a book for drawing that he liked to use. She said the staff tried to keep him busy and offered toileting regularly. She said the resident had been sitting in the dining room all morning. -Resident #66 did not have an art book or any activities while sitting in the dining room (see observations above). The director of rehabilitation (DOR) was interviewed on 9/26/24 at 1:00 p.m. The DOR said Resident #66 was doing well after his hip fracture but then he had a seizure. She said he returned from the hospital on antiseizure medications and was not able to participate in therapy. The DOR said the therapy staff decided to give the resident more time to adjust to the new medication so they did not pursue therapy the first or second week of his readmission. She said she planned to visit the resident this week (week three) to reevaluate his status going forward. The DOR said when Resident #66 was discharged from therapy on 8/27/24, he could stand, walk, self-propel, lock and unlock the wheels on the wheelchair. She said she was not notified by the nursing staff that the resident was unable to lock or unlock the wheels on his wheelchair. The DOR said residents should never be placed at a table with the wheelchair wheels locked for extended periods unless the resident had the cognitive capacity to ask to do so or unlock the wheels themselves.

Based on observations, record review and interviews, the facility failed to honor resident choices for one (#8) of three residents out of 45 sample residents. Specifically, the facility failed to ensure Resident #8's preference was honored by getting her dressed prior to Bible study. Findings include: I. Resident #8 A. Resident status Resident #8, age 88, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia (when the blood does not have enough oxygen), chronic obstructive pulmonary disease (lung disease that blocks airflow making it hard to breathe), bipolar disorder unspecified and Alzheimer's disease unspecified. The 5/6/24 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was dependent on staff for all activities of daily living (ADL), including dressing, incontinence care and personal hygiene. The assessment indicated that it was somewhat important to her that she chose what clothes to wear every day and very important to her to do her favorite activities. B. Resident observations and interviews On 9/23/24 at 10:30 a.m. Resident #8 was lying in bed dressed in a hospital gown. There were three individuals in her room, including her spouse. They were engaged in Bible study. Resident #8 was interviewed on 9/23/24 at 1:29 p.m. Resident #8 was still wearing a hospital gown. She said she was not always able to get dressed every day, even though it was her preference to get dressed daily. She said she particularly wanted to be dressed in her dress and ready for the day for Bible study, which took place once per week. Resident #8 said she had to participate in Bible study that day while dressed in her hospital gown. She said the facility staff did not get to her in time to get her dressed. She said she felt embarrassed because she was not in her dress for Bible study, but instead was wearing a hospital gown. Resident #8 said her preference was to get dressed in a dress every day. She said, at least once or twice a week, the staff was not able to get her dressed. She said she thought the facility staff were aware of her preference to get dressed every day. Resident #8 was interviewed a second time on 9/26/24 at 9:00 a.m. Resident #8 said Bible study took place every Wednesday at 10:00 a.m. However, she said there were times in which it was rescheduled and it would take place on another day. C. Record review The ADL care plan, revised 6/27/23, documented Resident #8 had an ADL self-care deficit due to impaired balance and pain. It documented that Resident #8 preferred to get up in the morning between 7:00 a.m. and 7:30 a.m. The Kardex (nursing tool that summarizes resident information regarding daily schedules and interventions) documented Resident #8's preference was to be up and dressed for Bible study. II. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 9/26/24 at 9:33 a.m. CNA #4 said resident preferences were documented on the Kardex or given through a report from the previous shift. She said after working with residents for a long time, she was able to get to know their preferences. CNA #4 said Resident #8 wanted to get dressed everyday but did not like to get out of bed everyday. She said she did not know the date or time of the Bible study in which Resident #8 participated. She said she did not know Resident #8 was involved in a Bible study, but knew a couple of people would visit her a couple of times per week. The social services director (SSD) was interviewed on 9/26/24 at 10:00 a.m. The SSD said Resident #8 did not come out of her room very often. She said she did not know Resident #8 attended a Bible study in her room and she did not know if she liked to get dressed in the morning. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 9/26/24 at 2:38 p.m. The NHA said every residents' preferences should be honored and documented on the Kardex for the CNAs to reference. The NHA said he knew Resident #8 participated in a Bible study but he did not know what day and time it occurred. The NHA said he would put a new system in place of a binder kept at the nursing station which would include every residents' specific preferences to ensure each residents' preferences would be honored.

Based on observations and interviews, the facility failed to ensure residents' personal privacy for one (#13) of one resident reviewed for privacy out of 45 sample residents. Specifically, the facility failed to ensure privacy during care for Resident #13 by providing the resident with a privacy curtain. Findings include: I. Resident #13 A. Resident status Resident #13, age 72, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included bipolar disorder, chronic obstructive pulmonary disease (lung disease narrowing the airways making it hard to breathe) and muscle weakness. The 7/9/24 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 supervision or touching assistance for all activities of daily living (ADL). B. Resident interview and observation Resident #13 was interviewed on 9/23/24 at 1:52 p.m. Resident #13 said he received treatment for his groin every day. He said he was afraid that someone would walk into the room while he was exposed, when the treatment was being provided, because he did not have a privacy curtain. -During the interview, observation of Resident #13's room revealed the resident did not have a privacy curtain. II. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 9/26/24 at 9:33 a.m. CNA #4 said Resident #13 was mostly independent with his ADL care. She said he received treatment to his groin from the nurses. CNA #4 said she had not realized Resident #13 did not have a privacy curtain. She said she did not know how the resident was provided privacy during the treatment since he did not have a privacy curtain. Licensed practical nurse (LPN) #3 was interviewed on 9/26/24 at 10:56 a.m. LPN #3 said the evening shift nurse was assigned to apply lotion to Resident #13's groin. LPN #3 said Resident #13 did not have a privacy curtain in his room. She said she would ask the resident to go into the bathroom for privacy during the treatment because there was not a privacy curtain in his room. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 9/26/24 at 2:38 p.m. The NHA said every resident should have a privacy curtain. He said facility staff should notify him or the maintenance department if a resident did not have a privacy curtain. The NHA said he was not aware Resident #13 did not have a privacy curtain. He said he would get a curtain put up immediately so the resident was provided privacy during his treatments and with his daily care.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for one (#25) of two residents out of 45 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to ensure the comprehensive care plan addressed Resident #25's use of hearing aids and compression socks. Findings include: I. Resident #25 A. Resident status Resident #25, age 74, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (a common lung disease causing breathing problems), Alzheimer's disease, type 2 diabetes mellitus, hypertensive chronic kidney disease and major depressive disorder. The 9/3/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She was dependent on staff for transfers, bathing and putting on footwear. She used a wheelchair for mobility and required assistance to propel her wheelchair. The assessment indicated Resident #25 had adequate hearing utilizing hearing aids. B. Resident interview and observations On 9/23/24 at 1:30 p.m. Resident #25 was in her room. Resident #25 was not wearing hearing aids or compression socks. Resident #25 said the certified nurse aide (CNA) got her dressed this morning (9/23/24) but did not put her hearing aids in her ears or put her compression socks on her feet. -Resident #25's hearing aides were observed laying on her dresser. Resident #25 pointed to a sign on her wall which had instructions for facility staff to put her hearing aids in and her compression socks on every morning. On 9/24/24 at 2:00 p.m. Resident #25 was not wearing compression socks. She said the facility staff told her all of her compression socks were in the laundry. C. Record review The communication care plan, initiated 12/19/23 and revised 5/22/24, indicated Resident #25 had the potential for a communication problem related to cognitive deficit. Interventions included allowing adequate time to respond, repeating as necessary, not rushing, requesting clarification from the resident to ensure understanding, facing the resident when speaking, maintaining eye contact and reducing environmental noise. -The communication care plan did not indicate Resident #25 wore hearing aids. The activities of daily living (ADL) care plan, initiated 12/7/23 and revised 3/19/24, indicated Resident #25 had a self-care deficit related to dementia, impaired balance, limited mobility and pain. The care plan indicated Resident #25 required assistance with mobility using a wheelchair, assistance with dressing and transfers -The ADL care plan did not include Resident #25 wore compression socks or needed assistance putting on compression socks. -The ADL care plan did not indicate Resident #25 wore hearing aids or needed assistance putting in hearing aids. The activities care plan, initiated 12/13/23 and revised 12/28/23, indicated Resident #25 enjoyed both group and independent leisure activities. Interventions included staff providing assistance to and from activities of interest and making sure the resident's hearing aides were in and turned on during activities. -There was no documentation in Resident #25's EMR to indicate that Resident #25 was receiving assistance putting in her hearing aids or putting on her compression socks. II. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 9/26/24 at 9:00 a.m. CNA #5 said resident preferences for each resident were listed on the resident's Kardex (nursing tool that summarizes resident information and directs care). She said the CNAs should follow the care and preferences indicated on the Kardex. The director of nursing (DON) was interviewed 9/26/24 at 2:38 p.m. The DON said the comprehensive care plan should reflect the preferences and use of ancillary devices for the resident. He said items documented on the comprehensive care plan were pulled to the Kardex to inform the CNAs how to provide care to each resident. The DON said Resident #25 required assistance with putting her hearing aids in her ears in the morning, taking them out at night and donning and doffing (putting on and taking off) her compression socks. He said Resident #25's use of hearing aids and compression socks should be documented on the comprehensive care plan and the Kardex. The DON said said he would update Resident #25's comprehensive care plan to include her use of hearing aids and compression socks.

Based on record review and interviews, the facility failed to ensure that one (#8) of one out of 45 sample residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure that Resident #8 was placed on a maintenance program after therapy treatment had been discontinued. Findings include: I. Facility policy and procedure The Restorative Nursing Services policy and procedure, undated, was provided by the nursing home administrator (NHA) on 9/27/24 at 5:01 p.m. It revealed in pertinent part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals may include, but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence and self-esteem; and participating in the development and implementation of his/her plan of care. II. Resident #8 A. Resident status Resident #8, age 88, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (when the blood does not have enough oxygen), chronic obstructive pulmonary disease (lung disease that blocks airflow making it hard to breathe), bipolar disorder (mental disorder that causes shifts in mood and behavior) and Alzhimer's disease. The 5/6/24 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was dependent on staff for all activities of daily living (ADL), including bed mobility, dressing, incontinence care and personal hygiene. It indicated Resident #8 was on a prescribed physical therapy program from 5/13/24 to 6/11/24. B. Resident interview Resident #8 was interviewed on 9/23/24 at 1:29 p.m. Resident #8 said she had received physical therapy a couple months ago. She said the physical therapy had stopped and she did not know why. She said she wanted to be able to do some ADLs by herself, instead of relying on the facility staff. She said her goal was to be able to sit up in bed by herself and get into the wheelchair. Resident #8 said she would love to be able to walk, but was aware that was a lofty goal. She said the facility did not put her on a maintenance program following the discontinuation of physical therapy. She said the physical therapist gave her a sheet of exercises to do, but never instructed the facility staff to assist her. She said the exercises were difficult to do on her own. Resident #8 said she would have liked to have been put on a maintenance program, but was never asked. C. Record review The ADL care plan, revised 5/16/24, documented Resident #8 had an ADL deficit due to her impaired balance. The documented goal was to ensure the resident maintained her current level and did not decline in her need for ADL assistance. The interventions included discussing with the resident and her family any concerns related to loss the resident's of independence, encouraging Resident #8 to participate to her fullest extent with each interaction and monitoring and documenting any changes or potential for improvement. The limited physical mobility care plan, revised 8/2/24, documented Resident #8 had limited mobility and required staff assistance. The interventions included providing gentle range of motion as tolerated with her daily care and physical therapy and occupational therapy referrals as ordered. The 6/13/24 physical therapy discharge summary documented Resident #8 made improvements with her bed mobility going from dependent to maximal assistance. The recommendations indicated Resident #8 should continue with a home exercise program to maintain and improve functional performance and safety. It indicated that Resident #8's prognosis would be good with consistent staff follow-through, however the physical therapist documented that a restorative program was not indicated at that time. A review of Resident #8's medical record did not reveal documentation that a maintenance program had ever been discussed or offered to Resident #8. III. Staff interviews The director of rehabilitation (DOR) was interviewed on 9/26/24 at 12:53 p.m. The DOR said when physical, occupational or speech therapy was discontinued, the facility typically placed the resident on a restorative program. She said the restorative program was a maintenance program that was used to ensure the resident maintained their current level of ADL status and did not decline. The DOR said Resident #8 did not have a physician's order for a restorative program. She said the physical therapist did not document that a restorative or maintenance program was offered to Resident #8. She said she thought that Resident #8 would have declined the program even if it had been offered, however since it was not documented she was unable to say for sure that Resident #8 had declined restorative services. The DOR said the physical therapist should have documented why he did not write a restorative program for Resident #8. She said Resident #8 would be evaluated for physical therapy that day (9/26/24). The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 9/26/24 at 2:38 p.m. The NHA said restorative services should be provided or offered to all residents that had been discontinued from therapy services. He said the restorative program should be documented in the residents medical record and have a physician's order. He said the restorative program was in place to ensure residents maintained their level of function and did not decline. The NHA said Resident #8 would be evaluated by the DOR to reinstate physical therapy and then once that was complete would be placed on a restorative program if the resident was agreeable.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring or to prevent reoccurrence of pressure injuries for one (#20) of two residents reviewed out of 45 sample residents. Specifically, the facility failed to ensure physician recommendations for heel protection boots and a wheelchair cushion were implemented for Resident #20, who had a deep tissue pressure injury on her right heel. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 10/1/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. For individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using a device specifically designed for heel suspension, offloading the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. Once a pressure injury develops, pressure relief on the heel is needed to promote perfusion and healing. Pressure on Category/Stage III, IV, and unstageable heel pressure injuries and deep tissue pressure injuries of the heel should be completely offloaded as much as possible. II. Resident #20 A. Resident status Resident #20, age 86, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included a fracture of the right femur (large bone in the upper leg), cerebral infarction (stroke), dysphagia (difficulty swallowing), muscle weakness and Parkinsonism (a general term for neurodegenerative diseases that cause similar motor symptoms, such as rigidity, tremors, and slow movement). The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial to maximal assistance with transfers and used a wheelchair for mobility. The MDS revealed The assessment indicated Resident #20 was at risk for developing a pressure injury and was using a pressure reducing device for her bed and chair. B. Observations On 9/23/24 at 3:54 p.m. Resident #20 was sitting in her wheelchair in her room. There was no cushion in her wheelchair. She had tennis shoes on both feet. A sign was posted on the wall near her bed stating she was to wear a heel protection boot on her right foot. The sign did not indicate when the boot was to be worn. Resident #20 said she had a sore on her right heel. -However, according to the resident's care plan she was to have heel protection boots on both feet (see record review below). On 9/24/24 the following observations were made: -At 11:08 a.m. Resident #20 was sitting in her wheelchair in the dining room. She was wearing tennis shoes on both feet and did not have a cushion in her wheelchair. At 1:55 p.m. Resident #20 was lying in bed on her back. She did not have a heel protection boot on her right foot. At 3:30 p.m. Resident #20 was sitting in her wheelchair with tennis shoes on both feet. She did not have a cushion in her wheelchair. Resident #20 said she used to have a cushion in her wheelchair but she did not know what happened to it. She said her wheelchair seat was hard and became uncomfortable after a while. At 5:00 p.m. Resident #20 was in the dining room sitting in her wheelchair. She had tennis shoes on both feet and no cushion in her wheelchair. On 9/25/24 the following observations were made: -At 9:34 a.m. Resident #20 was sitting in her wheelchair with tennis shoes on both feet. There was no cushion in her wheelchair. At 10:41 a.m. Resident #20 was sitting in the dining room in her wheelchair. There was no cushion in the wheelchair. She had tennis shoes on both feet. At 12:24 p.m. Resident #20 was lying in bed. She had a heel protection boot on her right foot. -However, according to the resident's care plan she was to have heel protection boots on both feet (see record review below). On 9/26/24 at 1:07 p.m. Resident #20 was observed receiving wound care from registered nurse (RN) #2. There was a very small scab present on the bottom of Resident #20's right heel. -Multiple observations during the survey (from 9/23/24 to 9/26/24) revealed Resident #20 did not have a cushion in her wheelchair and was not wearing heel protection boots on both of her feet, however, according to the resident's care plan, she was to have a wheelchair cushion and heel protection boots on both feet (see record review below). C. Record review A 7/16/24 Braden Scale Assessment (a tool used to determine risk for pressure injury) indicated Resident #20 was at risk for developing pressure injuries. Her risk factors included limited mobility, inadequate nutrition and shearing (occurs when forces are applied to body tissues or parts that cause the tissues to move in opposite directions). The pressure injury care plan, initiated 5/21/24 and revised 9/10/24, included the intervention of a pressure relieving wheelchair cushion and pressure relieving devices or adaptive equipment when appropriate to potential pressure areas. The skin integrity care plan, initiated 7/22/24 and revised 8/6/24, included the intervention of foam boots (heel protection boots) to bilateral feet as tolerated. The 9/19/24 wound physician progress note documented Resident #20 had a right heel deep tissue pressure injury which was acquired on 7/30/24 and was not healed. Wound measurements were 0.4 centimeters (cm) length by 0.2 cm width with no measurable depth. The wound bed had 100% epithelialization (new cells covering the wound in the final stage of healing). Interventions included ensuring a seat or wheelchair cushion was in place and floating heels while in bed. Review of the September 2024 CPO revealed Resident #20 had a physician's order to apply a right heel protection boot while in bed or in her wheelchair every shift, ordered 7/19/24. -However, according to the resident's care plan she was to have heel protection boots on both feet (see care plan above). Review of the September 2024 medication administration record (MAR) revealed nurses were documenting every shift that Resident #20 was wearing the heel protection boot on her right foot while in bed and in her wheelchair. -However, multiple observations during the survey revealed the resident was wearing tennis shoes while she was in her wheelchair (see observations above). III. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 9/25/24 at 2:30 p.m. CNA #5 said if a resident was at risk for pressure ulcers the staff could ask for an air mattress for the resident. She said the staff could apply barrier cream, change the residents frequently, make sure the residents' skin was clean and dry and reposition them as needed. CNA #5 said Resident #20 had a wound on her bottom but it was healed. She said the resident had a wound on her right heel that occurred after her hip fracture. CNA #5 said she thought the wound on the resident's heel was healed also but she still was supposed to wear the heel protection boot when she was in bed. CNA #5 said the therapy department provided wheelchair cushions and she thought Resident #20 had a cushion in her wheelchair. RN #3 was interviewed on 9/25/24 at 9:34 a.m. RN #3 said Resident #20 usually wore the boot on her right foot when she was in bed for pressure relief. RN #3 pointed out the boot on the floor near the head of the bed. RN #2 was interviewed on 9/26/24 1:07 p.m. while providing wound care to Resident #20. She said the wound on the resident's right heel was much larger initially but was almost healed. She said the wound physician visited Resident #20 weekly. The director of nursing (DON) was interviewed on 9/26/24 at 2:38 p.m. The DON said preventative measures for pressure ulcers could include air mattresses, foam boots to float the heels, repositioning and nutrition interventions. The DON said a wheelchair should have a pressure reduction cushion in it. He said Resident #20 was refusing to wear the boot on her right foot and the physician discontinued it on 9/25/24 (during the survey). The DON said he made a progress note on 9/25/24 (during the survey) reflecting the resident's preferences. The DON said nurses should have been documenting Resident #20's refusal to wear the heel protection boot. The DON said he would provide education to the staff. -However, there was no documentation in Resident #20's electronic medical record (EMR) to indicate the resident refused to wear the heel protection boots prior to 9/25/24, during the survey, when the DON entered his progress note.

Based on record review and interviews, the facility failed to notify the resident's representative when required for one (#20) of one resident reviewed out of 45 sample residents. Specifically, the facility failed to ensure Resident #20's representative was notified of her medical appointments. Findings include: I. Resident #20 A. Resident status Resident #20, age 86, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included fracture of the right femur (large bone in the upper leg), cerebral infarction (stroke), dysphagia (difficulty swallowing), muscle weakness and Parkinsonism (a general term for neurodegenerative diseases that cause similar motor symptoms, such as rigidity, tremors, and slow movement). The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial to maximal assistance with transfers and used a wheelchair for mobility. B Resident interview Resident #20 was interviewed on 9/23/24 at 3:54 p.m. Resident #20 said she had a doctor's appointment with a specialist last week (week prior to survey) but staff did not tell her ahead of time or notify her daughter, who was her medical power of attorney (POA), about the appointment. Resident #20 said she wanted her representative to be notified of all medical appointments. C. Resident representative interview Resident #20's representative was interviewed on 9/26/24 at 12:21 p.m. The representative said she was the resident's medical POA and she told the staff to call her for any medical issues and appointments. She said she had informed the social services director (SSD) and the director of nursing (DON). She said sometimes the facility called her brother, who was the financial POA but he did not relay information to her. The representative said Resident #20 told her she went to a doctor's appointment last week (week prior to survey) but staff did not call her to notify her of the appointment. She said she did not know what the appointment was for. The representative said Resident #20 also had a medical appointment approximately one month ago (August 2024) and she was not notified of that appointment either. D. Record review Review of Resident #20's electronic medical record (EMR) revealed that Resident #20 had a financial POA and a medical POA listed as contacts. The 8/15/24 progress note revealed Resident #20 had an appointment with an orthopedist on 8/15/24. -The progress note did not indicate the resident's representative was notified of the appointment. The 9/16/24 progress note revealed Resident #20 had an appointment with an orthopedist on 9/16/24. -The progress note did not indicate the resident's representative was notified of the appointment. II. Staff interviews The SSD was interviewed on 9/26/24 1:34 p.m. The SSD said she arranged medical appointments with outside providers and contacted resident representatives to notify them of appointments. The SSD said Resident #20 had an appointment on 9/16/24 with the orthopedist and she notified the resident's financial POA of the appointment. The SSD said the day after the appointment the medical POA told her to call her regarding all appointments and not the financial POA. The SSD said she was not aware that the medical POA had talked to someone in the past about being notified of the resident's appointments. The DON was interviewed on 9/26/24 at 4:51 p.m. The DON said the SSD had been helping with the arrangement of medical appointments and contacting resident representatives. The DON said they contacted the POA or guardian to notify them of appointments. He said if a resident had a financial and a medical POA they should contact the medical POA for appointments. The DON said Resident #20's representative did not talk to him about this in the past, but he said the medical POA should have been notified of the appointments.

Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent accidents for one (#20) of five residents reviewed for accidents/hazards out of 45 sample residents. Specifically, the facility failed to: -Ensure staff consistently implemented fall interventions for Resident #20, which included placing the resident's call light within reach when she was in her room. Findings include: I. Facility policy and procedure The Fall Management policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 9/27/24 at 5:07p.m. It read in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. The following interventions may be considered after identification of root cause: assess the environment and make appropriate changes (bed in lowest position, placement of furniture, lighting, personal items within reach, non-slip footwear, night light, walker, wheelchair within reach if applicable). The call light and fluids should be within reach of the resident. Document in (the electronic medical record) the resident's response to interventions and revise interventions if they are not successful. II. Resident #20 A. Resident status Resident #20, age 86, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included fracture of the right femur (large bone in the upper leg), cerebral infarction (stroke), dysphagia (difficulty swallowing), muscle weakness and Parkinsonism (a general term for neurodegenerative diseases that cause similar motor symptoms, such as rigidity, tremors, and slow movement). The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial to maximal assistance with transfers and used a wheelchair for mobility. B. Observations On 9/25/24 at 9:12 a.m. Resident #20 was sitting in her wheelchair in her room. The call light was clipped on the pillow at the head of the bed behind her. The resident was sitting towards the foot of the bed with the bedside table in front of her and could not reach the call light. On 9/25/24 at 12:24 p.m. Resident #20 was lying in bed. Her call light was clipped to the left side of her pillow where she could not see it. She said she did not know where it was. On 9/26/24 at 8:51 a.m. Resident #20 was sitting in her room in her wheelchair asleep. Her call light was laying on the bed in front of her, not easily reachable. On 9/26/24 at 2:40 p.m. Resident #20 was sitting in her wheelchair in her room. Her call light was clipped to her pillow behind her out of her reach. The director of nursing (DON) went into the resident's room and moved the call light right next to the resident. Resident #20 demonstrated she could reach it and demonstrated she could push the call light after the DON moved it closer to her. C. Record review The fall risk assessment, dated 9/5/24, indicated Resident #20 was at high risk for falls because she had three or more falls in the past 90 days, she took three or more high risk medications and had three or more high risk diagnoses. Review of the resident's electronic medical record (EMR) from 6/1/24 through 9/25/24 revealed Resident #20 had eight falls during that time frame with the following interventions implemented: On 6/10/24 the resident attempted to self-transfer and fell . Interventions implemented were educating her to lock her wheelchair brakes and reminding her to use her call light for assistance. On 7/2/24 the resident attempted to self-transfer with her wheelchair brakes unlocked and fell . Interventions implemented were educating and encouraging her to lock her wheelchair brakes prior to transfers. She was educated to call for assistance with transfers. Resident #20 sustained a left hip fracture from the fall. On 7/18/24 the resident had removed her socks, attempted to self-transfer and fell . Interventions implemented were providing her with non-skid socks and reminding her to keep them on. On 7/18/24 the resident attempted to self-transfer and fell . Interventions implemented were to place Resident #20 within staff eyesight at the nurse's station (as she allowed). Staff should talk with her, offer snacks/fluids or activity supplies. On 7/22/24 the resident attempted to self-transfer, slid out of her wheelchair and fell . Interventions implemented were to encourage the resident to sit at the nurses station when out of bed. Dycem (a sticky pad to prevent slipping) was placed in her wheelchair. On 9/4/24 the resident attempted to self-transfer and fell . Interventions were to re-enforce the use of the call light, encourage Resident #20 to call for assistance and offer hipsters to protect her from hip injury. On 9/8/24 the resident attempted to self-transfer to the toilet and fell . Interventions were to remind Resident #20 to request staff assistance with transfers and for staff to check and change her every four hours and as needed. The fall care plan, initiated on 5/10/24 and revised on 9/10/24. Additional interventions to the ones listed after each fall above, included ensuring the resident's call light was within reach and encouraging/reminding the resident to use it for assistance as needed, anticipating and meeting the resident's needs, providing routine rounding and offering assistance as needed, reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes and removing any potential causes if possible. III. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 9/26/24 at 9:00 a.m. CNA #5 said if a resident was a fall risk their Kardex (a tool utilized to assist staff with providing resident care) would list what interventions were in place. CNA #5 said Resident #20 liked to get out of bed on her own and did not use her call light for assistance. CNA #5 said Resident #20 had a fall mat when she was in bed, they kept her bed in the lowest position, did frequent checks on the resident and made sure her touchpad call light was near her. She said the call light should be right next to her, hooked to her pants or her wheelchair. Registered nurse (RN) #2 was interviewed on 9/26/24 at 10:58 a.m. RN #2 said if a resident was at risk for falls they should have a fall care plan with fall interventions. RN #2 said the staff reviewed the fall interventions during the nurse report and communicated them with the CNAs. RN #2 said it was the nurses job to oversee fall interventions and make sure they were implemented. She said the CNAs were responsible for making sure interventions were in place. RN #2 said Resident #20 had a history of falls. She said the facility put a lot of interventions in place for her, but the resident still believed she could get up without help. RN #2 said staff checked on her frequently, and if she was getting restless, they offered to take her to the bathroom. She said staff made sure the call light was within reach and provided continual reminders for her to call for assistance. RN #2 said if the resident was up in her wheelchair the call light should be clipped onto her clothing where she could reach it. RN #2 said Resident #20's call light should not be left on the bed behind her where the resident could not see it or reach it. The director of nursing (DON) was interviewed on 9/26/24 at 2:40 p.m. The DON said call lights should always be within reach for the residents. He said Resident #20's call light should be close to her so she could see it and reach it easily.

Based on observations, record review and interviews, the facility failed to ensure that a resident who displayed or was diagnosed with a mental disorder received appropriate interventions to correct behaviors or to attain the highest practicable mental and psychosocial well-being for one (#11) of one resident out of 45 sample residents. Specifically, the facility failed to ensure person-centered individualized interventions were implemented for Resident #11's behaviors. Findings include: I. Resident #11 A. Resident status Resident #11, age 66, was admitted on [DATE]. According to the September 2024 computerized physicians orders (CPO), diagnoses included schizoaffective disorder, depressive episodes, anxiety and dementia. The 6/24/24 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident had verbal behaviors directed towards others, rejected care and used a wheelchair due to impairments in her upper and lower extremities on both sides. The resident was dependent on staff for toileting and personal hygiene. B. Observations On 9/24/24 during a continuous observation, beginning at 2:51 p.m. and ending at 3:30 p.m., the following was observed: At 2:51 p.m. licensed practical nurse (LPN) #4 was sitting at the nurses station. LPN #4 yelled an expletive, made a loud sigh, pounded on the desk and yelled at Resident #11 to get out of the room on the right (this room was a living room/break room area for staff and residents). Resident #11 said she needed to blow her nose and LPN #4 told her to come to the nurses station where he was sitting and he would help her. At 2:53 p.m. Resident #11 asked LPN #4 if she could smoke. LPN #4 told Resident #11 that he already told her no and the next smoke break was at 4:00 p.m. Resident #11 aggressively turned her wheelchair around and the wheel hit the wall. -LPN #4 did not attempt to redirect Resident #11's aggressive behavior. At 2:55 p.m. Resident #11 again asked LPN #4 if she could smoke. -LPN #4 did not respond or acknowledge the resident. At 2:58 p.m. Resident #11 asked LPN #4 if she could smoke for a third time. LPN #4 told her no. Resident #11 asked how long until she could smoke and LPN #4 did not respond to the resident. Resident #11 aggressively turned her wheelchair and went down the hallway. -LPN #4 did not attempt to redirect Resident #11's aggressive behavior. At 3:23 p.m. Resident #11, another resident and a staff member were near the nurses station where LPN #4 was sitting. LPN #4 told everyone to stop, please stop. Resident #11 told LPN #4 her eyes were bothering her. LPN #4 approached the resident and told her it was probably allergies and directed her to rinse her eyes with water. The resident requested eye drops instead and LPN #4 administered the drops then walked away in a [NAME] and said good lord. At 3:30 p.m. Resident #11 asked LPN #4 if she could smoke again. LPN #4 told Resident #11 to stop and said she had not missed a smoke break yet today. -LPN #4 did not attempt to redirect Resident #11 from her repeated requests for a smoke break. On 9/25/24 at 9:06 a.m. Resident #11 yelled that she had to pee and asked registered nurse (RN) #2 to take her to the bathroom. RN #2 told Resident #11 to take her medicine first. Resident #11 continued to yell that she had to pee and asked RN #2 again to take her to the bathroom. Resident #11 said she was not going to take her medicine and that she had to pee. RN #2 told Resident #11 to take her medicine first and Resident #11 again said no. At 9:12 a.m. Resident #11 took her medicine and asked again to go to the bathroom. At 9:13 a.m. certified nurse aide (CNA) #2 assisted Resident #11 to her room to use the restroom, seven minutes after the resident initially requested to go to the bathroom. On 9/26/24 at 2:25 p.m. Resident #11 was yelling in the main hallway that someone had hit her. -An unidentified staff member started joking with Resident #11 about donuts and did not acknowledge or question Resident #11 about the situation. C. Record review The care plan, dated 9/18/24, revealed the resident had a history of behavioral problems of verbal and physical aggression with poor safety awareness. Interventions included offering tasks that diverted the resident's attention. D. Staff interviews The director of nursing (DON) was interviewed on 9/26/24 at 12:32 p.m. The DON said when Resident #11 was having repetitive behaviors, staff should redirect her by offering activities, taking her outside or engaging in conversation with her. The clinical consultant (CC) and the social services consultant (SSC) were interviewed together on 9/26/24 at 2:05 p.m. The CC said Resident #11 changed her mind often and required firm boundary setting. She said staff should offer to take her outside, visit with social services and offer to spend time with her discussing life.

Based on record review and interviews, the facility failed to report a resident to resident altercation that resulted in an injury to the State Survey and Certification Agency in accordance with the state law for one (#91) of one resident out of 45 sample residents. Specifically, the facility failed to report an incident of physical abuse involving Resident #91 to the State Agency in a timely manner. Findings include: I. Facility policy and procedure The Abuse Reporting and Investigating policy and procedure, dated 2/6/23, was provided by the nursing home administrator (NHA) on 9/27/24 at 5:01 p.m. It revealed in pertinent part, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing. If any type of abuse, neglect, or misappropriation of property is confirmed, the NHA will be responsible to notify the Health Department Occurrence Reporting website within 2 (two) hours from the time the incident occurred. All other occurrences can be reported the next business day. II. Resident #91 A. Resident status Resident #91, age 76, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), the diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified cataract (clouding of the clear lens of the eye and sensorineural hearing loss (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain). The 6/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) of three out of 15. He required supervision with all activities of daily living (ADLs). B. Record review The nursing progress note dated 9/2/24 documented Resident #91 was returned from the secured unit and remained separated from the resident he had an altercation with on a previous shift. It documented Resident #91 was placed on 15-minute checks and that the resident had taken off the dressings from his treatment of the laceration on his head. The interdisciplinary team (IDT) note dated 9/3/24 documented the resident to resident altercation was reviewed. It did not include any additional information. The provider progress note dated 9/5/24 documented the physician was following up with Resident #91 after a recent altercation with another resident. It indicated that Resident #91 was struck in the head. The note documented Resident #91 was unable to recall why he was struck, and denied any behaviors that would cause him to be struck. -A review of Resident #91's electronic medical record (EMR) did not reveal further documentation of the physical altercation between Resident #91 and another resident. The 9/3/24 abuse investigation documented Resident #91 and another resident had a physical altercation on 8/31/24, in which another male resident struck Resident #91 in the head after Resident #91 called the other male resident a racial slur. The altercation resulted in Resident #91 sustaining a laceration to the forehead. -The abuse investigation documented that the physical abuse incident occurred on 8/31/24, but was not reported, nor investigated until 9/3/24, three days after the incident occurred, which resulted in an injury to Resident #91. III. Staff interviews The social services director (SSD) and the social services consultant (SSC) were interviewed together on 9/26/24 at 11:08 a.m. The SSD said she was the one who reported the altercation between Resident #91 and another male resident. She said Resident #91 was in the way of another resident trying to enter the dining room. She said the other resident asked Resident #91 to move, however Resident #91 did not want to move. The SSD said the other male resident attempted to move Resident #91 out of the way, which led to Resident #91 grabbing the other resident's wrist. She said the other resident was able to get his wrist free and move into the dining room. The SSD said as the other male resident was leaving, Resident #91 called the other male resident a racial slur. She said the other male resident then struck Resident #91 on the forehead, which caused a laceration. -On 9/26/24 at 2:17 p.m., the SSC said the incident of physical abuse involving Resident #91 was not reported to the NHA until 9/3/24. She said, once it was reported to the NHA, he began an investigation and reported the incident to the State Agency. She said the incident should have been reported immediately. The NHA and the director of nursing (DON) were interviewed on 9/26/24 at 2:38 p.m. The NHA said the physical altercation between Resident #91 and another resident occurred on a holiday weekend. He said the staff that was working did not notify him until he returned to work on 9/3/24. He said the incident should have been reported immediately after it occurred. The NHA said the incident of physical abuse should have been reported to the State Agency within two hours of the incident because it resulted in an injury. He said any incidents or allegations of abuse that did not result in an injury should be reported within 24 hours of the incident.

Based on observation, record review and interviews, the facility failed to ensure one (#92) of six residents reviewed for accidents out of 29 sample residents remained as free from accident hazards as possible. Resident #92, was initially admitted for short term rehabilitation on 2/28/23 with a goal to return home. He was identified as a high fall risk and as a high elopement risk upon admission. The resident had numerous predisposing factors which included: dementia, confusion and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from: eloping on one occasion and falling seven times within a period of two months. The resident sustained major injuries from two out of seven falls which led to hospitalization . Due to the facility's failures, the resident was sent to the emergency department (ED) for an evaluation which identified the resident sustained an acute hip fracture to the right hip subsequent to a fall on 4/5/23 requiring surgery and hospitalization . The resident was discharged from the hospital on 4/8/23 and returned to the nursing facility. The resident refractured his right hip around the periprosthetic (structure in close relation to an implant), a distal femur fracture (fractures of the thigh bone that occur just above the knee joint) and nondisplaced left superior pubic fracture (a break in one of the bones that make up the pelvis), subsequent to a fall on 4/20/23 (12 days after the resident returned from the initial ED visit to the nursing facility). Subsequently, he declined, developing an unstageable pressure injury (cross-reference F686). The resident was admitted to hospice care and passed away on 5/7/23 (16 days after being readmitted from the ED on 4/21/22). Findings include: I. Facility policies and procedures The Fall Management policy, dated 3/10/23, was provided on 5/8/23 by the nursing home administrator (NHA). The policy read A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. To be effective, a fall reduction program is characterized by four components: -Fall risk evaluation -Care planning and implementation of interventions -Ongoing evaluation process Quality Assurance Performance Improvement (QAPI) -A commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representative will be invited to all care plan meetings. The interventions are to be re-evaluated when a resident falls. II. Resident #92 A. Resident status Resident #92, age 88, was admitted on [DATE] and passed away on 5/7/23. According to the May 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, without behavioral disturbance, benign prostatic hyperplasia and muscle weakness. The 3/3/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score five out of 15. The resident required supervision with transfers, walking in the room, dressing, toileting and personal hygiene. He was always continent of bowel and bladder. The fall section revealed the resident did not have a fall in the last six months prior to admission. The prognosis section revealed the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. The behavior section indicated the resident did not resist the care, he did not have hallucinations, delusions or other types of behaviors. B. Resident observations The resident was observed on 5/3/23 at 3:10 p.m. The resident was laying down in bed on his back with his eyes open. The resident's mattress appeared to be winged on the edges. The resident was non-verbal, however, he would emit sound to indicate pain and or attempt to communicate. A fall mat was observed under his bed (the fall mat protruded approximately one foot from the edge of the left side of the bed upon entry and obstructed the entryway to the residents room). C. Representative interview The resident's wife was a resident at the facility and resided in the same room as Resident #92. The resident's wife was interviewed on 5/3/23 at 3:15 p.m. She said her husband had become bed ridden and was awaiting his last days since he has fallen so many times and injured himself. The resident has declined that he was unable to speak, eat and was no longer who he once was since he was first admitted . She said the facility did not do much to prevent his falls. The nursing staff at the facility mostly provided education on call light use. The resident's wife said she asked staff to raise the guard rails on the side of the bed to prevent him from getting out of bed but nursing staff refused. The resident's wife said they barely checked on him (every four to six hours) throughout the day and night and they mostly relied on the resident to use his call light if he needed something, which he would not remember to do. Furthermore, the resident's wife said she would not be able to use the call light for him because she was unable to monitor the resident all the time, especially when she was asleep. The facility gave him a urinal and told him to use it, however, he did not want to use the urinal. The facility tried to do more after his last fall on 4/19/23. The facility obtained a winged mattress and put a fall mat on the floor, however, the mat did not help because it was under the bed and was a tripping hazard to get into the bathroom or even to try and open the room door. The resident's wife said she almost tripped on it a few times. Even with everything the facility tried to do, it was too late. Resident #92 was admitted to hospice and awaited to pass after 4/19/23. The last thing the facility offered the resident's wife was to transfer him to a secured unit away from her. She said she did not know how being locked up in a different unit was going to do anything for him since he just laid in bed all day. She said she questioned why the facility wanted to separate the resident and his wife during his final days. D. Record review The resident was assessed for wandering upon admission on 2/28/23. The wandering assessment revealed the resident was at an increased risk for wandering outside the facility. The care plan for elopement, initiated on 2/28/23 and revised on 4/9/23, revealed the resident had potential for elopement risk/wandering due to decline in cognition related to dementia diagnosis. Interventions included: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? The resident was wandering to look for his wife and asked for transportation to go home. Intervene as appropriate; distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The care plan for elopement prevention, initiated on 2/28/23 and revised on 3/21/23, revealed the resident required placement on a secure neighborhood due to elopement attempts. Interventions included: Resident will be accompanied when going off of the unit/neighborhood and staff to monitor safety of exit seeking by redirecting away from doors, engage in meaningful activity. -The facility failed to maintain interventions listed for elopement prevention as the resident was able to elope out of the building on 3/3/23 (see below). The resident was assessed for fall risk on several occasions since 2/28/23. Specifically, he was assessed on 2/28/23, 3/3/23, 3/16/23, 3/29/23, and 4/21/23. He consistently scored high risk for falls. The care plan for activities of daily living (ADLs), initiated on 3/2/23 and revised on 5/8/23, revealed that the resident had potential for self care related deficit due to unsteady and or shuffling gait. Interventions included to provide assistance with bed mobility, bathing, and toileting. Additionally, the resident required the use of a walker for mobility. The care plan for physical mobility initiated on 3/2/23 and revised on 5/8/23, revealed that the resident was weight bearing and was able to ambulate with assistance. The care plan for falls, initiated upon admission on 3/2/23 and revised on 5/8/23, revealed the resident was at risk for falls due to confusion , deconditioning, gait/balance problems, history of falls, poor communication/comprehension, unaware of safety needs ,hearing problems and wandering. Interventions included: to make sure call light was within the reach and encourage resident to use it, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage rest periods when signs of fatigue are noted, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure adequate lighting and visual aids are in place on admission, assess for communication needs as indicated, ensure appropriate positioning in center of bed, provide assistance with repositioning as indicated, ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, physical therapy (PT) to evaluate and treat as ordered or as needed (PRN). Intervention added on 3/26/23 (after fall #3, see below); staff to check on the resident frequently at night for toileting needs to help decrease risk for falls. Intervention added on 3/27/23 (after fall #4, see below); encourage the resident to use the urinal to void and call for assistance to help decrease risk for falls. Intervention added for a sensor light in the room (sensor triggered night light). Intervention added on 4/4/23 (after fall #5, see below); remove extra layer of sheets on wheelchair cushion prior to assisting resident to wheelchair as needed. Staff to ensure wheelchair brakes are on during transfers to help decrease his risks for falls. Intervention added on 4/17/23 (after fall #6, see below); review information on past falls and attempt to determine the cause of falls. Record possible root causes, and remove any potential causes if possible. Educate resident/family/caregivers/integrated multi-disciplinary team (IDT) as to causes, per IDT review resident to move to a bigger room. Intervention added on 4/19/23 (after fall #7, see below) to review medications and order labs as needed. Intervention to place fall mat at bedside as needed. -There were no interventions added to the care plan for the resident after his fall #1, #2, #4 and #6 (that resulted in a hip fracture). Interventions were added 12 days after fall #6. -Interventions that were added were not effective such as education due to poor memory and dementia. -The resident required supervision assistance from staff with his activities of daily living and often the interventions added (see below) after the resident fell were to provide Resident #92 with education, redirection and encouragement. Interventions were not defined, verbiage used such as frequently were subjective to staff and did not specify clear direction to ensure the resident's safety was maintained to prevent falls. 1. Elopement Incident on 3/3/23 (within 72 hours of admission) The incident report dated 3/3/23, revealed Resident #92 eloped out of the facility on 3/3/23 around 3:10 p.m. The resident was found on the west side of the building, exited through the back door. The resident was brought back inside. The resident remained confused, looking for his wife who is in the hospital. Consent obtained from the resident's wife to place resident in the dementia unit due to wandering and exit seeking behavior. 2. Fall #1 on 3/3/23 The incident report dated 3/3/23, revealed Resident #92 sustained a fall on 3/3/23 around 3:39 p.m. The resident was observed tripping over cement barrier on west side of the building related to confusion looking for his spouse. The resident was assisted back to the facility by four staff members and assisted to the memory unit, footwear evaluated. Predisposing factors for the fall were listed as hearing impairment and wandering. No injuries observed at the time of the incident. The IDT review, dated 3/9/23 (six days after the elopement and fall#1) revealed resident sustained an unwitnessed fall on 3/9/23, the root cause of the fall was identified as resident noted with unsteady gait, poor safety awareness, noted outside on uneven ground. Interventions included resident was assisted to locked unit 5, footwear assessed for proper footwear. Treatment required included neurological checks (a series of questions and tests to check brain, spinal cord, and nerve function) for the next 72 hours. -The facility was unable to provide documentation to evidence the neurological checks and vitals were completed after the fall; as indicated in the risk management review note under treatment required (see above). -The physician was notified and no response was documented, no further orders were given. -The resident's care plan was not updated with any new interventions to prevent resident from falling. 3. Fall #2 on 3/16/23 The incident report dated 3/16/23, revealed Resident #92 sustained a fall on 3/16/23. Resident #92 was found kneeling on the floor holding on to his wheelchair, walker overturned on the floor, wife at side. Resident stated he needed to pee. Predisposing factors were identified as confused, gait imbalance, identified as high risk for falls, ambulating without assistance, on the way to the bathroom and using a walker. Immediate action taken revealed registered nurse (RN) assessed, assisted back into wheelchair, urinal given and demonstrated on use. After voiding, grippy socks put on and with stand by assist, walker was utilized to ambulate back to bed. Instructed resident to call for assistance and to use the urinal for urination, verbalized understanding. Encouraged spouse to call for staff assist as needed. The IDT review, dated 3/23/23 revealed resident sustained a witnessed fall on 3/16/23, the root cause of the fall was identified as poor safety awareness, unsteady gait/dementia, says he had to pee. Interventions included encourage the resident to use the urinal to void, call for assistance for needs. -The resident's care plan was not updated with any new interventions to prevent resident from falling. -The physician was notified. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neuro checks and vitals. 4. Fall #3 on 3/26/23 The incident report dated 3/26/23, revealed Resident #92 sustained a fall on 3/26/23 around midnight. A certified nurse aide (CNA) advised the RN that during rounds the resident was observed on the floor between the bed and the bedside table. The resident's wife stated she believes he was attempting to stand up to use his urinal but unsure on how the resident fell . Immediate actions taken revealed resident was assessed by the nurse, and a set of vital signs were obtained. RN completed the initial RN assessment and the CNA assisted with getting the resident back in bed. Neurological checks were started on the resident and the provider was notified. No injuries were observed at the time of the incident. Predisposing factors were identified as poor lighting, gait imbalance, hearing impairment, incontinent and ambulating without assistance. -The incident report did not mention any other immediate interventions to prevent the resident from falling. The IDT review, dated 4/3/23 revealed resident sustained an unwitnessed fall on 3/26/23, the root cause of the fall was identified as poor safety awareness. Interventions included staff to check on resident periodically at night for unmet needs, toileting, to help decrease risk for falls. -The IDT review did not define periodical checks, which was subjective to staff and did not specify clear direction to ensure the resident's safety was maintained to prevent falls. -The resident's care plan was updated with the following interventions: staff to check on the resident frequently at night for toileting needs to help decrease risk for falls. -Frequent checks were subjective to staff and did not specify clear direction to ensure the resident's safety was maintained to prevent falls. -No additional interventions were added to keep the resident from falling besides frequency of rounding. -The physician was notified with no response documented, no further orders given. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. 5. Fall #4 on 3/27/23 (second fall in 26 hours) The incident report dated 3/27/23, revealed Resident #92 sustained a fall on 3/27/23 at 1:34 a.m. (this was his second fall in 26 hours). Resident assessed by RN, no injuries noted. Resident present with confusion due to dementia. MD (medical doctor) to review medication and staff to encourage toileting before bed time. The resident was unable to give a description. No injuries observed at time of incident. The resident reported no pain. Predisposing factors were identified as poor lighting, impaired memory, poor safety awareness, hearing impairment, fall in the past 30 days, incontinent, poor impulse control and high risk for falls. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT review, dated 3/28/23 noted as a late entry by administration, revealed the resident sustained an unwitnessed fall on 3/27/23. The root cause of the fall was identified as poor safety awareness. Confusion due to dementia. No treatment was required. Interventions included the medical Doctor (MD) to review medications. Staff encouraged to toilet resident before bed. -The IDT review did not address the fact that the resident was confused, had poor impulse control, impaired memory and poor lighting to be able to see clearly and utilize the urinal and or call light. -The resident's care plan was not updated with any specific interventions based on the cause of fall. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. 6. Fall #5 on 4/4/23 The incident report dated 4/4/23, revealed Resident #92 sustained a fall on 4/4/23 at 1:13 p.m. RN alerted that the resident was on the floor. RN observed the resident on his buttocks between his bed and the wheelchair. The resident apparently landed on his buttocks and right elbow. Initially the resident complained of slight pain to his right elbow. Five minutes later the resident denied any pain. Range of motion adequate in all extremities. Vital signs taken were stable. No redness, bleeding or open skin involved. The resident's wife was in the room when the incident occurred. Immediate interventions included the resident was assisted back into the wheelchair. Therapy to screen, evaluate and treat as indicated. The resident presents with poor safety awareness due to dementia. Resident's wife reported that the resident slid to the floor. The resident noted with extra layer of sheets on his wheelchair cushion. Fall consistent with the resident sliding to the floor due to an extra layer of sheet on his wheelchair. Extra layer of sheet removed. Predisposing factors were identified as poor lighting, impaired memory, poor safety awareness, hearing impairment, fall in the past 30 days, ambulating without assistance and on the way to the bathroom. Other information section revealed the resident was confused, hearing impaired with unsteady gait, despite repeated warnings, he kept trying to go to the bathroom by himself. The IDT review, dated 4/4/23 noted as a late entry by administration, revealed the resident sustained a witnessed fall on 4/4/23. The root cause of the fall was identified as poor safety awareness due to dementia. Extra layers of sheet on his wheelchair.No treatment was required and no injuries were observed at the time of the incident. Interventions included extra sheets removed from wheelchair. Therapy to screen, evaluate and treat as indicated. A referral was made to the MD for further review. -The documentation was incomplete and did not include whether the MD was notified of the event. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. 7. Fall #6 on 4/5/23 (second fall within 24 hours) The incident report dated 4/4/23, revealed Resident #92 sustained a fall on 4/5/23 at 1:14 p.m. (this was his second fall 24 hours) RN answered the call light and observed the resident on the floor between his walker, bedside table and his wife's bed. He fell again per wife. Sustained a cut on the back of his left hand, dorsal (back) surface. The resident complained of right hip pain. Range of motion to upper and lower extremities adequate. Vital signs taken. Alert but confused. Moaning in pain and touching his right hip. Immediate interventions included give pain medication and sent out to hospital. Predisposing factors were identified as confused, impaired memory, hearing impairment, fall in the past 30 days, identified as high risk for falls and ambulating without assistance. Other information section revealed the resident was in the presence of his wife this afternoon. The resident did not use his call light and probably got confused and forgot. -The IDT review was not completed for this incident. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. -The resident's care plan was not updated with any specific interventions based on the cause of fall. The hospital documentation revealed the resident sustained an acute right femoral fracture which required intramedullary nail placement surgery (surgery to repair a broken bone and keep it stable by placing a permanent nail or rod into the center of the bone.) The resident was discharged from the ED on 4/8/23 and returned to the facility. The skilled nursing progress note dated 4/16/23 revealed the resident had right hip surgery on 4/6/2023 and had noticeable cognitive decline after the surgery. 8. Fall #7 on 4/19/23 The incident report dated 4/19/23 revealed that Resident #92 sustained another fall on 4/19/23 around 8:00 p.m. During CNA rounding, the CNA informed the nurse that the resident was observed on the floor. Upon entry, the resident was on the floor in a fetal position grimacing in pain. The resident's wife was unsure how the resident fell , she was asleep and heard the resident fall. RN completed an RN assessment, resident assisted with toileting and the resident was placed back in bed. The resident stated he was attempting to walk to the restroom when he fell . The immediate action taken revealed the resident was given as needed (PRN) oxycodone 5 mg (pain medication) and repositioned the right lower extremity with a pillow under the knee. The resident presented with poor safety awareness, confused and present with poor judgment regarding functional limitation. Neurological checks initiated. MD notified and x-ray ordered. Resident encouraged to use call light, frequent checks initiated by staff. Therapy to screen and evaluate plan of care as indicated. Predisposing factors were identified as poor lighting, confused, gait imbalance, impaired memory, pain, restlessness, recent change in ability to transfer/ambulate, hearing impairment, fall in the past 30 days, identified as high risk for falls, poor impulse control, weakness, poor safety awareness, recent room change and ambulating without assistance. The IDT note dated 4/21/23 noted as a late entry by administration, revealed the resident sustained an unwitnessed fall on 4/20/23, in contrast with the correct event date of 4/19/23. The root cause of the fall was identified as poor safety awareness due to dementia, lack of knowledge regarding functional limitations, attempting to ambulate without using call light for assistance, x-ray treatment required and ordered. Interventions included placement to the dementia unit due to confusion, frequent checks initiated, therapy to screen for a toileting plan. -The IDT note was incomplete; the MD notification had no documented response provided. The nursing note dated 4/20/23 revealed X-rays taken on resident's right hip and knee. Unofficial results show fracture. Provider notified and ordered to send the resident out to the hospital for evaluation and treatment. Report called to hospital. The follow up note dated 4/20/23, completed by nurse practitioner (NP) #1 revealed, The (patient) is seen for a reported fall to which he apparently was up, lost his footing, and slammed onto his right lower extremity directly to knee. The patient has significant pain to palpation of his knee. It is rather edematous (swelling caused by excess fluid in body tissues), painful, mild crepitus (crackling or grating sound caused by bones rubbing against each other), mild deformity. It is reasonable to consider the outcomes of residents with cognitive deficits that have multiple falls with injuries such as this resident and we will provide and aid in facilitation of regaining his strength and healing but ultimately concerned of a pending global decline. The hospital encounter notes dated 4/20/23 revealed, Varus angulation (excessive inward angulation of the distal segment of a bone or joint) across the fixation site (previous surgery site) appears to be new and likely represents an acute injury. 2. Acute periprosthetic fracture (fractures that occur in association with an orthopedic implant) of the distal right femur at the level of the distal interlocking screw. 3. Acute nondisplaced fracture of the left superior pubic ramus(a break in one of the bones of the pelvis). The nursing note dated 4/22/23 revealed, The resident returned from the hospital and continues on observation with new fracture to upper right thigh and hip. Immobilizer in place to right leg. A nursing progress note dated 5/7/23 revealed in part, Physician pronounced death of resident at 8:07 a.m. on May 7, 2023. Time of death was 03:40 a.m. Resident's condition had been declining for several weeks after 2 falls with many fractures. Resident had a rapid decline overnight and death was not unexpected. III. Staff interviews CNA #4 was interviewed on 5/9/23 at 10:17 a.m. He said he was new to the unit, but provided care for the resident for a few weeks. The care he provided consisted of ensuring the resident was provided meals, was toileted, repositioned and checked on. The resident never used the call light while he provided care for him. During the time CNA #4 provided care to the resident, the resident fell and then was hospitalized . After the fall, the resident did not eat anymore and stayed in bed. CNA #4 said he was not aware of any fall interventions due to the resident being on end of life care and was on his way to pass. CNA #5 was interviewed on 5/9/23 at 10:27 a.m. She said she worked with the resident since he was admitted to the facility. The care she provided to him changed during his time as a resident. Initially, upon admission the resident was independent and did not require much assistance and the resident was able to use his call light, walk and eat. Once the resident fell and broke his hip he required extensive assistance. Staff had to change him, turn him and assist him with eating. The resident wandered at times because he would try to look for his wife. The interventions put in place to prevent the resident from wandering were to walk with staff assistance back to the room and two hour checks; the checks were not documented. The resident was at risk for falls and he had two interventions in place which included keeping an eye on him and ask him if he needed to use the restroom. The resident was not on a toileting program and although he was always educated on call light use, he would never remember to use it but his wife would use it for him as much as she could. RN #2 was interviewed on 5/9/23 at 10:46 a.m. He said he worked with the resident intermittently over the course of his stay. The care he provided to the resident consisted of ensuring medications were administered and ensuring the resident was assisted with meals, toileted, assisted with physical mobility and educated on call light use. The resident hardly used the call light but his wife used it for him. The resident was at risk for wandering and he was placed on a one-to-one with staff (according to the director of nursing the resident was within line of sight) to prevent him from attempting to elope. Interventions put in place to prevent falls included ensuring the call light was in reach and checking in as often as possible between 10 to 15 minutes. The resident's wife was educated to use the call light anytime the resident got up. The resident did have dementia before the fall, but after the fall he was unable to comprehend the use of call light for help. After the resident fell the first time, staff hoped he was going to recover, after the second fall the physician notified staff that the resident was not going to survive. The falls were due to the resident's dementia and he did not follow or comprehend the plan of care for him such as call light use and he overall had poor safety awareness. The physical therapy assistant (PTA) was interviewed on 5/9/23 at 12:35 p.m. She said the resident's cognition was a little difficult to work with. At first the resident was admitted to rehabilitation to get him back to where he was. The resident was hard of hearing but was pleasant and nice. The resident used a walker to walk and a needed staff stand by assistance to get in and out of bed. He was modified to independent or staff to be close stand by; he would go to the bathroom on his own. A few days after admission he wandered off and fell because he was looking for his wife. The resident was supposed to be checked on frequently, however the PTA was uncertain at what intervals. Subsequently, he had a few falls and declined cognitively and functionally after each fall. The PTA had to increase safety cueing and visual scanning due to the resident's poor carry over of education, cognition and unsteady gait. The interventions recommended by the PTA included his bed in the lowest position, decreased clutter in his room, education to wife and safe walks to the bathroom with staff. The PTA did not recommend the fall mat because of the potential of the resident tripping due to unsteady balance/gait. The resident participated in the exercise program but was not evaluated again after each fall only when he broke his hip he was evaluated. The PTA said after he fell and broke his hip he sustained another fall which led to his overall decline.The resident's numerous falls contributed to his admission to hospice care due to high pain and his impacted ability to do anything and it was excruciating for him to get out of bed. NP #1 was interviewed on 5/9/23 at approximately 1:30 p.m. NP #1 said areas of opportunity existed related to fall prevention. Interventions could have been in place such as placement on the memory care unit and toileting interventions by staff. The NP acknowledged the falls the resident experienced did contribute to the overall decline in function. The director of nursing (DON) was interviewed on 5/9/23 at approximately 3:30 p.m. She said the resident was assessed upon admission for both fall risk and elopement risk. The resident was at high risk for both. Initial interventions were to have the resident on line of sight observation, however, the resident was able to[TRUNCATED]

Based on record review and interviews, the facility failed to ensure one (#92) of three residents reviewed for pressure injuries out of 29 sample residents remained free from worsening of a pressure injury. Resident #92, was admitted on [DATE] for short term rehabilitation with a goal to return home. The resident was admitted to the facility without any skin conditions. The resident had a fall on 4/5/23 in which he sustained a right hip fracture. In addition, the resident had a subsequent fall on 4/20/23 in which he refractured his right hip around the periprosthetic (structure in close relation to an implant), a distal femur fracture (fractures of the thigh bone that occur just above the knee joint) and nondisplaced left superior pubic fracture (a break in one of the bones that make up the pelvis) The resident sustained numerous falls including two falls with major injuries during his care at the facility that led to his functional decline (cross-reference F689). Due to the resident's functional decline staff were required to turn and reposition the resident to prevent pressure injuries from forming and or subsequently worsening. The facility failed to implement effective interventions to prevent the resident's open areas (discovered on 4/17/23) from progressing to an unstageable pressure injury (4/21/23). Findings include: I. Professional reference The National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 5/12/23 read in pertinent part: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. The National Pressure Injury Advisory Panel (NPIAP), Prevention and Treatment of Pressure Ulcers reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policies and procedures The Pressure Ulcer/Injury Risk Assessment policy and procedure, dated March 2023, was provided by the social services quality mentor (SSQM) on 5/10/23. In pertinent part it read: to assess and implement interventions as appropriate to reduce the likelihood of development of pressure injuries, and that a resident who has a pressure injury receives appropriate care and services to promote healing and to prevent additional pressure injuries. Daily monitoring with accompanying documentation should include: an evaluation of the status of the dressing, including tissue surrounding the pressure injury. Interventions to protect against the effects of pressure, friction, and shear include: reduce pressure over bony prominences by offloading and positioning and develop turning and repositioning plans for residents in bed or chair. A care plan will be developed with a plan of care in conjunction with the multidisciplinary team based on the individual's goals. Provide dressing and treatments as ordered by the physician and per the plan of care. III. Resident #92 A. Resident status Resident #92, age 88, was admitted on [DATE] and passed away on 5/7/23. According to the May 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance and muscle weakness. The 3/3/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score five out of 15. The resident required supervision with transfers, walking in the room, dressing, toileting and personal hygiene. He was always continent of the bowel and bladder. The resident was not at risk for developing a pressure ulcer and the resident was not admitted with a pressure ulcer. B. Representative interview The resident's wife was a resident at the facility and resided in the same room as Resident #92. The resident's wife was interviewed on 5/3/23 at 3:15 p.m. She said the wound started shortly after he fell and the facility barely checked on it. Resident #92 would be lucky to even have them reposition him every four to six hours, sometimes it could be as long as 12 hours. The nursing staff did not consistently change the dressing. Resident #92 did not receive an air mattress until hospice got involved, but he was already bed ridden and was waiting to pass away since his fall on 4/11/23. C. Record review The Braden Scale Observation/Assessment (for predicting pressure sore risk), dated 2/28/23, revealed a score of 22, which indicated the resident was not at risk for the development of pressure injuries. The resident was in the hospital 4/5/23 to 4/8/23 from a fall where he sustained a right hip fracture (cross-reference F689) making him at increased risk for developing pressure injuries with reduced mobility. The Braden Scale Observation/Assessment, dated 4/9/23 (after the resident sustained six falls with injury and a decline in cognition and function), revealed a score of 13, which indicated the resident was at moderate risk for the development of pressure injuries. -No specific interventions were noted in the assessment. The Braden Scale Observation/Assessment, dated 4/11/23, revealed a score of 15, which indicated the resident was at risk for the development of pressure injuries. -No specific interventions were noted in the assessment. The Braden Scale Observation/Assessment, dated 4/21/23, revealed a score of 14, which indicated the resident was at moderate risk for the development of pressure injuries. The Braden Scale Observation/Assessment , dated 4/26/23, revealed a score of 13, which indicated the resident was at moderate risk for the development of pressure injuries. -No specific interventions were noted in the assessment. The incident report dated 4/17/23, revealed Resident #92 acquired a skin injury that was not pressure related. The resident was observed with a skin injury not pressure related. The root cause of the incident: decreased mobility with incontinence. Treatment required: area cleansed and barrier cream applied. Interventions put into place: Barrier Cream - facility protocol. Referrals made: wound nurse and medical doctor (MD) were notified. The nursing note dated 4/17/23 at 1:37 p.m. revealed call placed to MD #1 requesting treatment orders and to inform him about a top layer skin shearing to right medial buttocks nickel sized area and noted surrounding area with blanchable redness up to coccyx site. Return call pending and placed skin protocol. -The wound care physician assessed the resident on 4/27/23 (see below). The resident was in the hospital from a fall from 4/20/23 to 4/22/23 due to a fall (cross-reference F689). The 4/20/22 hospital documentation revealed the resident's skin was warm, dry, no erythema (superficial reddening of the skin) and no rash. The nursing progress dated 4/22/23 read, The resident has a bruise on left elbow and small bruises to right hand and upper arm, two small open areas to buttocks near coccyx. -The resident was readmitted from the hospital with two small areas to his buttocks near his coccyx. There were no measurements or indication the resident had a pressure injury after being readmitted from the hospital. Five days later the resident had an unstageable pressure ulcer with 100 percent slough (dead tissue, often yellow/white in color and can be spongy or creamy in texture). -There were no physician's orders for the two open areas to his buttocks near coccyx indicated on the 4/22/23 progress note until 4/27/23 (see below). According to the physician orders, the resident was admitted to hospice care on 4/23/23 for progressive decline in cognitive and functional status. The physician's order dated 4/27/23 revealed an order that read Sacral wound clean with normal saline or wound cleanser, apply Medihoney and cover with foam dressing every day shift every Tuesday, Friday, Sunday for pressure wound. -The order was not carried out by nursing staff on 5/2/23. -The order was discontinued on 5/4/23 (during the survey process) and updated. The updated order read sacral wound clean with normal saline or wound cleanser, apply Medihoney and cover with foam dressing every day shift every Monday, Wednesday, Friday for pressure wound. -The physician's orders did not include an order for turning and repositioning. -The physician's orders did not include an order for an air mattress. The wound care physician note dated 4/27/23 read, hospice to provide air mattress. -The air mattress was provided by hospice on 4/24/23 (seven days post wound identification by the RN; the resident was at risk of pressure injury after returning from the hospital with a hip fracture on 4/8/23. The wound care note dated 4/27/23 revealed Date of Onset: 4/21/23; type of wound: pressure; site of wound and current measurements: sacrum 3 x 1.5 x 0.2 (centimeters); stage of wound if injury is pressure related: unstageable; wound bed description: 100 (percent) slough. Surrounding skin condition: mild erythema (abnormal redness of the skin or mucous membranes due to capillary congestion, as in inflammation.) Interventions in place/equipment: reposition, hospice to provide air mattress; current treatment order: honey, foam; progress of wound: readmitted with pressure injury. Comments: education provided, updates to family, resident, MD, care plan updates, consults: end of life. The wound care note dated 5/4/23 revealed Date of Onset: 4/21/23; type of wound: pressure; site of wound and current measurements: sacral 3 x 2 x 0.1; stage of wound if injury is pressure related: unstageable; wound bed description: 100 eschar (collection of dry, dead tissue within a wound.); surrounding skin condition: mild erythema. Interventions in place/equipment: air mattress; current treatment order: honey, foam; progress of wound: co change; comments: education provided, updates to family, resident, MD, care plan updates, consults: end of life, not eating, hospice care. The 5/2/23 nutrition/dietary note revealed Resident with unstageable pressure injury on sacrum. His condition is declining, admitted to hospice. Nurse reports his oral intakes are very poor, closes lips, gets combative when encouraged to eat/drink. Currently unrealistic to meet estimated needs for wound healing. Will continue with order for oral supplements-provide as accepted and tolerated. Will monitor. The comprehensive care plan for pressure wound, initiated on 3/2/23 and revised on 5/8/23 revealed the resident was readmitted with an unstageable pressure wound to the sacrum due to decreased mobility, cognitive deficits, poor appetite, incontinence and end of life. -The care plan revealed the resident was readmitted with an unstageable pressure injury. The care plan is in contrast with the nursing progress note (see above). On 4/19/23 the care plan was updated with following interventions: Encourage adequate by mouth (po) intake and acceptance of registered dietician's recommendations to aid in wound healing, reposition frequently for comfort throughout shift, utilize pressure relieving devices/adaptive equipment when appropriate to potential pressure areas. The resident uses pressure relieving mattress. -Pressure relieving equipment was not provided until 4/24/23 (five days after the care plan's start date of the intervention). -Repositioning frequently, which did not provide a defined standard of care for the staff to follow. The treatment administration record (TAR) did not include physician recommendations for offloading and or repositioning. -The facility was unable to provide task documentation to evidence the resident was repositioned. -The task ADL-self mobility was reviewed from 4/9/23 to 5/7/23 indicated the resident was turned on average every 7.5 hours per 24 hours within the last 30 days. IV. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 5/9/23 at 10:17 a.m. He said he was new to the unit, but provided care for the resident for a few weeks. The care he provided consisted of ensuring the resident was provided meals, toileted, repositioned and checked on. The CNA said the resident had a small pressure injury and the nurse primarily provided the interventions to treat it. Nurses would place a pad to protect the pressure injury and would apply cream to it, otherwise the CNA did not provide the resident with any other care to the pressure injury. CNA #5 was interviewed on 5/9/23 at 10:27 a.m. She said she worked with the resident since he was admitted to the facility. The care she provided to him changed during his time as a resident. Initially, upon admission the resident was independent and did not require much assistance and the resident was able to use his call light, walk and eat. Once the resident fell and broke his hip he required extensive assistance. Staff had to change him, turn him and assist him with eating. The CNA said the resident had a small pressure injury, the nurse would place a patch to protect the pressure injury and CNA staff would turn and reposition the resident about every two hours. Registered nurse (RN) #2 was interviewed on 5/9/23 at 10:46 a.m. He said he worked with the resident intermittently over the course of his stay. The care he provided to the resident consisted of ensuring medications were administered and ensuring the resident was assisted with eating, toileted, assisted with physical mobility and educated on call light use. The pressure injury developed towards the end of his stay. The pressure injury started when he stayed more in bed. The registered dietitian (RD) was interviewed on 5/9/23 at 11:46 a.m. She said the resident did not trigger for weight loss and the resident was doing well until he declined after the fall on 4/19/23. Treatment was recommended for pressure injuries, however, at the time of the recommendations the resident was no longer swallowing. Therefore, the supplement would not have made a difference because the resident refused at that point. The physical therapy assistant (PTA) was interviewed on 5/9/23 at 12:35 p.m. She said the resident initially was able to reposition himself without assistance from admission until his second fall (occurred on 3/16/23). After the second fall, the resident required one to two person assistance for repositioning. Nurse practitioner (NP) #1 was interviewed on 5/9/23 at approximately 1:30 p.m. NP #1 said he reviewed the resident's labs and the review indicated that skin breakdown was not related to a protein deficiency and the resident did not suffer from end of life skin failure (Kennedy ulcers). NP#1 said the pressure injury developing was avoidable. The director of nursing (DON) was interviewed on 5/9/23 at approximately 3:30 p.m. She said the resident was assessed upon admission for pressure injury risk. However, the resident was not at risk on admission and the only risk factor was nutrition. The resident became at risk after his first fall (occurred on 4/5/23) that led to hospitalization . She said nursing staff should follow the wound care orders and the interventions listed on the resident's care plan. Additionally, staff should reposition the resident and or offload him every two hours to prevent pressure injuries from developing and or worsening. The nursing home administrator (NHA) was interviewed on 5/9/23 at 3:45 p.m. He said there were no updates for interventions from the first fall (occurred on 4/5/23) for pressure injuries. He said there was an opportunity there; repositioning would have been an appropriate intervention to prevent pressure injury from developing and would have promoted healing.

Based on observations and interviews, the facility failed to provide a comfortable environment and homelike environment in two out of three units. Specifically, the facility failed to keep room temperature at a comfortable level under 81 degrees Fahrenheit. Findings include: I. Resident interviews Resident #65 who was identified as cognitively intact, was interviewed on 5/3/23 at 10:14 a.m. He said the facility was having difficulty regulating the temperature. The heater was on and it was too warm in the room. He asked the staff to turn off the heater but it was still too warm. Resident #92 who was identified as cognitively intact, was interviewed on 5/3/23 at 3:08 p.m. He said when the temperature was warm outside, it was miserable in his room. He said the only window in his room barely opened which allowed for very little air flow. Resident #19 who was identified as cognitively intact, was interviewed on 5/3/23 at 10:07 a.m. She said the facility was always too warm. She said that her roommate treated their personal window unit as hers and refused to turn it on most of the time. She said she asked the staff about turning on the main air conditioner for the facility and they said they were not allowed until a certain time of year. Resident #9 who was identified as cognitively intact, was interviewed on 5/4/23 at 9:50 a.m. She said the facility could get really warm and the staff did not turn on the air conditioner. II. Observations On 5/3/23 at 11:33 a.m. while interviewing a resident on the 200 wing of the facility, she was notably sweating on her forehead and when she had staff turn on her window unit the thermostat read the current temperature was 83 degrees Fahrenheit (F). After 45 minutes, the temperature was still 82 degrees F. On 5/4/23 at 3:15 p.m. on the 400 wing of the facility, the ambient temperature was recorded at 83.4 degrees F. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 5/9/23 at 11:50 p.m. She said all the resident rooms had a window air conditioning unit but some did not work. She said she did what she could to ensure a comfortable temperature but it could still get too warm in the rooms and surrounding hallways. She said if she was not able to make the residents comfortable she would contact the maintenance director (MTD). The MTD was interviewed on 5/9/23 at 11:00 a.m. He said for a month or so around April to May the facility would run both the heaters and air conditioners due the variety of weather during that time. He said that the swamp coolers that cooled the entire facility were not currently turned on. He said he would potentially turn them on in the near future but did not have a set date. He said that the facility would stay between 72 and 74 degrees F and if the temperature rose about that threshold he would then turn on the air conditioning. He said only when he received multiple complaints about the facility being too hot would he then turn on the air conditioning. He said the facility did not currently have a system in place to track when residents had a problem with their room that required the maintenance department to come fix. The director of nursing (DON) was interviewed on 5/9/23 at 3:22 p.m. She said she was aware of the facility being too warm but she said that if residents were too hot they could open their windows or turn on their window units. She said that some residents were dependent for care and needed a staff member to assist them with the windows or window units. She said if a resident had a problem with their room to include their air conditioner or window that the staff was to contact the MTD. She said 82 degrees F was too warm for the facility. The nursing home director (NHA) was interviewed on 5/9/23 at 3:22 p.m. He said the boilers that heat the facility were too hard to get running if they were to turn off the heaters. He said until the facility was ready to turn them off for the summer the facility kept them on at the lowest possible setting. He said the facility experienced this issue every year for several weeks and the staff had been urged to help make the best of it. He said if the temperature were to be recorded being higher than 81 degrees F that he would have had the air conditioning turned on.

Based on record review and interviews, the facility failed to ensure four (#66, #70, #29 and #50) of six residents reviewed for accidents out of 35 sample residents remained as free from accident hazards as possible. Resident #66, who was identified as a high fall risk, had numerous predisposing factors which included dementia, confusion, unsafe sleeping habits, and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from falling on multiple occasions. Due to the facility's failures, the resident sustained an acute distal ulna fracture to her left wrist subsequent to a fall on 1/18/22 requiring hospital treatment for trauma to the left wrist and pain. In addition, the facility attributed the forearm fracture to a fall on 1/5/22 (13 days previous) and 1/8/22 (10 days previous). The facility failed to conduct an investigation to determine if the resident had a subsequent fall after 1/8/22. Additionally, the facility failed to update the comprehensive resident care plan with person centered, effective interventions post fall for Resident #70, #29 and #50. Findings include: I. Facility policy and procedure The Fall Management policy, revised 9/10/19, was provided on 2/2/22 by the nursing home administrator (NHA). The policy read A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. To be effective, a fall reduction program is characterized by four components: -Fall risk evaluation -Care planning and implementation of interventions -Ongoing evaluation process Quality Assurance Performance Improvement (QAPI) -A commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representative will be invited to all care plan meetings. The interventions are to be re-evaluated when a resident falls. II. Resident #66 A. Resident status Resident #66, age 86, was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included [CONDITION(S)] ([CONDITION(S)]), and dementia with behavioral disturbance. The 1/7/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score three out of 15. The resident required supervision with transfers, walking in the room, dressing, toileting and personal hygiene. She was always incontinent of the bowel and bladder. The fall section revealed the resident did not have a fall in the last six months. -However she had one fall since last assessment. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. B. Resident observations The resident was observed on 1/31/22 at 12:55 p.m. The resident was sitting at the edge of the recliner with closed eyes. A four wheel walker was parked next to the resident on the left side. -At 2:57 p.m. the resident was asleep at the edge of the seat of her recliner. She rested her head and both hands on her lap and was asleep. On 2/1/22 at 10:56 a.m. resident was sleeping in the recliner, in the same position as above. The walker was parked on the right side from the resident. No fall mat observed on the floor. C. Family interview The resident's daughter was interviewed on 2/9/22 at 3:15 p.m. She said her mother had a single size bed and she would just sit on it and flop over, or she would slip off the bed and fall. She said the recliner was delivered a couple of weeks ago in January 2022 and staff were reporting to her that that really helped with falls. She said her mom probably needs a floor mat on the floor to cushion her falls and she asked staff to provide that. She said her mom had dementia and had an inability to remember things and to follow the instructions. -The resident required supervision assistance from staff with her activities of daily living and often the interventions added (see below) after the resident fell was to provide Resident #66 with education, redirection and encouragement. D. Record review The resident was assessed for fall risk on several occasions since 11/1/21. Specifically, she was assessed on 11/11/21, 1/3/22, 1/5/22, 1/8/22, and 1/21/22. She consistently scored high risk for falls. The care plan for activities of daily living (ADLs), initiated on 6/29/19 and revised on 8/27/2020, revealed that the resident had potential for self care related deficit due to cognitive deficit. Interventions included to provide supervision with transfers, bed mobility, and toileting. The care plan for physical mobility initiated on 12/28/21 and revised on 1/4/22 (at time of the survey), revealed that the resident was using a four wheel walker for ambulation, and she needed reminders to use it. The care plan for falls, initiated on 6/29/19 and revised on 12/30/21, revealed the resident was at risk for falls due to cognitive status, poor safety awareness, and history of falls. Interventions included to make sure call light was within the reach and encourage resident to use it (initiated in 2019); intervention to ensure that the resident was wearing appropriate footwear, and to discuss with the family option to use a recliner as resident did not like to sleep with her feet on the bed was added 1/5/22 (after fall #3, see below). Intervention to provide assistance and redirection as tolerated to empty items from purse as it can become quite heavy and increase fall risk with poor balance, and to encourage resident to lay in bed with legs on top of bed was initiated 12/30/21 (after the fall #1) and revised on 1/5/22 (at the time of the survey). -There were no interventions added to the care plan for the resident after her fall #2, #4, #5 (that resulted in ulnar fracture), and fall #6 (after the resident was readmitted from the emergency room with a splint on her left arm). 1. Fall #1 on 12/27/21 The incident report dated 12/27/21, revealed Resident #66 sustained a fall on 12/27/21 around 10:30 a.m. Resident was observed sitting on the floor next to her bed complaining of right knee, hip and head pain. Resident was assessed by a registered nurse and later refused the x-ray from x-ray tech. Predisposing factors for the fall were listed as weakness, and ambulating without assistance in a way to the bathroom. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT (also called Risk Management) review, dated 12/29/21 revealed resident sustained unwitnessed fall by rolling out of the bed. Interventions included to assist the resident with care related to her increased pain and to empty out the purse which is very heavy that she carries on her shoulder every day. -The IDT review did not mention any intervention related to the actual cause of fall that was unassisted transfer to the bathroom. The resident's care plan was updated with intervention to provide assistance and redirection as tolerated to empty items from the purse as it can become quite heavy and increase fall risk with poor balance. Encourage me to lay in bed with legs on top of bed. 2. Fall #2 on 1/1/22 The incident report dated 1/1/22, revealed Resident #66 sustained a fall on 1/1/22. Resident #66 was found on the floor, and had a little abrasion on her nose. Resident stated she fell from the bed, she was sleeping and lost her balance, she was not walking. Predisposing factor was identified as restlessness with a note the resident was sleeping at the end of the edge on her bed, and refused to move to the center of the bed. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT review, dated 1/5/22 revealed resident sustained unwitnessed fall on 1/1/22, the root cause of the fall was identified as resident lays in bed with feet hanging off the bed. Interventions included educate the resident and encourage to lay with her feet up on the bed. -The resident's care plan was not updated with any new interventions to prevent resident from falling. 3. Fall #3 on 1/5/22 The incident report dated 1/5/22, revealed Resident #66 sustained a fall on 1/5/22 around midnight.Nurse heard a loud noise and resident yelled out 'oh man' , when nurse entered the room, resident was sitting on her bottom on the side of her bed. Resident stated she fell out of bed. Resident was assessed by the nurse, and had no obvious injuries. Resident was educated on the importance of laying down in bed correctly, and the resident continued to insist on sleeping in a sitting position. Predisposing factors were identified as confusion, impaired memory, poor safety awareness, and high risk for falls. -The incident report did not mention any other immediate interventions besides providing education to the resident, even though the resident did not respond to the education and continued to sleep in a sitting position. The IDT review, dated 1/5/22 revealed resident sustained unwitnessed fall on 1/5/22, the root cause of the fall was identified as resident lays in bed with feet hanging off the bed. Interventions included speaking with the family and asking for a recliner since the resident was not cooperative with proper positioning in bed. -The IDT review did not assess the potential factors of resident's non-compliance with proper positioning, and did not mention what was done to keep the resident from falling until the family delivered the recliner. In addition, the facility wanted the family to provide the recliner instead of providing it in order to prevent future falls. -The resident's care plan was updated with the following interventions: Ensure that the resident is wearing appropriate footwear. Talk with family about getting a recliner as the resident does not like to sleep with feet on the bed. -No additional interventions were added to keep the resident from falling until the arrival of the recliner. 4. Fall #4 on 1/5/22 (second fall in the last 24 hours) The incident report dated 1/5/22, revealed Resident #66 sustained a fall on 1/5/22 at 11:45 a.m. (this was her second fall in less than 24 hours). Resident was sitting on the floor with back resting against the bed, and assisted her up off the floor after assessment. Resident reported no pain, but can ' t make the connection that not sitting on the edge of the bed will keep her from falling. The resident was encouraged to sit in a lazy boy recliner. Resident prefers to sit on the edge of her bed, she then falls asleep and slops off the bed onto the floor landing on the floor mat. She has on proper shoes, a large coat, and her purse heavy with bits and scraps of papers. She did not allow staff to unload the purse, she was not interested in a better sitting position, removing clutter from her bed, or sitting in the recliner. Predisposing factors were identified as confusion, impaired memory, poor safety awareness, and high risk for falls. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT review, dated 1/7/22 revealed resident sustained unwitnessed fall on 1/5/22, the root cause of the fall was identified as resident sitting on the edge of bed and attempting to lay down. Interventions included to encourage resident to sit in a chair not on the edge of the bed. Encourage her to clear off her bed. -The IDT review did not address the fact that the resident was confused and was refusing staff assistance on proper way of sleeping. -The resident's care plan was not updated with any specific interventions based on the cause of fall and resident's lack of response to education. 5. Fall #5 on 1/8/22 The nursing progress note on 1/8/22 documented resident sitting up on the floor leaning against the recliner with legs bent at knees. Resident complained of right arm, and leg pain. Stated she hit her head but was unable to say if the floor or the recliner. No bumps or redness to head. No evidence of injury, bleeding, swelling. Able to move all limbs.Call light was clipped to the bed. Resident was wearing shoes. It appears the resident was getting up in hurry to go smoke. Bilateral hand grip strong. Hip Bones even. Speech at baseline, no change in mental status. Resident educated to get up out of bed slowly. Staff will place her walker next to the bed. The IDT note dated 1/10/22 revealed that Resident #66 had a fall on 1/8/22 when she was hurring to get outside to smoke. Intervention included not to remind residents about smoking times. -There was no incident report for this fall -The resident's care plan was not updated with any new interventions. The nurse's note on 1/10/22 documented resident still continues to sleep sitting up in bed despite continuous education, frequent checks throughout the night to make sure resident is staying on the bed. The nurse's note on 11/17/22 documented resident needs a fall mat placed by bed for safety precaution as she refuses to actually lay in her bed. Resident only sits on the edge of bed all hours of day and night. -No follow up notes on if the floor mat was obtained for the resident. 6. Change of condition on 1/18/22 (identified bruising) The incident report dated 1/18/22 revealed that a certified nurse aide (CNA) reported to the nurse that the resident had bruises to left eye and left side of forehead. The resident was unable to recall the origin of the bruises. Under the section of immediate actions it was documented that the resident denied any pain, and she had multiple falls in the last month. Neurological checks were completed and were at the baseline. The IDT note dated 1/19/22 revealed that Resident #66 had bruises due to previous falls. Interventions were to monitor the bruises. -The last documented fall was on 1/8/21, therefore it was unclear if it took 10 days for bruises to appear or if the resident had additional falls that were not documented. The nurses note on 1/20/22 at 7:04 a.m. documented, Bruise on left eye, purple in color. The resident seems to be lifting the sleeve of her clothes when moving left arm to aid movement. Complained of pain and rated pain as four out of 10, gave Tylenol, resident went back to sleep. -At 11:55 a.m. it was documented Increased pain and swelling to left wrist post possible fall. Resident has great difficulty moving left wrist on its own and is using her right hand to lift her left arm/hand. X-ray order placed to be completed as soon as possible. -At 4:27 p.m. documented by medical provider: got message about patient with acute distal ulna fracture to the left arm. Please send the patient to the hospital to immobilize the hand. According to the admission summary, the resident was admitted to the emergency department (ED) on 1/20/22 at 6:32 p.m. Resident sustained a fall two days ago when she fell on her left side and injured her left arm. She was diagnosed with trauma with left wrist injury and pain. Splint was applied to stabilize the left ulnar fracture and the resident was discharged back to the facility on the same day. 7. Fall #6 on 1/21/22 The incident report dated 1/21/22 revealed that Resident #66 sustained another fall on 1/21/22. Resident found on the floor in room alone in front of her armchair trying to get up. Resident complained of pain in left wrist and arm, no other injuries observed. Resident was very restless and was unable to wait for a registered nurse to assess prior to moving. The resident was assisted to a standing position and then back into the chair. Neuros (neurological checks) started. Resident was reminded to ask for assistance when needed. Call light within reach. The IDT note dated 1/23/22 revealed that Resident #66 had a fall on 1/21/22. The resident was not able to say what happened. No additional findings were documented. Intervention was listed as daughter to buy her a recliner as she does not sleep laying flat straight in bed. -It was unclear if resident already had a recliner as this intervention was mentioned initially on 1/5/22 after the fall #3 and #4, and on 1/8/22 after resident's fall #5 she was leaning against the recliner. -No additional interventions were added to the resident's care plan. E. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 2/3/22 at 3:30 p.m. She said she worked the shift when a resident was sent to the ED for the evaluation. She said she noticed swelling on the resident's arm and the resident was not using her arm with movement. She said she contacted her physician who ordered an x-ray. RCNA #2 was interviewed on 2/7/22 at 9:30 a.m. She said she was a restorative aide, but worked with Resident #66 on many occasions as a CNA. She said the Resident #66 was confused, did not follow the recommendations. She frequently refused or would take off her splint. She said the resident was able to ambulate with a four wheel walker and required assistance with personal care and ambulation. Regarding the falls, she said the plan was to check on the resident frequently and when passing by to make sure she was properly positioned in the recliner. She said the resident frequently fell asleep leaning forward. CNA #4 was interviewed on 2/7/22 at 11:30 a.m. She said she was an agency CNA and was new to the unit. She said she did not know how much assistance Resident #66 required, she said she would ask other CNAs that were working with her. She said to her knowledge, the resident ambulated with a walker and should be reminded to use it every time she was up. She said these were the interventions to keep the resident safe from falling. LPN #1 was interviewed on 2/7/22 at 11:30 a.m. He said the resident was confused due to her dementia diagnosis. He said the resident was recently hospitalized and diagnosed with ulnar fracture. He said he did not work the shift when fall occurred. He said for fall prevention staff were checking on the resident frequently due to her unsafe habit of sleeping on the edge of the bed or the recliner. He said the resident occasionally refused care such as wearing the splint but was otherwise cooperative. She said when one of the residents sustained the fall, nursing responsibility was to assess the resident for injury, notify family, physician and follow any received orders from the physician. She said nurses were expected to fill out an incident report and put in place immediate interventions to keep the resident safe and prevent any additional falls. The director of rehabilitation (DOR) was interviewed on 2/7/22 at 3:00 p.m He replied to the questions via email. He said the resident was not currently receiving physical or occupational therapy services. The most recent evaluation was completed between 12/27/21 and 1/5/22 in response to resident's falls. The resident was provided with a four wheel walker which significantly improved her balance and decreased her fall risk. In addition, education was provided to the resident and staff to utilize the rolling walker with mobility. The resident's care plan was updated to include use of the rolling walker with mobility. The DON was interviewed on 2/7/22 at 4:30 p.m. She said after she reviewed Resident #66's record, she identified some confusing and incomplete documentation about the potential fall on 1/18/22. She said she completed the investigation regarding the events on 1/18/22 and determined that the resident had a fall on that day (see below facility follow-up documentation). She said she prepared an education list on the items that she planned to educate nurses immediately. Specifically on proper documentation of falls, assessment by a registered nurse and reporting to her or manager on duty. She demonstrated the list of educational topics. She said this was not new, but since 75% of staff who currently were working in the building were agency staff, she felt that they needed to be educated on post fall interventions and proper documentation. Regarding safety interventions, she said the resident was on frequent checks by nurses and CNAs to encourage the resident to lean backwards in the reclined for her safety. She said the resident was resistant to follow the recommendation and this was why they continued to check on her. She said the entire team was responsible for updating the care plans with new interventions but she had not had a chance to review them to make sure everything was written down what was attempted to prevent the resident from falling. F. Facility follow-up before the survey exit on 2/7/22 During the interview DON on 2/7/22 provided following documents: QAPI meeting notes regarding the falls for Resident #66, investigation of events on 1/18/22 with conclusion that resident sustained a fall, interviews with staff who were working on 1/18/22, and list of items that she planned to educate nurses and CNAs. III. Resident #70 A. Resident status Resident #70, age 93, was initially admitted on [DATE] and readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included vascular dementia with behavioral disturbance and contracture to right and left knee. The 1/6/22 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. She required extensive assistance with bed mobility, dressing, personal hygiene and toileting. It documented the resident had falls and one with injury. B. Record review The comprehensive care plan revised with last revision on 5/11/21, identified Resident #70 was high risk for falls related to impaired balance, unsteady gait, incontinence, communication deficit and cognitive deficits. It further documented Resident #70 intentionally lower herself from bed to floor and seat herself on the ground or floor at times, as well as crawl on floor. Interventions included: to observe for unsteady gait, anticipate and meet the resident's needs, frequent checks, apply nonskid socks as resident will allow, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, Monitor and assist as necessary when she attempts to sit and/or crawl on the ground or floor every shift and as needed and monitor for falls when she is performing exit seeking behaviors. C. Fall incident report investigation The Post Fall Investigation documented 10/2/21 was reviewed. It documented the resident called for a nurse to come to her room. She was observed sitting on her buttocks in the doorway. It documented resident had done this before, likes to crawl. Immediate action taken was assisted resident from floor, assessed all extremities, no injury found. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 10/4/21 was reviewed. It documented the resident had an unwitnessed fall on 10/2/21. It documented the root cause was the resident sitting on the edge of bed when wanting to get up and will scoot off the bed. Intervention was staff to get resident up when sitting on the edge of bed. The Post Fall Investigation documented 10/12/21 was reviewed. It documented the resident being observed on the floor near roommate ' s bed. It documented her wheelchair was close by but was full of clothes. It documented resident was assessed and there was no injury. Immediate action taken was resident assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 10/14/21 was reviewed. It documented the resident had an unwitnessed fall on 10/12/21. It documented the root cause was resident behavior was to crawl on the floor related to not being able to stand. Intervention put in place was for staff to make frequent rounds and offer assistance. The Post Fall Investigation documented 1/1/22 was reviewed. It documented the certified nurse aide(CNA) called a nurse to the resident's room. It documented the resident was found on the floor on her left side next to the dresser. It documented the resident was assessed and she sustained a large hematoma on her left forehead. It further documented she was given two Tylenol for pain. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 1/3/22 was reviewed. It documented the resident had an unwitnessed fall on 1/1/22. It documented the root cause was that the resident was attempting to get out of bed unassisted. Intervention put in place was for staff to make frequent rounds when the resident was in bed. -The resident had multiple falls (see above) in which one of the falls resulted in an injury. The facility failed to update the care plan with interventions to prevent fall from reoccurring. The intervention often put in place were frequent rounds, which was ineffective in preventing the resident from falling. IV. Resident #29 A. Resident status Resident #29, age 66, was admitted on [DATE]. According to the February 2021 computerized CPO, diagnoses included cerebral vascular accident ([CONDITION(S)]) and stroke. The 12/3/21 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15. He required extensive assistance with bed mobility, dressing, personal hygiene and toileting. It documented the resident had falls. B. Record review The comprehensive care plan revised on 9/10/21, identified Resident #29 was at high risk for fall related to deconditioning, gait/balance problems and incontinence. Interventions included: to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, ensure that the resident is wearing appropriate footwear when mobilizing in wheelchair and the resident needs a safe environment with: the bed in low position at night, personal items within reach, fall mats next to bed while in bed, nonskid strips next to bed. C. Fall incident report investigations The Post Fall Investigation documented 10/8/21 was reviewed. It documented the CNA observed resident lying on the right side, middle of the room on the floor. It documented resident said he was going to the bathroom and did not think he needed his walker. It documented the resident was assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 10/14/21 was reviewed. It documented the resident had an unwitnessed fall on 10/8/21. It documented the root cause was the resident did not use a walker to go to the bathroom. Intervention was staff to remind resident to utilize his walker when getting up without assistance. The Post Fall Investigation documented 11/5/21 was reviewed. It documented the CNA responding to the resident ' s call light. It documented the CNA told the resident he was going to get help to assist him. It further documented when the CNA arrived back to the room, the resident was on the floor. It documented the resident was assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 11/10/21 was reviewed. It documented the resident had an unwitnessed fall on 11/5/21. It documented the root cause was the resident did not want to wait for staff to get another person to help with transfer. Intervention put in place was for staff to get staff assistance before entering the room to assist the resident to transfer. The Post Fall investigation documented 1/9/22 was reviewed. It documented the resident was observed sitting on his buttocks up against his bed with his legs in front of him. It documented the resident was assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 1/10/22 was reviewed. It documented the resident had an unwitnessed fall on 1/9/22. It documented the root cause was the resident was attempting to stand unassisted. Intervention put in place was for staff to remind resident to wait for assistance when putting on call light. -The care plan was not updated with interventions after multiple falls (see above). V. Resident #50 A. Resident status Resident #50, age 69, was admitted on [DATE]. According to the February 2021 computerized CPO, diagnoses included unsteady on feet and muscle weakness. The 12/21/21 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision with bed mobility and transfer. It documented the resident had fallen. B. Record review The comprehensive care plan revised on 2/9/21, identified Resident #50 was at high risk for fall related to vision/hearing deficits and [CONDITION(S)] drug use. Intervention included the resident needs a safe environment with: even floors free from spills and/or clutter, adequate glare-free light; a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach. Anticipate and meet the resident's needs, ensure walker was near resident when in bed or in a chair. The Post Fall investigation documented 12/4/21 was reviewed. It documented the resident was found by the snack machine on her knees holding on to the back of the soda. Resident was assessed and a bruise was noted on the left elbow. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 12/8/21 was reviewed. It documented the resident had an unwitnessed fall on 12/4/21. It documented the root cause was the resident was getting items from the vending machine and lost balance and fell to her knees. Intervention put in place was for staff to remind resident to use her walker at all times and request assistance as needed. -The care plan was not updated after the fall with intervention (see care plan above). VI. Staff interviews The director of nursing (DON) was interviewed on 2/7/22 at 1:18 p.m. She said the interdisciplinary team (IDT) was responsible to update the resident care plan after each fall with interventions. She said it was a team ' s effort to update the care plan. She said the residents care plan should have been updated with interventions to enable staff to know what interventions were put in place to prevent the fall from reoccurring. She said she would immediately audit all residents who had a fall to ensure their care plans were updated with the current interventions.

Based on interviews and record review, the facility failed to ensure two (#1 and #4) of three residents reviewed out of 11 sample residents were kept free from abuse. The facility failed to ensure Resident #5 was kept free from resident-to-resident abuse by Resident #4. Resident #4 who had a known history of verbal aggression toward others was not provided the necessary tools and behavioral interventions when she expressed she was unhappy with her roommate (Resident #5) on multiple occasions over a six month period of time. Furthermore, the facility failed to determine the root cause of Resident #4 frustration with Resident #5 and provide intervention to prevent a potentially abusive incident from occurring. Resident #4 ultimately, through her frustration with Resident #5, pushed Resident #5 causing harm, which resulted in Resident #5 sustaining a [MEDICAL CONDITION] requiring a hospital evaluation and multiple staples. In addition, residents were kept free from sexual and physical abuse by Resident #1. Findings include: I. Facility policy and procedure The Abuse Policy, last revised October 2020, was provided by the nursing home administrator (NHA) on 3/3/21 at 4:30 p.m. It revealed in pertinent part,Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, metal or psychosocial well-being. Sexual abuse is non-consensual sexual contact of any type with a resident. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. II. Failed to ensure Resident #5 was kept free from abuse by Resident #4 A. Resident #4 status Resident #4, age 75, was admitted on [DATE]. According to the March 2021 computerized physician orders [REDACTED]. The 12/14/2020 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 level assistance with bed mobility, transfers, walking, dressing, eating, toileting and hygiene. The resident did not exhibit physical, verbal, or behavioral symptoms directed towards others during the assessment period. 1. Record review The behavior care plan, initiated 9/21/2020, documented Resident #4 was at risk for displaying emotional distress related to her [DIAGNOSES REDACTED]. It revealed the resident cried inconsolably, was verbally aggressive towards staff and other residents, and made false accusations. The interventions included: assist the resident in developing methods for coping and interacting, encourage expression of feelings appropriately and work with counseling services on mindfulness and reframing situations. It indicated the triggers for Resident #4 verbal aggression included disagreements with others. The 6/8/2020 nursing progress note revealed Resident #4 recently moved to a new room and was having difficulty adjusting to her new roommate. The 6/17/2020 physician progress notes [REDACTED]. It did not indicate the physician notified facility staff of the resident's desire to change rooms. The 6/22/2020 psychosocial progress note revealed the resident expressed to the social services assistant (SSA) she did not get along with her roommate. The resident was offered a room change but refused. Resident #4 said she did not like any of the other residents residing in the available rooms. The 7/10/2020 psychosocial progress note revealed the resident continued to express frustration with her roommate. The 12/2/2020 weekly nursing progress note revealed the resident continued to express frustration with her roommate and other residents. The 12/8/2020 activities progress note revealed the resident expressed to staff she was upset and scared to go to her room. It did not reveal documentation that any other staff members were notified of the resident stating she felt scared to go to her room. It did not indicate any interventions made by staff to ensure the resident felt safe in her room. The 12/17/2020 resident services director (RSD) progress note revealed she met with the resident regarding their statement of feeling scared, 11 days prior. The resident said she was no longer scared and refused a room change. It indicated the RSD provided reassurance, however did not note any interventions put into place to ensure Resident #4 felt comfortable in her room. The 12/22/2020 psychosocial progres note revealed the resident was disruptive at times and expressed verbal aggression towards others. It did not provide examples or triggers for the resident's verbal aggression toward others. B. Resident #5 status Resident #5, age 83, was admitted on [DATE] and 2/17/21. According to the March 2021 CPO, the [DIAGNOSES REDACTED]. The 1/20/21 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required supervision with bed mobility, transfers, walking, dressing, eating, toileting and hygiene. C. Incident of physical abuse on 2/16/21 The 2/16/21 physical abuse investigation revealed Resident #4 and Resident #5 were roommates. The facility staff overheard Resident #4 and Resident #5 engaged in a verbal altercation. The facility staff observed Resident #4 push Resident #5. Resident #5 lost her balance, fell and hit their head. The residents were separated immediately and Resident #5 was sent to the hospital for further evaluation and treatment. The facility immediately placed Resident #4 on frequent safety checks. Resident #4's medical record was reviewed on 3/2/21 and 3/3/21. It did not reveal documentation the facility staff provided frequent safety checks for the resident following the episode of physical abuse directed toward Resident #5. The 2/17/21 hospital discharge notes revealed Resident #5 received multiple staples for a [MEDICAL CONDITION] following the incident of physical abuse on 2/16/21. E. Staff interviews Registered nurse (RN) #1 was interviewed on 3/3/21 at 1:15 p.m. She said Resident #4 exhibited anxious behavior every day. She said the resident often talked to herself, repeated the same sentence and became tearful. She said the resident was alert and oriented, but required frequent reminding due to her anxiety. She said there was a physical altercation between Resident #4 and Resident #5. She said Resident #4 pushed Resident #5 down during an argument. She said Resident #4 believed her roommate was stealing her personal belongings. She said Resident #5 fell , hit her head and sustained a laceration to the head that required the resident to be sent to the hospital for further evaluation and treatment. She said Resident #4 intended to push Resident #5. She said when Resident #5 returned from the medical facility, she was moved to new room away from Resident #4. She said that Resident #5 expressed she was not fearful of Resident #4. She said and a few days after the incident, Resident #4 was moved to another room further down the hallway from Resident #5. The RSD, NHA and director of nursing (DON) were interviewed on 3/3/21 at 3:37 p.m. The RSD said Resident #4 and #5 used to be roommates and were involved in a physical altercation. She said the staff heard both residents yelling and before they were able to intervene, Resident #4 pushed Resident #5. Resident #5 fell to the ground and hit their head. She said Resident #5 was immediately sent to the hospital for evaluation and treatment. The NHA said Resident #5 received multiple staples for a [MEDICAL CONDITION] she sustained when Resident #4 pushed her to the ground. The RSD said Resident #4 said she pushed Resident #5 because she believed Resident #5 had stolen her personal belongings. The RSD, NHA and DON said Resident #4 intentionally pushed Resident #5 down to the ground. III. Incidents of sexual abuse directed by Resident #1 toward Resident #2 A. Resident #1 status Resident #1, age 84, was admitted on [DATE]. According to the March 2021 CPO, the [DIAGNOSES REDACTED]. The 12/18/2020 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of eight out of 15. He required supervision with all activities of daily living. It indicated the resident required supervision to walk throughout the corridor and in his room. It indicated the resident did not exhibit behaviors during the assessment period. Per Resident #1's face sheet he was not responsible for himself. 1. Record review The 9/22/2020 MDS assessment revealed the resident had physical behavioral symptoms such as hitting, kicking, scratching, grabbing, and abusing others sexually one to three days during the assessment period. It indicated the resident exhibited verbal behavioral symptoms directed toward others such as threatening, screaming and cursing at others one to three days during the assessment period. The behavioral care plan, initiated and last revised on 9/24/2020, revealed the resident exhibited behaviors related to his [DIAGNOSES REDACTED]. It indicated the resident was verbally aggressive if he believed a woman was being disrespected. The interventions included: provide reassurance and redirection as needed, anticipate the resident's needs, provide an opportunity for positive interaction and attention, and monitor the resident's behavioral episodes and attempt to determine the underlying cause. The cognitive function care plan, initiated on 9/24/2020 and revised on 10/8/2020, revealed the resident had impaired cognitive function and thought processes related to the [DIAGNOSES REDACTED]. The physical mobility care plan, initiated on 9/23/2020 and revised on 12/21/2020, revealed the resident had potential for limited physical mobility related to the resident's cognitive deficits. It indicated the resident was able to ambulate throughout the unit with a cane. The 12/24/2020 interdisciplinary team (IDT) care conference summary revealed a care conference was conducted with the resident representative. The resident declined to attend. It indicated the resident was able to ambulate independently with a cane throughout the unit. It indicated the resident was psychosocially stable with no mood concerns at this time. The resident showed a cognitive decline and increased confusion. Staff were providing cues and supervision for the resident. It indicated the resident could be verbally and physically aggressive, disruptive, refuse care and often exit seeks. The resident was easily redirected. The 1/28/21 IDT [MEDICAL CONDITION] medication management review revealed the resident exhibited the following behaviors: possessive and sexually inappropriate with female residents, verbally and physically aggressive toward staff when they attempted to intervene. It indicated the resident should maintain space from other residents as able and to focus on the safety of other residents. It indicated the facility should look for alternate placement for the resident. The recommendations included trialing [MEDICATION NAME] 25 MG (anti-depressant) every day and to increase if the resident's behaviors continued. If the resident's behavior did not change, then discontinue the medication and transfer the resident to a male only unit. The 3/2/21 psychosocial progress note revealed due to an increase in behaviors, the resident would be transferred to an all-male secured unit. It indicated social services sent a referral on 2/26/21 which was denied. It indicated referrals were sent to three other facilities on 3/1/21. B. Incident 1/23/21 The 1/23/21 nursing progress note revealed another staff member witnessed Resident #1 and Resident #2 involved in a situation which was cognitively questionable. The nurse indicated she asked Resident #2 to accompany her to a phone call, to which Resident #2 was agreeable. Another nurse sat with Resident #1. The resident became vulgar towards the staff. The facility was unable to provide documentation an investigation had been completed following the 1/23/21 allegation of sexual abuse from Resident #1 to Resident #2 during the survey process. Cross-reference F610: the facility failed to conduct an investigation regarding allegations of abuse. Cross-reference F609: the facility failed to report an allegation of abuse to the state agency. 1. Interview A staff member, who wished to remain anonymous, was interviewed on 3/1/21 at 7:11 p.m. The staff member said when they walked onto the secured unit, they witnessed Resident #1 fondling the breasts of Resident #2, while sitting on the couch in the common area. The staff member said Resident #1 was kissing Resident #2 and was moving one of his hands lower down Resident #2's abdomen. Thes staff member said they immediately got a staff member on the unit to separate Resident #1 and Resident #2. The staff member said the staff told them the resident's had been engaging in that behavior for a couple days. The staff member said the incident was reported to the nurse on the secured unit. The staff member said the staff on the unit acted as if the behavior of Resident #1 was not concerning. The staff member said the staff told her the nursing home administrator (NHA) and director of nursing (DON) were aware of the behavior. The staff member said the resident services director (RSD) informed the staff Resident #2 was able to provide consent and the incident had already been investigated. The staff member said Resident #2 was unable to comprehend situations and complex conversation. The staff member said Resident #2 was able to answer yes or no questions, but not complex sentences. The staff member said there was not a doubt in their mind, Resident #2 could not consent to a sexual relationship. The staff member said they did not feel the facility management had conducted a thorough investigation of the incident. The staff member said they felt the NHA, DON and RSD brushed off the incident because they had determined Resident #2 could provide consent. The staff member said Resident #2's family was never contacted regarding the incident with Resident #1. 2. Resident #2 a. Resident status Resident #2, age 70, was admitted on [DATE]. According to the March 2021 CPO, the [DIAGNOSES REDACTED]. The 2/25/21 MDS assessment revealed the resident had short-term and long-term memory impairment and severe impairment making decisions regarding tasks of daily life. She required extensive assistance of one person with dressing, eating and toileting. She required total assistance of one person for personal hygiene. It indicated the resident had difficulty focusing attention and disorganized thinking. It indicated the resident did not exhibit behavioral episodes during the assessment period. b. Record review The communication care plan, initiated 1/13/21 and revised on 1/25/21, revealed the resident had a communication problem related to the resident's severe cognitive loss. The interventions included: encourage the resident to continue stating thoughts even if the resident was having difficulty, focus on a word or phrase that made sense or responds to the feeling the resident was trying to express, and provide a safe environment. The 1/13/21 nursing progress note revealed the resident was alert and oriented to self only. It indicated the resident was non-verbal most of the time and did not answer when spoken to. The resident had a flat affect. The 1/16/21 nursing progress note revealed the resident was non-verbal when she was admitted but had started to become verbal. It indicated the resident required prompting and was able to answer questions appropriately. The 1/19/21 weekly nursing progress note revealed the resident was alert to herself with poor memory recall and was able to comprehend simple sentences. The 2/2/21 speech therapy evaluation revealed the resident understood 50% (percent) of yes or no questions and was able to follow one step commands 25% of the time. -It indicated the resident was able to understand less than 25% of conversation. The 2/16/21 psychosocial progress note revealed the resident was unable to answer the questions for the PHQ-9 (patient health questionnaire for depression) appropriately. The 2/16/21 weekly nursing progress note revealed the resident was confused and wandered around all day. It indicated the resident was unable to express herself. The resident's medical record was reviewed on 3/2/21 at 11:40 a.m. It did not reveal documentation the resident had inappropriate sexual interactions directed toward her from Resident #1, a male resident, on 1/23/21. It did not reveal monitoring to determine if the interaction caused the resident distress. It did not indicate an assessment of the resident was completed following the sexual interaction from Resident #1 or Resident #2 representative had been contacted. It did not reveal documentation Resident #2 sought after Resident #1 and engaged in a physical and sexual relationship with Resident #1. 3. Observations During a continuous observation on 3/2/21 beginning at 10:45 a.m. and ended at 12:15 p.m. the following was observed: Resident #2 was observed sitting in her wheelchair in the dining room. She was using a green colored pencil to color a picture in her lap. The memory care director (MCD) was observed asking the resident a question. She did not respond and continued to color the picture. At 11:10 a.m. an activity staff member asked her if she could wash the resident's hands. Resident #2 did not respond. The activity staff began to wash her hands with a warm washcloth. At 11:22 a.m. Resident #2 was served lunch. She continued to color and did not look up at her lunch meal placed in front of her on the table. At 11:30 a.m. CNA #2 was observed sitting down next to the resident. She put the coloring paper on the table and began to assist the resident with eating. She lifted the spoon for the resident and wiped her mouth with a napkin. This continued for the entire meal. Resident #2 did not speak with the CNA, even after multiple attempts to get the resident to engage. -At 11:32 a.m. Resident #1 entered the dining room area, ambulating with a cane. He sat down at the bar by the kitchen. A CNA served the resident his lunch and brought him an apple juice. He had his back to Resident #2 and did not appear to look in the direction nor interact with Resident #2. -At 11:53 p.m. Resident #1 was observed getting up from his chair. He told the CNA he was going to his room to get his hat and would return. -At 12:00 p.m. the activity staff provided Resident #2 with a new colored pencil. The MCD approached the resident as asked her if she could place a surgical mask on the resident's face. Resident #2 did not respond. The MCD placed the surgical mask on the resident's face and walked away. After the MCD walked away, Resident #2 removed the surgical mask from her face. -At 12:06 p.m. Resident #1 returned to the dining room, wearing his hat. He sat down and finished his lunch. -At 12:09 p.m. the MCD asked the resident how she was doing and if she felt ill. The resident did not respond. -At 12:12 p.m. Resident #1 got up from his chair and began to leave the dining room. The MCD told him a movie was playing in the television area. He said he would take a look and began to walk down the hallway with his cane. He did not interact with Resident #2. Resident #2 remained in the dining area, sitting in her wheelchair. C. Incident on 1/27/21 The 1/27/21 nursing progress note revealed Resident #1 was hugging and kissing a female resident. The female resident attempted to pull away from Resident #1 and he grabbed her hand. The facility staff removed the female resident from the situation. Resident #1 became very upset, yelling, screaming and attempted to punch the staff. The resident was redirected back to his room. It indicated the social services department was aware of the resident's behavior. The 1/28/21 psychosocial progress note revealed an investigation was conducted to ensure the safety of both residents involved in the altercation on 1/27/21. It indicated Resident #1 would initiate hugging and kissing with the female resident. The female resident would pull away from Resident #1 and then resume hugging and kissing. -It indicated the female resident would also seek out Resident #1 throughout the day. Resident #1 was placed on 15 minute safety checks. The 1/28/21 alleged sexual abuse investigation identified the female resident as Resident #2. Resident #1 was interviewed on 1/28/21, the day following the incident. He said Resident #2 was his wife and he loved her. He said the facility could not stop them from being together. Resident #2 was interviewed on 1/28/21, the day following the incident. She was asked if it was okay if Resident #1 kisses, touches, and holds her hand. It indicated the resident shook her head yes and softly said, yes. -It did not indicate the resident was asked if she knew who Resident #1 was or if she recalled the incident. The resident interviews for sexual abuse were conducted with the residents on the secured unit. The interview, with Resident #2 identified as the interviewed, revealed Resident #2 was unable to respond appropriately to the questions. The questions included: have staff, other residents, or anyone else at the home said anything to you that violated your personal boundaries; have staff, other residents, or anyone else at the home been in your room that should not be; and have staff, other residents, or anyone else at the home touched you in a way that violates your personal boundaries? -The area which indicated the notification of the resident representative and state agency were left blank. The electronic medical record of Resident #2 was reviewed on 3/1/21 at 11:00 a.m. -It did not reveal documentation to indicate Resident #2 would seek out Resident #1. It did not reveal documentation of the incident on 1/27/21. -It did not reveal documentation Resident #2 representative had been contacted regarding the incident on 1/27/21. III. Incidents of physical abuse involving Resident #1 A. Incident on 1/18/21 The 1/19/21 nursing progress note revealed on 1/18/2020, when she was assisting another resident, she heard two resident's arguing. When she entered the hallway, Resident #1 and Resident #10 were attempting to hit one another. A certified nurse aide (CNA) attempted to intervene and separate the residents. Resident #1 was assessed with [REDACTED].#10 when both residents were attempting to hit one another. The physician was notified and a treatment order obtained to address the skin tears. Both residents were separated by staff members. The 1/18/21 abuse investigation revealed Resident #1 and Resident #10 were involved in a resident to resident physical altercation on 1/18/21. It indicated Resident #10 as the alleged perpetrator. It indicated Resident #1 sustained an injury of an accidental scratch. The physician, NHA, and social services were notified of the incident. The notification of the resident representative and the state agency were left blank. The resident interviews revealed both residents did not recall the incident. The resident interviews were conducted on 1/20/21, two days after the incident. The nurse interview, conducted on 1/20/21, revealed she heard two residents yelling at each other. She entered the hallway from another resident's room and saw a CNA in between Resident #1 and Resident #10. She said she removed Resident #10 from the area and then came back to assess Resident #1. She said he was bleeding from a skin tear to his forearm. The CNA interview, conducted on 1/22/21, revealed Resident #10 was telling everyone to leave her house. She attempted to enter Resident #1 room when the CNA tried to re-direct her. Resident #1 approached and got involved. The CNA said Resident #10 was hitting her and Resident #1 was attempting to help. Cross-reference: F609 the facility failed to ensure allegations of abuse were reported to the state agency. B. Incident on 2/13/21 The 2/13/21 nursing progress note revealed Resident #1 was sitting in the television room when a female resident, Resident #11, approached Resident #1. Resident #1 became angry and grabbed Resident #11 by the right wrist tightly. The facility staff immediately intervened and separated the residents. It indicated Resident #11 was not injured. It did not reveal documentation the incident was reported. The facility was unable to provide documentation an investigation had been completed following the 2/13/21 incident of physical abuse by Resident #1 toward Resident #11. Cross-reference F610: the facility failed to ensure an investigation was conducted for all allegations of abuse Cross-reference F609: the facility failed to ensure allegations of abuse were reported to the state agency III. Staff interviews CNA #2 was interviewed on 3/3/21 at 12:57 p.m. She said the secured unit was her regular assignment. She said she worked on the secured unit every shift. She said if an abusive situation was observed between two residents, staff should separate the residents to ensure their safety. She said the nurse, DON, NHA and social services should be informed right away to start an investigation. She said Resident #1 required supervision and was able to ambulate throughout the unit on his own with a cane. She said it was difficult to care for the resident at times because he could be aggressive. She said the resident would fixate on a female resident and become possessive of that resident. She said Resident #1 was possessive over Resident #2. She said there had been an incident where Resident #2 was sleeping on the couch in the television area and Resident #1 kissed and touched the resident. She said the staff on the secured unit tried to keep them separated. She said Resident #1 would touch Resident #2 breasts and attempt to touch her lower private area. She said when Resident #1 touched Resident #2, staff try to redirect him and take Resident #2 away from the area. She said Resident #1 has gotten violently angry at times when they have taken Resident #2 away from him. She said Resident #2 was non-verbal most of the time. She said she was not able to communicate her wants and needs and did not understand most conversations. She said Resident #2 could absolutely not consent to a physical or sexual relationship. She said she considered Resident #1 touching Resident #2 in a sexual manner sexual abuse and each incident should be reported to the NHA, DON, and social services right away. She said Resident #1 has had episodes of becoming angry and grabbing other residents on the secured unit. She said she recalled the incident of Resident #1 grabbing Resident #11 wrist. She said most times Resident #1 behavior was unprovoked. She said the resident was under 15 minute safety checks. She said the facility staff documented the safety checks on a form at the nursing station. Licensed practical nurse (LPN) #1 was interviewed on 3/3/21 at 1:08 p.m. She said if an altercation occurred between residents, the residents would be separated immediately, provide first aid and care if needed, residents would be placed on every 15 minute checks by staff, notifications would be made to the physician, NHA, DON, social services and the police. She said the nurse should document the incident in each resident's electronic medical record and complete the appropriate assessments. She said social services conducted the abuse investigations. She said Resident #1 typically became more confused in the afternoon and would become possessive over Resident #2. She said Resident #2 was passive and he would grab her hand for her to sit with him and tell her what to eat and drink. She said Resident #1 had touched Resident #2 in an inappropriate sexual manner. She said it was not consensual and staff would intervene immediately. She said Resident #1 had episodes of becoming aggressive toward staff when they intervened and removed Resident #2 from the situation. She said Resident #2 was unable to give consent to a sexual or physical relationship. She said Resident #2 did not speak very often and will communicate with body language. She said she did not think the resident could understand complex sentences or situations. The NHA, DON, RSD, and clinical consultant (CC) were interviewed on 3/3/21 at 3:40 p.m. The RSD said she served as the head of the social services department. She said if a situation of abuse occurred, staff should notify the NHA, DON and RSD immediately. She said the social services department was responsible for conducting the investigation. She said police, the Ombudsman, resident representative and the state agency should be notified when an abuse occurred. The CC said any suspected allegation of abuse should be reported to the state agency and the facility should conduct a full investigation. The NHA said the facility did not conduct an investigation for the incidents on 1/23/21 and 2/13/21 involving Resident #1. She said the incident on 1/23/21 was not investigated because they thought it was an incident between the resident and a staff member. She said she did not know what the statement situation which was cognitively questionable meant. She said she did not contact the nurse for further clarification when the incident occurred. She said after reviewing the nursing note again, she realized it was an incident between two residents. She said she contacted the nurse today to get further clarification. She said she had not heard back from the nurse. The NHA said the investigation of the incident on 1/27/21 revealed the relationship between Resident #1 and Resident #2 was consensual. The RSD said social services conducted the investigation. She said she felt Resident #2 could consent to a physical and sexual relationship with Resident #1. She confirmed the resident had severe cognitive impairment. She said she was unaware of the speech therapist assessment completed on 2/2/21 that indicated the resident could understand less than 25% of conversation. The NHA said social services determined the relationship was consensual because Resident #2 would seek out Resident #1. She said she was not aware Resident #2 medical record did not reveal documentation that indicated Resident #2 had ever sought out Resident #1. The RSD said the facility did not notify Resident #2 representatives of (TRUNCATED)

Based on record review and interview, the facility failed to ensure one (#40) of five residents reviewed for dementia care of 17 residents, that resided in the secure unit, out of 38 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The facility was aware that Resident #40 with a [DIAGNOSES REDACTED].#50 by going through his belongings and urinating on the floor in the bathroom prior to the incident occurring in which Resident #40 sustained a right elbow fracture as a result of an altercation. The facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #40 by addressing repeated behavioral issues created an environment where Resident #40 was subjected to harm. The facilities failures to implement appropriate interventions timely for Resident #50 who had documented delusions, verbal aggression and physical aggression towards multiple residents contributed to the physical harm of Resident #40 with a [DIAGNOSES REDACTED].#50. Cross-reference F600-facility failed to ensure resident remained free from resident-to-resident altercations Findings include: I. Facility policy and procedure The Abuse policy, revised 11/15/19, was provided by the nursing home administrator (NHA) on 12/9/19 at 12:40 p.m. It read in pertinent part, Routine assessment of facility physical environment for potentially hazardous resident outcomes is done. If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident ' s care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization , can then be implemented. II. Resident census and conditions The 12/5/19 resident census and condition form documented 101 total residents with 44 residents (44%) with dementia and 30 residents with behavioral healthcare needs (30%). The facility had a secured unit with 17 residents. III. Resident-to-resident altercation between Resident #50 and Resident #40 [NAME] Resident altercations The 11/13/19 nurse progress note documented the nurse went to check on Resident #40 when he was found sitting on the floor. Resident #50 reported to the nurse that Resident #40 came over to his bed and made a gesture of throwing a punch and he defended himself by grabbing Resident #40 ' s arm and putting him on the floor. -Resident #50 was placed on 15 minute checks and there was no injury for Resident #40. The 11/14/19 nurse progress note documented the nurse entered the room and found Resident #50 on top of Resident #40, who was on the ground. Resident #50 was holding Resident #50 ' s right arm down across his abdomen. Resident #50 told the nurse that he had seen Resident #40 going through his belongings and he grabbed his roommate's right arm when he slipped and fell on the floor on top of the Resident #40. -The residents were immediately separated and Resident #50 was placed with a staff member 24 hours a day and the physician ordered for [MEDICATION NAME] (antipsychotic) medication to be increased to three milligrams (mg) per day from two mg per day. -Resident #40 had pain in his right elbow and an x-ray of his right arm was ordered. The results of the x-ray were a fracture of his right ulnar (elbow). Physical therapy was ordered subsequently on 11/15/19 and Tylenol was ordered scheduled and as needed for pain. The 11/18/19 interdisciplinary team (IDT) progress note documented interventions put in place was Resident #50 was placed on close supervision by staff and for the staff to anticipate his needs for the 11/13/19 incident. The 11/18/19 IDT progress note documented interventions that Resident #50 was placed on one to one staffing and moved to another unit for the 11/14/19 incident. B. Resident #40 1. Resident status Resident #40, age 81, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/20/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment according to the brief interview for mental status (BIMS) score of three out of 15. He did not exhibit any behaviors and required extensive assistance from staff for most activities of daily living (ADLs). 2. Record review a.) Behavior documentation The 10/28/19 behavior care plan documented the resident had a [DIAGNOSES REDACTED]. Pertinent interventions included anticipate and meet his needs, caregivers provide an opportunity for positive interaction, explain all procedures to him before starting and allow time to adjust, intervene as necessary to protect the right and safety of others, he preferred to be in his underwear in his room, will walk out of room at times without being fully clothed, he preferred to spend most of his day in the room by himself, encourage activities as he tolerates and he will urinate on the floor at times due to his dementia and remembering where the toilet was located with staff to remind him where his urinal was located and clean floor as needed. Review of the behavior monitoring from (MONTH) 2019 to (MONTH) 2019 revealed the resident had mood issues on two occasions, disorganized thinking on one occasion, verbal aggression on one occasion, physical aggression on one occasion, [MEDICAL CONDITION] on one occasion and disruptive/intrusive on one occasion. -The 9/22/19 behavior note documented the resident was new admission to the facility and was confused looking for his room and belongings. He had physical aggression toward staff attempting to assist him. Review of progress notes from (MONTH) 2019 and (MONTH) 2019 revealed: -The 9/21/19 incident note documented the resident was aggressive with staff and his roommate. It was reported to the nurse that the resident was destructive to roommate's belongings and the resident swung his cane in his direction and hit the resident in his left upper arm and his fist and threatened to kill the resident. The resident was placed on 15 minute checks. He was separated from Resident #50 and left alone to de-escalate. The resident continued to be angry, striking out at staff. The resident urinated on the floor near Resident #50 ' s bed. -The 9/21/19 nurse note documented the resident required frequent reminders of where his room was located and in other residents beds. -The 9/22/19 nurse note documented the resident was getting clothing from his roommate ' s closet, was forgetful and angry when confronted. -The 9/23/19 nurse note documented the resident roommate reported he was angry and argumentative at times. -The 9/27/19 weekly nurse note documented the resident was going through his roommates belongings. -The 10/9/19 nurse note documented that Resident #50 reported he was fighting with Resident #40 and he hit Resident #50 with a chair and he hit him back. Resident #40 reported that Resident #50 threw him on the floor and he was ok. The residents were separated, 15 minute checks were initiated and police were notified. -The 10/28/19 weekly nurse note documented the resident was pacing on the unit at times. -The 11/5/19 weekly nurse note documented the resident was agitated with his roommate and pacing on the unit at times. The resident had a tendency to urinate on the floor and given a urinal. -The 11/8/19 weekly nurse note documented the resident was getting agitated with his roommate and began to pace. b.) Physician documentation The 9/25/19 physician history and physical documented the resident had advanced dementia and was appropriate for secured unit placement due to his exit seeking behaviors. The 10/23/19 physician progress notes [REDACTED]. The resident had no documented exit seeking behaviors and pleasant and cooperative. The 11/20/19 physician progress notes [REDACTED]. C. Resident #50 1. Resident status Resident #50, age 62, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/30/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of six out of 15. He did not exhibit any behaviors and required supervision from staff for most ADLs. 2. Record review a.) Behavior documentation The 5/3/19 behavior care plan documented the resident was physically and verbally aggressive to others and he believed he was a staff member and assists others with care, watching others behaviors and breaks up fights. Pertinent interventions were to anticipate the resident needs, staff to provide positive interactions, inform the resident that he was not a staff member if attempting to help with other residents care, remind the resident he was retired cop and security guard if he intervenes with other resident ' s behaviors and provide activities of choice. -The interventions were staff to provide one-to-one was not added to the care plan until 11/16/19, but initiated by staff on 11/14/19 when he was moved from secured unit and for staff to prevent and redirect all behaviors. Review of progress from (MONTH) 2019 to (MONTH) 2019 revealed: -The 6/23/19 psychosocial note documented the resident had an episode of verbal aggression and physical aggression. -The 8/11/19 incident note documented the resident had an altercation with another resident and sustained a scratch on his right arm. The resident had black tape over the handle of his bedroom door to divert other residents from entering his room. -The 8/15/19 nursing note documented the resident was agitated when a female resident gets near him or his room. Resident #50 grabbed the female resident by her shirt and pulled her out of his room. -The 8/17/19 incident note documented the resident verbalized not wanting residents in his room and was uncomfortable with any other residents near his room or too close to him in the common area. -The 8/31/19 nursing note documented he was involved with a resident altercation when he was escorting another resident out of a common area. -The 9/21/19 nursing note documented that the resident reported that his roommate was taking his belongings and he told the roommate no and his roommate swung a cane at him. The residents were separated. -The 10/9/19 nursing note documented the resident had reported that he was fighting with his roommate and that his roommate hit him with a chair. The resident said he hit the roommate back and he was on the floor. -The 10/14/19 nursing note documented the resident pushed another resident hard, she fell as a result and hit her head. The resident reported that the other resident had grabbed his shirt so he pushed her. -The 11/1/19, 11/5/19, 11/8/19 and 11/13/19 nursing notes documented the resident was irritated or agitated with his roommate urinating on the floor in the bathroom. Review of the behavior monitoring from (MONTH) 2019 to (MONTH) 2019 revealed the resident had verbal aggression on two occasions, delusions on one occasion and disruptive/intrusive on one occasion. b.) Physician documentation The 10/23/19 physician progress notes [REDACTED]. The resident had not had any aggressive behaviors since 10/18/19. The resident reported that a resident came into his room in the middle of the night, standing over his bed which scared him. The facility was looking for alternative placement for him. The 11/6/19 physician progress notes [REDACTED]. The resident was aware that he was being watched by the staff and was controlling his temper. The 11/20/19 physician progress notes [REDACTED]. The resident was on [MEDICATION NAME] three mg each day due to his aggressive behaviors. IV. Staff interviews The social service director (SSD) was interviewed on 12/10/19 at 1:47 p.m. She said when a resident altercation occurred the staff ensured each of the residents ' safety that were involved initially by separating them and the staff immediately reported it to the NHA, who was the abuse coordinator. The IDT then worked on figuring out the cause of the resident-to-resident altercation, whether a resident was bothered by a congested common area or another resident wandering into their room. The IDT implemented interventions like room changes, reevaluating their activity programming whether one to one was required or more diversional activities. She said the IDT documented their review of each altercation in the resident ' s medical record. She said at the end of (MONTH) the IDT implemented daily huddles in the secured unit where most of the resident-to-resident altercations were occurring. During the daily huddle, the team discussed all resident behaviors, what worked with each resident to alleviate their behaviors and what activities were happening. She said since the implementation of the daily huddles, the resident altercations had lessened. She said for Resident #50, his previous work experience included being a cop and security guard at a hospital. She said due to his previous work, he felt as if he was a part of the staff and intervened with other residents that had behaviors. She said he did not have dementia but had cognitive impairment from a [MEDICAL CONDITION] and did not understand why the residents with dementia had confusion. She said he resided on the secured unit due to his elopement and wandering risk in order to keep him safe. She said his behaviors of verbal and physical aggression started to get worse after he had surgery in (MONTH) 2019 and possibly due to effects from the anesthesia. She said Resident #50 was irritated and upset when other residents wandered into his room. She said the staff had tried a stop sign outside of his door to deter wandering residents but it did not work. She said he did not do well with having a roommate and he was able to reside without a roommate for awhile but the staff moved a roommate into his room on 9/20/19 because they did not have enough rooms. She said there were two incidents that occurred with Resident #50 and Resident #40 that happened on 11/13/19 and 11/14/19. She said Resident #50 had been getting upset with his roommate because he urinated on the floor and going through his belongings prior to the incident but an altercation did not occur until 11/13/19 and 11/14/19. She said for the 11/13/19 incident the Resident #50 had reported he had pulled Resident #40 ' s arm and pulled him onto the ground. There was no injury to Resident #40 during the 11/13/19 altercation and the staff were to anticipate Resident #50 ' s needs and he was placed on 15 minute checks. She said on the 11/14/19 incident, Resident #50 was upset because Resident #40 was going through his belongings. Resident #50 grabbed his arm and fell on top of him, which caused pain to Resident #40 ' s elbow. She said an x-ray was performed on Resident #40 ' s elbow where it was determined it was fractured. She said subsequent to the altercation, Resident #50 was moved off of the secured unit into a private room and had a staff member with him at all times. She said the activities staff had geared activities that keep him occupied and he enjoyed like work therapy projects, raking leaves and talking with him. She said with the staff member with him at all times and being off the secured unit he had not had any recent behaviors with other residents. She said she was working on placement to another skilled nursing facility that specialized in behavioral health. The NHA was interviewed on 12/10/19 at 2:47 p.m. She said the facility staff made efforts to prevent resident-to-resident abuse. She said before a resident was admitted to the facility, an assessment was completed to identify if there were any behavioral concerns. She said by knowing the information in the forefront, the staff were able to implement interventions. She said the IDT tried to determine what may trigger a resident ' s aggression such as loud noises or congested areas. She said the activities staff completed an assessment to ensure the residents were engaged in programs that kept the residents occupied to lessen the aggressive behaviors that could lead to any abusive incidents. She said if a resident-to-resident altercation did occur the staff ensured both residents involved were safe with immediate separation and implemented one-to-one for an hour after the incident. She said standard approaches that were initiated were 15 minute checks for three days and providing diversional activities like walking. She said if the incident was severe or several incidents of abuse occurred then the IDT implemented one-to-one staff indefinite until it was determined the resident would not harm any others or until appropriate placement was determined if transferring to another facility. She said Resident #50 previously had been on one-to-one staffing but it was discontinued usually within a few days after the IDT determined he was not having aggressive behaviors or further altercations. -However the resident continued to have behaviors and the one-to-one was not made indefinite until 11/14/19 (see behavior documentation above). She said most of the resident-to-resident altercations occurred on the secured unit. She said the IDT implemented 10 to 15 minute education huddles daily to identify resident trigger points and interventions to help provide de-stimulation for the residents. She said the facility used a strategy called best friends approach, where the staff working in the unit talked with residents to calm them down if having a bad day or converse with them as if they were friends. She said she planned on implementing two full time activity assistants, as opposed to one activity assistant currently in place, to keep the residents engaged with dementia care activities and provide more programming. She said that the activity staff took residents off the unit, with supervision, to integrate them in facility-wide activities. She said the memory care director was certified in dementia care and training and had started three months previous to provide specialized training to staff regarding dementia and behaviors. She said for Resident #50, he currently had one-to-one staff due to his previous aggressive behaviors with other residents residing on the secured unit. She said due to his elopement concerns he was placed on the secured unit to ensure his safety. She said he had cognitive impairment from a [MEDICAL CONDITION] but still was alert and oriented at times. She said he thought he was on duty working as a security guard and interfere with other residents so the staff constantly reminded him that he was retired and had to take it easy. She said the resident did not do well with roommates because he thought they were trying to take his belongings. She said at one point, he did not have roommates and was able to lock his door. She said unfortunately the facility could no longer accommodate a private room for him on the secured unit because the facility needed to admit Resident #40.

Based on record review and staff interviews, the facility failed to ensure four residents (#40, #50, #93 and #64) involved in two of five occurrences reviewed for abuse were free from resident-to-resident altercations out of 38 sample residents. The facilities failures to implement appropriate interventions timely for Resident #50 who had documented delusions, verbal aggression and physical aggression towards multiple residents contributed to the physical harm of Resident #40, who subsequently sustained a fractured elbow from and altercation with Resident #50. The facility was aware shortly after Resident #50's admission in (MONTH) 2019 that he believed he was a staff member and assisted others with care, watched others behaviors, and thought he needed to break up fights. He was on antipsychotic medication for aggressive behaviors and resided on the secured unit with residents who had dementia. It was known to the staff he did not like other residents in his room. The facility choose to place Resident #40 into a shared room with Resident #50 with this known behavior factors placing Resident #40 at great risk of being harmed by Resident #50. Furthermore, not until eight altercations later was Resident #50 placed with a staff member to monitor his actions 24 hours a day. The facility failed to keep Resident #64 safe from Resident #93. Resident #64 sustained a skin tear to her right arm. Findings include: I. Facility policy and procedure The Abuse policy, revised 11/15/19, was provided by the nursing home administrator (NHA) on 12/9/19 at 12:40 p.m. It read in pertinent part, -Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain and maintain physical, mental, or psychosocial well-being. -Residents at risk for abusive situations are identified and appropriate care plans are developed. Resident rooms are selected or changed to reduce any identified risk of resident to resident conflict or abuse. -Routine assessment of facility physical environment for potentially hazardous resident outcomes is done. If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident' s care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization , can then be implemented. II. Resident-to-resident altercation between Resident #50 and Resident #40 [NAME] Resident altercations The 11/13/19 nurse progress note documented the nurse went to check on Resident #40 when he was found sitting on the floor. Resident #50 reported to the nurse that Resident #40 came over to his bed and made a gesture of throwing a punch and he defended himself by grabbing Resident #40's arm and putting him on the floor. -Resident #50 was placed on 15 minute checks and there was no injury for Resident #40. The 11/14/19 nurse progress note documented the nurse entered the room and found Resident #50 on top of Resident #40, who was on the ground. Resident #50 was holding Resident #50's right arm down across his abdomen. Resident #50 told the nurse that he had seen Resident #40 going through his belongings and he grabbed his roommate's right arm when he slipped and fell on the floor on top of the Resident #40. -The residents were immediately separated and Resident #50 was placed with a staff member 24 hours a day and the physician ordered for [MEDICATION NAME] (antipsychotic) medication to be increased to three milligrams (mg) per day from two mg per day. -Resident #40 had pain in his right elbow and an x-ray of his right arm was ordered. The results of the x-ray were a fracture of his right ulnar (elbow). Physical therapy was ordered subsequently on 11/15/19 and Tylenol was ordered scheduled and as needed for pain. The 11/18/19 interdisciplinary team (IDT) progress note documented interventions put in place was Resident #50 was placed on close supervision by staff and for the staff to anticipate his needs for the 11/13/19 incident. The 11/18/19 IDT progress note documented interventions that Resident #50 was placed on one to one staffing and moved to another unit for the 11/14/19 incident. B. Resident status 1.Resident #50 Resident #50, age 62, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/30/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment according to the brief interview for mental status (BIMS) score of six out of 15. He did not exhibit any behaviors and required supervision from staff for most activities of daily living (ADLs). 2. Resident #40 Resident #40, age 81, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 11/20/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of three out of 15. He did not exhibit any behaviors and required extensive assistance from staff for most ADLs. C. Record review for Resident #50 1. Behavior documentation The 5/3/19 behavior care plan documented the resident was physically and verbally aggressive to others and he believed he was a staff member and assisted others with care, watched others behaviors and broke up fights. Pertinent interventions were to anticipate the resident needs, staff to provide positive interactions, inform the resident that he was not a staff member if attempting to help with other residents care, remind the resident he was retired cop and security guard if he intervenes with other resident's behaviors and provide activities of choice. -The interventions were staff to provide one-to-one was not added to the care plan until 11/16/19, but initiated by staff on 11/14/19 when he was moved from secured unit and for staff to prevent and redirect all behaviors. Review of progress from (MONTH) 2019 to (MONTH) 2019 revealed: -The 6/23/19 psychosocial note documented the resident had an episode of verbal aggression and physical aggression. -The 8/11/19 incident note documented the resident had an altercation with another resident and sustained a scratch on his right arm. The resident had black tape over the handle of his bedroom door to divert other residents from entering his room. -The 8/15/19 nursing note documented the resident was agitated when a female resident gets near him or his room. Resident #50 grabbed the female resident by her shirt and pulled her out of his room. -The 8/17/19 incident note documented the resident verbalized not wanting residents in his room and was uncomfortable with any other residents near his room or too close to him in the common area. -The 8/31/19 nursing note documented he was involved with a resident altercation when he was escorting another resident out of a common area. -The 9/21/19 nursing note documented that the resident reported that his roommate was taking his belongings and he told the roommate no and his roommate swung a cane at him. The residents were separated. -The 10/9/19 nursing note documented the resident had reported that he was fighting with his roommate and that his roommate hit him with a chair. The resident said he hit the roommate back and he was on the floor. -The 10/14/19 nursing note documented the resident pushed another resident hard, she fell as a result and hit her head. The resident reported that the other resident had grabbed his shirt so he pushed her. -The 11/1/19, 11/5/19, 11/8/19 and 11/13/19 nursing notes documented the resident was irritated or agitated with his roommate urinating on the floor in the bathroom. Review of the behavior monitoring from (MONTH) 2019 to (MONTH) 2019 revealed the resident had verbal aggression on two occasions, delusions on one occasion and disruptive/intrusive on one occasion. 2. Physician documentation The 10/23/19 physician progress notes [REDACTED]. The resident had not had any aggressive behaviors since 10/18/19. The resident reported that a resident came into his room in the middle of the night, standing over his bed which scared him. The facility was looking for alternative placement for him. The 11/6/19 physician progress notes [REDACTED]. The resident was aware that he was being watched by the staff and was controlling his temper. The 11/20/19 physician progress notes [REDACTED]. The resident was on [MEDICATION NAME] three mg each day due to his aggressive behaviors. D. Staff interviews The social service director (SSD) was interviewed on 12/10/19 at 1:47 p.m. She said when a resident altercation occurred the staff ensured the safety of each resident involved initially by separating them and the staff immediately reported it to the NHA, who was the abuse coordinator. The IDT then worked on figuring out the cause of the resident-to-resident altercation, whether a resident was bothered by a congested common area or another resident wandering into their room. The IDT implemented interventions like room changes, reevaluating their activity programming whether one to one was required or more diversional activities. She said the IDT documented their review of each altercation in the resident's medical record. She said at the end of (MONTH) the IDT implemented daily huddles in the secured unit where most of the resident-to-resident altercations were occurring. During the daily huddle, the team discussed all resident behaviors, what worked with each resident to alleviate their behaviors and what activities were happening. She said since the implementation of the daily huddles, the resident altercations had lessened. She said for Resident #50, his previous work experience included being a cop and security guard at a hospital. She said due to his previous work, he felt as if he was a part of the staff and intervened with other residents that had behaviors. She said he did not have dementia but had cognitive impairment from a [MEDICAL CONDITION] and did not understand why the residents with dementia had confusion. She said he resided on the secured unit to keep him safe due to his elopement and wandering risk. She said his behaviors of verbal and physical aggression started to get worse after he had surgery in (MONTH) 2019 and possibly due to effects from the anesthesia. She said Resident #50 was irritated and upset when other residents wandered into his room. She said the staff had tried a stop sign outside of his door to deter wandering residents but it did not work. She said he did not do well with having a roommate and he was able to reside without a roommate for awhile but the staff moved a roommate into his room on 9/20/19 because they did not have enough rooms. She said there were two incidents that occurred with Resident #50 and Resident #40, on 11/13/19 and 11/14/19. She said Resident #50 had been getting upset with his roommate because he urinated on the floor and he would go through his belongings. She said there were two incidents that occurred with Resident #50 and Resident #40 that happened on 11/13/19 and 11/14/19. She said Resident #50 had been getting upset with his roommate because he urinated on the floor and going through his belongings prior to the incident but an altercation did not occur until 11/13/19 and 11/14/19. She said for the 11/13/19 incident the Resident #50 had reported he had pulled Resident #40's arm and pulled him onto the ground. There was no injury to Resident #40 during the 11/13/19 altercation and the staff were directed to anticipate Resident #50's needs and he was placed on 15 minute checks. She said on 11/14/19 Resident #50 was upset because Resident #40 was going through his belongings. Resident #50 grabbed Resident #40's arm and fell on top of him, which caused pain to Resident #40's elbow. She said an x-ray was performed on Resident #40's elbow where it was determined it was fractured. She said subsequent to the altercation, Resident #50 was moved off the secured unit into a private room and had a staff member with him at all times. She said the activities staff had geared activities to keep him occupied and he enjoyed like work therapy projects, raking leaves and talking with him. She said with the staff member with him at all times and being off the secured unit he had not had any recent behaviors with other residents. She said she was working on placement to another skilled nursing facility that specialized in behavioral health. The NHA was interviewed on 12/10/19 at 2:47 p.m. She said the facility staff made efforts to prevent resident-to-resident abuse. She said before a resident was admitted to the facility, an assessment was completed to identify if there were any behavioral concerns. She said by knowing the information in the forefront, the staff were able to implement interventions. She said the IDT tried to determine what may trigger a resident's aggression such as loud noises or congested areas. She said the activities staff completed an assessment to ensure the residents were engaged in programs that kept them occupied to lessen the aggressive behaviors that could lead to any abusive incidents. She said if a resident-to-resident altercation did occur the staff ensured both residents involved were safe with immediate separation and implemented one-to-one for an hour after the incident. She said standard approaches that were initiated were 15 minute checks for three days and providing diversional activities like walking. She said if the incident was severe or several incidents of abuse occurred then the IDT implemented one-to-one staff indefinite until it was determined the resident would not harm any others or until appropriate placement was determined if transferring to another facility. She said Resident #50 previously had been on one-to-one staffing but it was discontinued usually within a few days after the IDT determined he was not having aggressive behaviors or further altercations. -However the resident continued to have behaviors and the one-to-one was not made indefinite until 11/14/19 (see behavior documentation above). She said most of the resident-to-resident altercations occurred on the secured unit. She said the IDT implemented 10 to 15 minute education huddles daily to identify resident trigger points and interventions to help provide de-stimulation for the residents. She said the facility used a strategy called best friends approach, where the staff working in the unit talked with residents to calm them down if having a bad day or converse with them as if they were friends. She said she planned on implementing two full time assistants, as opposed to one activity assistant currently in place, to keep the residents engaged with dementia care activities and provide more programming. She said for Resident #50, he currently had one-to-one staff due to his previous aggressive behaviors with other residents residing on the secured unit. She said due to his elopement concerns he was placed on the secured unit to ensure his safety. She said he had cognitive impairment from a [MEDICAL CONDITION] but still was alert and oriented at times. She said he thought he was on duty working as a security guard and interfere with other residents so the staff constantly reminded him that he was retired and had to take it easy. She said the resident did not do well with roommates because he thought they were trying to take his belongings. She said at one point, he did not have roommates and was able to lock his door. She said unfortunately the facility could no longer accommodate a private room for him on the secured unit because the facility needed to admit Resident #40. III. Resident-to-resident altercation involving Resident #64 and Resident #93 on 11/17/19. [NAME] Resident altercation The 11/17/19 nurse progress note documented that Resident #64 was attempting to force her roommate, Resident #93, to go to bed against her will for approximately 30 minutes. Resident #93 was yelling at her in German and tried to push her away. In the process Resident #93 caused a skin tear to Resident #64' s right forearm measuring 2-5 centimeters long. Resident #64 was then removed from the room so Resident #93 could fall asleep. -This action was documented by staff to have knowingly allowed this to occur for 30 minutes. The 11/19/19 interdisciplinary team (IDT) progress note documented the type of incident was physical aggression resulting in a skin tear to Resident #64' s right forearm. It documented that the root cause was Resident #93 swinging her arms and hands to prevent Resident #64 from helping her due to increased agitation. The interventions that were put in place were to separate the residents, one-on-one until calm and asleep and to monitor frequently. B. Resident #64 1.Resident status Resident #64, age 83, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/22/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She required supervision from staff for her activities of daily living (ADLs). She had inattention and disorganized thinking. She exhibited physical behaviors towards others. 2. Record review Behavior documentation from 9/8/19 to 12/9/19 documented Resident #64 was physically aggressive five times, verbally aggressive four times and destroyed property two times. - Physical aggression included trying to get the attention of another resident with a hair brush, hitting staff, pulling eye glasses off staff members face, kicking and pulling hair of staff and pushing other residents. - Verbal aggression included cursing, yelling at other residents and yelling at staff. - Property destruction included throwing furniture and items in the kitchen, throwing a plant, throwing pillows off the chair, knocking over cups, pulling drawers out and throwing them on the floor. Pertinent interventions were verbal redirection, one on one, limit setting and reality orientation. The 5/13/19 behavior care plan documented pertinent interventions to remind her that staff will assist the other residents with care, engage her in alternative activities to distract her from other residents, explain all procedures to her before starting, monitor behavior episodes,document behaviors and potential causes, offer non-medication interventions prior to administering medications, offer a snack, redirect to an activity, offer to call a loved one, sit with her and offer her a shower. The 10/9/19 psychosocial quarterly note documented Resident #64 continued to have behaviors of physical aggression, verbal aggression, refusal of care and exit seeking. The 11/6/19 physician progress notes [REDACTED]. The plan was to continue supportive care and to monitor. Previous to the resident altercation on 11/17/19 Resident #64 was involved in five other altercations in the past 12 months. 3. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 12/10/19 at 11:05 a.m. She said Resident #64 got physically aggressive with staff and other residents. She said Resident #64 got agitated when staff tried to help her or when other residents did not do what she told them to do. CNA #1 said she separated them and a room change was done between Resident #64 and Resident #93. She said if the resident refused care or got agitated she just walked away and tried again at a later time. The registered nurse (RN)#3 was interviewed on 12/10/19 at 11:15 a.m. He said Resident #64 liked to help other residents because she thought they were her babies. He said it became a demand and Resident #64 and other residents got frustrated. He said since the room change between Resident #64 and Resident #93 behaviors have gotten better. He said the staff redirect Resident #64 when she became agitated or demanding and that was all they could do. The social services director (SSD) was interviewed on 12/10/19 at 2:07 p.m. She said Resident #64 thought Resident #93 was her baby and frequently Resident #64 would go to the staff and ask them to get her baby up. This altercation was because Resident #64 wanted her baby, Resident #93, to go to bed. Resident #93 was yelling at Resident #64 in German. Staff heard the yelling and went to see what was happening. When they arrived they saw Resident #64 pulling on Resident #93' s arm trying to get her into bed. Resident #93 was swinging her arms at Resident #64 causing a skin tear to her right arm. She said Resident #93 said she did not feel safe, so they moved Resident #64 to a new room. She said Resident #64 would hit others to get attention, exit seek, yelled and screamed because she wanted to leave and threatened to break windows to get out. She said it agitated other residents when Resident #64 tapped on them to get their attention, when she got in their face to talk and when she tried to help other residents with care. She said interventions were put into place including one-on-one with conversation to calm her down, allow her to write a police report to be given to the police, offer her reading material since she liked to read and offer her coffee. She said staff did daily huddles with dementia training and ideas on activities to keep the residents engaged. B. Resident #93 1. Resident status Resident #93, age 94, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/31/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 0 out of 15. She required extensive assistance from staff for ADLs. She had inattention and disorganized thinking. She exhibited physical and verbal behaviors towards others. She was short tempered and easily annoyed. She rejected care at times. 2. Record review Behavior documentation from 9/8/19 to 12/9/19 documented Resident #93 was disruptive and intrusive five times, verbally aggressive four times, physically aggressive two times and destroyed property two times. -Disruptive and intrusive behavior included destroying property, wandering and repetitive statements. -Verbally aggressive behavior included yelling at peers and staff. -Physically aggressive behavior included pushing. Pertinent interventions were verbal redirection, distraction, one on one, reality orientation, limit setting, alternate activity, positive reinforcement and quiet place. The 5/14/19 behavior care plan documented pertinent interventions to anticipate and meet the residents needs, provide an opportunity for positive interaction, engage in conversation or other activity, take her outside and sit with her, redirect conversations, offer tasks which divert attention and provide a program of activities that is of interest to her. The 10/14/19 physician progress notes [REDACTED]. The 10/28/19 psychosocial note documented Resident #93 and her roommate argued at times. It documented that staff separated them and after a period of time the residents relaxed and were friends again. It documented that staff would continue to assist and intervene as needed. Previous to the resident altercation on 11/17/19 Resident #93 was involved in nine other altercations in the past 12 months. 3. Staff interviews CNA #1 was interviewed on 12/10/19 at 11:05 a.m. She said Resident #93 yelled and screamed and wanted to leave. She said she was not aware of any current altercations with other residents. She said they had dementia training every day during the morning huddle. She said the staff documented the residents' behaviors on the computer and reported the behaviors to the nurse. She said Resident #93' s interventions included taking her to the 200 unit for activities and redirecting her. The RN#3 was interviewed on 12/10/19 at 11:15 a.m. He said the staff received dementia train daily at the morning huddle. He said Resident #93 had progressed in her dementia and spoke more German than English. He said she was exit seeking and kicked the exit doors. He said when he saw her getting angry he would redirect her and if she could not be redirected he would just leave her alone until she calmed down or forgot what she was angry about. He said she used a wheelchair so they were able to remove her from an agitated situation. The social services director (SSD) was interviewed on 12/10/19 at 2:07 p.m. She said the staff did daily huddles with dementia training and ideas to engage the residents in activities. She said Resident #93 yelled in German and was exit seeking. She said in the past Resident #93 was physically aggressive but had turned more to verbal aggression. She said interventions that were put in place for her included German speaking staff and a tablet on wheels that interrupts in German because when she got angry and yelled she would revert to German speaking. She said Resident #93 also liked a change in her surroundings so she was taken on walks.

Based on observations, record review and interviews, the facility failed to provide two (#2 and #97) of three residents reviewed, the care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers. Specifically, the facility failed to: -Identify, assess, care plan and implement interventions to prevent the formation of pressure ulcers for residents #2 and #97; -Provide thorough initial assessments for residents #2 and #97 upon identification of newly formed pressure ulcers, as well as thorough, ongoing assessment of pressure ulcers for residents #2 and #97. The facility's failures contributed to resident #2 acquiring a stage III pressure ulcer; and resident #97 acquiring two stage IIs and one unstageable pressure ulcer. The findings included: 1. Professional reference The National Pressure Ulcer Advisory Panel, NPUAP Pressure Ulcer Stages/Categories 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ (3/16), read in part: Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough .Presents as a shiny or dry shallow ulcer without slough or bruising . Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling . Bone/tendon is not visible or directly palpable. 2. Facility policy and procedure: On 3/25/16 the nursing home administrator (NHA) on 3/25/16 provided a copy of the facility's Pressure Ulcer policy, revised 2/18/16, which included: Conduct a thorough skin assessment. The facility will complete this assessment upon admission and weekly thereafter unless otherwise indicated. The skin assessment should include the following: skin color, skin turgor, skin integrity .breaks or sores on the skin, drainage or pus, pain or soreness, swelling anywhere on the body, excessive moisture . If an ulcer is present: daily monitoring with accompanying documentation should include: evaluation of the ulcer and the peri-wound area, an evaluation of the status of the dressing, including tissue surrounding the ulcer, if the dressing cannot be removed (i.e. order is to change dressing every third day) observe whether the dressing is intact, the amount of drainage present/percentage of saturation as well as the status of the surrounding tissue area, the presence of possible complications (e.g., increased redness or swelling around the wound or increased drainage from the wound), and whether pain if present, is being adequately controlled . Weekly documentation of the pressure ulcer should include at least the following: size, depth, presence, location and extent of any undermining or tunneling, wound bed, pain, exudate, and description of wound edges and surrounding tissue. 3. Resident #2 Resident #2, age 46, was admitted on [DATE]. According to the 3/16 computerized physician orders, [DIAGNOSES REDACTED]. According to the 3/4/16 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required two person assist with transfers and one person assist with showering, dressing, toilet use and personal hygiene. Record review: The care plan initiated 2/25/14 and revised on 11/18/15, identified potential for pressure ulcer development due to decreased mobility. Interventions included: follow facility policies/protocols for the prevention/treatment of [REDACTED]. The Braden scale of predicting pressure sore risk dated 10/29/15 revealed a score of 15, which indicated the resident was at risk for developing pressure sores. The weekly nursing skin documentation dated 11/8/15 and 11/15/15 read, Small open area to coccyx, treatment in place. The documentation did not include: identification of the wound as being a pressure ulcer, a description of the wound, and the staging of the wound. The review of skin tears and bruises form dated and signed on 11/9/15, revealed an open area on the right side of the coccyx. The most identified probable cause listed was shearing. This form was to be provided to the wound nurse according to the director of nursing (DON), to initiate an assessment, see interview below. According to the nurses' progress note dated 11/16/15, the resident was admitted to the hospital for acute [MEDICAL CONDITION]. According to the discharge summary note from the hospital dated 12/5/15, the resident had been admitted to the hospital with [REDACTED]. The note did not offer more information on the status of the wound at date of discharge. The Braden scale of predicting pressure sore risk assessment dated [DATE] revealed the resident scored a 16 which indicated the resident was at high risk for developing pressure sores. The nursing data collection (re-admit) document dated 12/5/15 revealed, Deep wound to coccyx, pressure ulcer stage III. The documentation did not include a description or the measurements of the pressure ulcer. According to the weekly pressure ulcer monitoring form dated 12/7/15, the resident had a coccyx pressure ulcer. The wound was classified at stage III. No tunneling/undermining was found. The wound bed had slough and the surrounding tissue was normal. The note documented that it was the first assessment completed, and referred to the detailed nursing note for this date. According to the nurse's progress note dated 12/7/15, The resident was readmitted from the hospital with what appears to be a stage III pressure wound on his coccyx. As the wound bed is covered with 90% slough, determining the stage is a challenge at this minute . There is a small amount of serous drainage, no odor at this time. Edges are fixed, no tunneling/undermining upon probe w/ (with) cotton swab. NP (nurse practitioner) has written orders for wound care. The care plan, initiated on 12/10/15 and revised on 3/8/16, identified the resident had a stage III pressure ulcer on the coccyx. Interventions included: administer treatments as ordered, assistance needed to turn/reposition the resident at least every two hours, or often as needed or requested. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. The weekly pressure ulcer quality indicator (QI) logs contained the following information: -whether the pressure ulcer was acquired at the facility or if they were admitted with it -the site and stage -the measurement, odor, amount of drainage, and whether a culture had been completed -it identified the treatment and intervention used -dietary interventions -the pressure ulcer risk assessment score -if the care plan had been updated and family and physician had been notified. -it included the date of when the pressure ulcer was healed. The log dated 2/19/16 to current did not contain pressure ulcer characteristics such as wound bed description, type of drainage, resident's pain level, and if the wound was infected (not all infections require a culture, as indicated above). The weekly pressure ulcer monitoring forms contained the following pressure ulcer information: - date of wound evaluation - location and measurements - drainage type and amount - odor - pressure ulcer wound bed characteristics - surrounding skin color/tissue/wound edges - pain level and interventions - response to wound treatment - skin/wound summary - care plan reviewed and updated. Six weeks of weekly monitoring forms were not completed on the following dates: from 1/21/16 to 2/17/16 and 3/3/16. The QI logs and the weekly monitoring forms were completed by licensed practical nurses (LPNs). The resident was not assessed by a registered nurse (RN) during the time frame. (Cross reference F282, services by qualified persons.) Staff interviews: The DON was interviewed on 3/30/16 at 9:20 a.m. She said the normal process was for the nursing staff to complete an incident report for newly identified pressure ulcers and complete notification and evaluations for onset of skin breakdown form. She said once she received the assessment form she would notify the wound nurse. The LPN was to assess and monitor the pressure ulcer. She said she collected the data supplied by the LPN regarding the pressure ulcers and brought the information to the quality assurance (QA) meetings. RN #2 was interviewed on 3/29/16 at 11:05 a.m. She said the floor nurses were not responsible for measuring the pressure ulcers, the wound nurse was. She said the normal process for a newly found pressure ulcer was to complete an incident report and notify the physician. She said the wound nurse was responsible for assessing the newly found pressure ulcer. She said the wound nurse was responsible for measuring and monitoring the pressure ulcers for decline and improvements. LPN#1, the wound nurse, was interviewed on 3/30/16 at 1:20 p.m. He said he would receive an assessment or verbal notification to look at a new pressure ulcer. He said he would assess the wound, measure, and complete a drawing of the wound. He said he would document these findings on the weekly pressure ulcer form and on the QI logs every week. He said he would inform the wound physician for follow up during his next visit. The NHA was interviewed on 3/30/16 at 4:30 p.m. She said the previous DON had completed wound assessments and wound follow up until her resignation a couple of months ago. She felt the assessments had been completed weekly by the DON during that time frame. She was not aware of the missing assessments. 4. Resident #97 Resident #97, age 73, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 2/18/16 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required extensive assistance of two persons with bed mobility, transfers, and toileting. The resident was identified as being at risk for pressure ulcers. The resident required a pressure reducing device for the wheelchair and bed. The resident was not on a turning or repositioning program. The resident ambulated with one person assistance. According to the 3/18/16 MDS assessment, the information remained the same regarding the pressure ulcers but included the newly identified nutritional support interventions. The resident was no longer ambulatory and was wheelchair bound. Record review: According to the nursing admission data collection form completed on 2/11/16, the resident was not admitted with a pressure ulcer. According to the Braden scale for predicting pressure sore risk assessment form dated 2/11/16, the resident was at risk for developing pressure sores. The facility failed to develop a care plan which addressed the resident being at risk of pressure ulcers. There were no interventions put in place to prevent pressure ulcers from developing. According to the pressure ulcer care plan initiated 3/21/16 (after the development of the pressure ulcers), the resident had a stage two pressure ulcer to the coccyx and an unstageable pressure ulcer to the left heel. Interventions included: provide a pressure relieving mattress, the resident preferred to be positioned on her back, follow facility policies for the prevention and treatment of [REDACTED]. According to the care plan initiated on 3/21/16, the resident was resistive to care as she declined related to adjustment to the facility and end of life issues. Interventions included: collaborating and communicating with the palliative team, encourage participation/interaction during activities, explain cares prior to contacting resident, re-approach when she resists, negotiate another time for cares if possible, and allow her to make her own choices. According to the weekly nursing documentation form dated 2/29/16, the resident had redness to her buttock and abdominal folds. The intervention documented was for nursing to apply a barrier cream. According to the nursing note dated 3/1/16, Resident with dime size open area to right buttock and dime size open area to right/central abdominal fold. She developed these wounds prior to beginning [MEDICAL CONDITION] sessions. According to the nursing note dated 3/8/16, the resident had her first [MEDICAL CONDITION] session. According to the physician's orders [REDACTED]. A new treatment order was provided. No documentation was found in the resident's medical records that a pressure reducing device for the wheelchair or bed was provided until after the pressure ulcer developed on 3/10/16. According to the nursing progress note dated 3/10/16, the resident received a new air overlay mattress. The physician progress notes [REDACTED].; candidiasis rash in abd (abdominal) folds with areas of shallow erosion and serosanguenous drainage . Will confer with our wound care nurses who have been following these before recommending any treatment changes . I am seeing them for the first time today so don't have great perspective on the evolution, though it seems they are progressing . According to the nursing note on 3/16/16, an air bed was ordered and estimated to arrive on 3/17/16. No weekly pressure ulcer monitoring forms were found in the resident's medical records until 3/18/16. The pressure ulcers had not been assessed by an RN from the onset of the pressure ulcers on 3/1/16. The LPN completed the weekly monitoring form on 3/18/16. (Cross-reference F282 qualified staff.) Requested information from the facility: On 3/29/16 at 3:00 p.m. and on 3/30/16 at 11:00 a.m., the therapy evaluation for the pressure relieving devices was requested from the nursing home administrator, along with the daily wound notes and interdisciplinary team meeting notes regarding the pressure ulcers. The documentation was not provided during or after the survey. Staff interviews: LPN #2 was interviewed on 2/23/16 at 10:27 a.m. He stated the resident had a history of [REDACTED]. LPNs #2 and #9 were interviewed on 3/30/16 at 2:45 p.m. They stated when the resident was admitted to facility she was alert, oriented and active. According to LPN #9 the resident had back pain and was unable to ambulate with a walker; the walker was for transfers. -They both said the resident deteriorated after her initial [MEDICAL CONDITION] session. The resident responded poorly to the session and did not complete additional [MEDICAL CONDITION] sessions. The resident became bed bound following [MEDICAL CONDITION]. Prior to [MEDICAL CONDITION] the resident was able to get out of bed. The director of nursing (DON) was interviewed on 3/30/16 at 6:15 p.m. She stated the staff identified redness on the resident's buttock and abdominal folds on 2/29/16 which had opened on 3/1/16. She said the resident had acquired the stage II ulcers on the left buttock and between the abdominal folds, and a large fluid filled blister to the left heel at the facility. She said she felt the pressure ulcers were caused by the prolonged sitting the resident had to do during [MEDICAL CONDITION] sessions. She was not aware the pressure ulcers had formed prior to the [MEDICAL CONDITION] sessions. She said she had not worked at the facility during this time frame so she could not comment on what interventions were in place. She started in her current position approximately three weeks ago. She said she would assume the staff had in place to frequently reposition the resident and provide the necessary pressure reducing devices for the wheelchair and mattress.

Based on observations, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for two residents (#1, #2) of five sample residents. Specifically: -The facility failed to thoroughly and timely assess and address resident #1's needs after a significant change of condition. Resident #1 was transported to the hospital in respiratory distress. -The facility failed to appropriately assess resident #2's change of condition (buttock, hip and groin pain) after a fall. The findings include: On 10/23/12, the Colorado Department of Health received a complaint regarding resident care and services with allegations specific to lack of assessment for a change of condition. A. Facility Expectations 1. The facility ' s Change of Condition policy provided, in pertinent part: -The physician is to be notified immediately of a fall resulting in significant injury, critical lab values, respiratory arrest, acute changes in respiratory status, significant changes to vital signs, sudden cognitive changes or any life threatening episode ... " -Documentation of the change of condition in the resident ' s medical record is to include: Date and time of change of condition, who (physician/family member/responsible party) was notified, the information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, and care provided. A licensed practical nurse (LPN) was interviewed on 11/27/12 at 9:25 a.m. about staff response to a change in a resident's condition. The LPN stated that when a resident had a change in condition, the RN supervisor should be notified. The LPN stated that she would take direction from the RN supervisor and or the physician. When a resident had a change in condition the nurses should notify the physician and family of the change, note the change on the 24 hour report, and charting should be completed for 72 hours after the change has been identified. Another LPN interviewed on 11/27/12 at 1:25 p.m. stated that when a change in condition was noticed for a resident, she would do a head to toe assessment on the resident. She stated she would then notify the nursing supervisor, physician, and the family of the change. 2. Registered Nurse (RN) Responsibilities According to the facility's RN Supervisor Requirements, the RN supervisor is responsible for all documentation related to "...all and any change of condition ... falls, abnormal vitals or neuros, lethargy, increase in confusion, behaviors, temperature ... RN supervisors are to be on the floors at all times ...are to assist the nursing staff with their duties ...are to be present with all change in conditions ... " On 11/29/12 at approximately 12:45 p.m., the Director of Nurses (DON) was interviewed regarding her expectations when a resident has a change of condition. The DON stated the RN supervisors are responsible for the overall management when a resident has a change of condition, including an initial assessment as well as follow up and also are expected to help the nurses on the unit. B. Resident #1 Resident #1, age 82, was admitted to the facility on [DATE] and discharged on [DATE] to an acute care facility. Review of the closed record revealed the following [DIAGNOSES REDACTED]. 1. Resident Status on Admission - Respiratory Risks and Oxygen Therapy - Facility Response According to an admission minimum data set ((MDS) dated [DATE], the resident was cognitively intact scoring a "13" out of "15" on the BIMS (brief interview of mental status). The resident usually understood others and was usually understood. The resident required extensive assistance of one staff person with most activities of daily living and was mobile per wheelchair. The resident was oxygen dependant as coded in section O; O0100(c), oxygen therapy. Additional [DIAGNOSES REDACTED]. Review of a faxed copy (date of fax illegible) of the resident's original admission orders O2 (oxygen) 3L (liters) at rest; 4L (liters) continuously per nasal cannula - check SPO2 (saturation of peripheral oxygen) q (every) shift." Review of an admission nursing assessment dated [DATE], revealed under the section entitled "special treatments and procedures" the words "See TAR (treatment administration record)" was written in. However, further review of the closed record revealed there was no admission TAR found. Review of a physician's admission progress note dated 7/11/12, documented the resident's past medical history in pertinent part, "[MEDICAL CONDITION], CAD, [MEDICAL CONDITION] ([MEDICAL CONDITIONS] and [MEDICAL CONDITION]) ..." In the section entitled "Assessment and Plan" the following was documented: "[MEDICAL CONDITION]; O2 depend (dependant) ..." Although the resident was oxygen dependent, and had orders for continuous oxygen, no care plan was found in the closed record, identifying the resident's need/use of continuous oxygen therapy or direction for the monitoring of or administration of oxygen. 2. Change of Condition Review of the resident's clinical record revealed the resident had a significant (decline) change of condition on 10/5/12. a. Documentation of Initial Changes 10/5/12 -Nurses notes at 5:30 a.m. read, "Resident c/o (complaint of) hurt all over, temp 101.6. Tylenol 1000 mg (milligrams) given." Another note at 6:30 a.m. read, "Temp now 100.8." The above two entries were made by the licensed practical nurse (LPN) working the night shift. There was no further documentation found after the last entry at 6:30 a.m. of any further interventions at this time. There was no documentation the registered nurse (RN) supervisor was notified and the resident's fever and complaint of 'hurting all over' was assessed. b. Documentation of Further Changes 10/5/12 Nurses notes at 9:30 a.m. read, "Res (resident) temp checked at 100.5, APAP ([MEDICATION NAME]) 650 mg (milligram) given PO (by mouth), res has red face and diaphoretic, no c/o (complaint of) pain, is weaker than usual." Nurses notes at 10:30 a.m. read. "...writer able to obtain urine specimen to dip, reads as follows (a copy of an internal recording slip was photocopied on to the nurse note page): leukocytes-Lg (large) ...Protein-trace ...pH 6.5 ...blood - Lg ...SG (specific gravity) 1015 ..." "Res (resident) urine is cloudy and dark, cont (continue) to have red face and be lethargic (nurse practitioner/NP) called from (physician practice group) new order noted to straight cath (catheterize) for urine sample and sent out STAT (immediately)." c. Documentation of Further Decline 10/5/12 Nurses notes at 12:00 p.m. read, "2 person moderate assist to W/C (wheelchair) to DR (dining room) for lunch. Pt sleepy but arousable, sips of apple juice ...6 bites of puree food for lunch. Became increasingly lethargic with incoherent speech. Returned to room; 2 person maximum assist for transfer back to bed." Nurses notes at 1:45 p.m. read, "Respirations noted 7-10 min (minute). Occ (occasional) cough to clear secretions at back of throat. Responds only to sterna rub ...P.O. (pulse ox) 86% 3.5 L (liters) O2 NC (nasal cannula). Breath sounds are clear. In no apparent distress. Call placed to dau (daughter) ....re status/actions (UA collection). Informed we could, with Dr (doctor) orders, do further labs/CXR if indicated. She states she may want (resident) seen in ER (emergency room ) ...She is on her way in to see for herself." Nurses notes at 1:50 p.m. read, "Call to (physician) office with update to (NP). (NP) has not yet spoken with (name of physician). If dau (daughter) wants ER eval - we may do. If she wants labs - CMP/CBC (complete metabolic panel/complete blood count) and no CXR at this time." Nurses notes at 2:25 p.m. "Res (resident) dtr (daughter) came into facility and called 911. Paramedics came and took res (resident) to (name of acute care facility)." A SBAR (Situation, Background, Assessment, Request) form (a tool utilized by the facility to communicate resident change of conditions to physician/NP/PA) dated 10/05/12 at 1:45 p.m., and filled out by the Registered Nurse (RN), documented in pertinent part: The physician's office was contacted at the time above and the reason for the call was the resident had a change in status that started "last eve" with a positive UA (WBC/RBC) (urinalysis with white and red blood cells present) and that it had become worse. -The form documented the resident's vital signs with a fever of 99.6 to 98.1; the form appeared to document the temperature at 98.1 at the time of the call at 1:45 p.m. The resident was described as confused. Her pulse oximetry was documented at 86% on 3.5L (liters) of oxygen via NC (nasal cannula). The RN documented s/he suspected the resident had an infection or dehydration. -Under the "request" section the following was documented: "Labs/CXR and ER (emergency room ) at (name of acute care facility) if family wants." The information was communicated to the NP. 3. Facility Failures in Response to Resident's Change of Condition a. Record Review Review of the nurses notes (see above) on 10/5/12 revealed the entries from 12:00 p.m. through 1:50 p.m. were made by the RN supervisor on duty who, per facility expectations (see above), was responsible for assessing and communicating resident changes of condition. -See nurses notes above; there was no documentation that the RN supervisor assessed the resident's initial change of condition (elevated temperature and complaint of 'hurt all over,' ) or weakness later that morning; there were no other notes until 12:00 p.m.. Finally, there was no documentation (other than vital signs and lung sounds not above) that the RN comprehensively assessed the resident's condition after lunch (increased lethargy, decreased respirations, incoherence) and no documentation to support the RN's comment that the resident was "in no apparent distress." -See nurses notes and SBAR above; there was no documentation the physician was 'immediately notified' of the resident's decline after lunch on 10/5/12. Likewise, there was no documentation the RN contacted the family/responsible party until 1:45 p.m. b. Interview Interviews revealed the resident's needs were not timely addressed on 10/5/12. Specifically, the resident was left unattended for an unknown amount of time after she was documented as being in respiratory distress and a planned intervention was not timely or correctly implemented. (1) On 10/29/12 at 1:20 p.m. the resident's family member was interviewed by phone. -The family member stated on 10/5/12, the RN supervisor called around 2:00 p.m. in the afternoon. The RN supervisor said the resident had a decline in her condition and was having difficulty with her breathing and she reported to the family member that she (RN) was going to place an oxygen mask on the resident to help her breathe better. -The family member stated the RN commented the resident could possibly be dying. The family member said s/he then requested that the resident be sent to the hospital; however, the RN responded that could not be done until the doctor was notified. The family member recalled the RN supervisor stating the resident didn't need to be sent out to the hospital necessarily, and that any treatment could be administered there at the facility just as easily. -The family member stated s/he then told the RN he/she would be on their way to the facility right away. The family member stated that upon arrival at the facility, approximately 25-30 minutes later, the resident was in her room with the door partially closed. No staff was in the immediate area. Upon entering the room, no staff was attending the resident. The resident was lying in bed without an oxygen mask, gasping to breathe and congested. -The family member stated they immediately called 911. A few minutes later, the day nurse entered the room and placed the oxygen mask on the resident without saying a word and left the room. The nurse did not assess the resident's vital signs or respiratory status. The family member said neither the RN supervisor, director of nursing (DON) nor the nursing home administrator (NHA) came to check on the resident's condition before the resident left the facility with the paramedics. (2) On 11/28/12 at 9:52 a.m. LPN #1 was interviewed. -LPN #1 stated he was on duty the day the resident had the change of condition. Although not assigned to care for the resident that day, LPN #1 said he was aware the resident had a change of condition; he recalled she had a fever and was requiring more oxygen. -LPN #1 stated he was not directly involved in overseeing the resident's change of condition but was involved with communicating with the family member present and the paramedics in order to get the resident transported. LPN #1 stated sometime after lunch, a certified nurse aide (CNA) told him the paramedics had arrived to take the resident to the hospital. -LPN #1, when asked if he recalled the resident having oxygen on via a mask, said he knew the resident was to be on oxygen continuously, and had heard from the nurse assigned to care for the resident that she had placed a mask on the resident prior to leaving the unit. LPN #1 said he overheard a paramedic state that the mask the resident had on was the 'wrong one,' because it required at least 10 liters of oxygen or above to be effective. (3) On 11/28/12 at 12:05 p.m. the RN supervisor on duty 10/5/12 was interviewed. -The RN stated she heard in the morning report on 10/05/12 that the resident had a low grade fever and that a urinalysis was obtained. The RN did not recall if the resident's change of condition occurred during the night shift or early on day shift. The RN stated she makes rounds when she comes in after 6:00 a.m. and before the morning meeting at 9:00 a.m. The RN could not recall the resident being in any distress when she first did rounds or if she had a conversation with the nurse at that time regarding the resident. -The RN stated she went back to check on the resident around 11:15-11:30 a.m. She recalled the resident was awake but did not have a lot of energy. She stated she and another staff person assisted the resident to get up to go to the dining room for lunch. The RN stated she assisted the resident to eat but that she was not eating much. The RN stated the resident became increasingly lethargic so she and another staff person assisted the resident back to her room to bed. -The RN stated she checked on the resident every 15 minutes but did not recall documenting these visits. The RN stated there was a point in time that the resident's respirations changed and became slow and apneic (temporary cessation of respirations). -The RN acknowledged the resident was on continuous oxygen via a nasal cannula and said she remembered giving a mask to the primary nurse caring for the resident to place on the resident. The RN stated she left the resident's room after noticing the change in her breathing to call the physician. The RN stated she then called the family. -The RN stated she did not recall telling the family that she would place the mask or the family member telling her they wanted the resident sent out to the hospital; rather, she said the family member wanted to come in and see the resident first. The RN stated she recalled discussing with the family member how aggressive they wanted to be with treatment. -The RN stated she recalled in the conversation with the physician and that he had said to do whatever the family wanted. -The RN stated she had left the unit where the resident resided after the conversation ended with the family member to go to a unit on the other side of the building to do a dressing change on a wound. The RN stated she recalled getting a call on her portable phone about the resident and instructed the primary nurse to get a hold of the assistant director of nursing (ADON). The RN supervisor stated she was not aware of anything that had transpired regarding the oxygen mask until after the resident left the building. (4) On 11/28/12 at 1:55 p.m. a telephone interview was conducted with LPN #2, who was assigned to care for the resident 10/5/12. -LPN #2 stated she had taken care of the resident the day before her decline and that the resident had been fine. LPN #2 stated the morning of 10/5/12, after arriving at 6:00 a.m., she received report from the night nurse that the resident had a fever and was urinating more than usual. LPN #2 stated her first thought was the resident might have a urinary tract infection. LPN #2 stated the resident appeared fine and she took her morning pills without difficulty. -LPN #2 stated she took the resident's vital signs after breakfast and the resident's face was red, she was diaphoretic, lethargic and weak. LPN #2 said she then contacted the RN supervisor to let her know she was going to attempt to get a urine sample from the resident. After doing this, LPN #2 said she noted it was abnormal, called the physician's line and spoke to the NP. She was instructed to do a straight cath procedure to obtain a urine sample to be sent to the lab STAT for analysis. -LPN #2 stated the RN supervisor then came to assess the resident but she did not recall what time the assessment was done, although the RN told her to attempt to get the resident up for lunch which she did. After lunch the resident was placed back to bed and LPN #2 recalled the resident had declined significantly by that time. -LPN #2 recalled the RN supervisor had called a family member after lunch, around 1:45-2:00 p.m. LPN #2 said was subsequently called to another unit to help a CNA. LPN #2 stated on her way back to her unit the RN supervisor handed her a "mask" to go and place on the resident. LPN #2 stated when she entered the resident's room she saw a family member present in the room and they were on the phone. LPN #2 stated she did not bother the family member and simply went over and changed out the resident's oxygen tubing, placing the mask on the resident and putting the liter flow dial to 4 liters. LPN #2 stated she was not aware the mask she had placed on the resident that day (non rebreather) could not be used with the type of oxygen concentrator the resident had in the room at the time. (5) On 11/29/12 at approximately 1:20 p.m., the DON was interviewed regarding resident #1's change of condition on 10/5/12. -The DON stated she recalled the resident was noted to have a spike in temperature right when the night nurse was preparing to end her shift in the early morning of 10/5/12. She said the night nurse gave the resident Tylenol then gave verbal report to the day nurse. She said the resident was a DNR (do not resuscitate), so they were not going to do anything until the family member arrived. -The DON said she was not aware that the family had phone the paramedics after arriving at the facility. She said if the family member had communicated to them their choice to send the resident to the hospital, they would have done so. -The DON was asked if she would have expected the RN supervisor to stay with the resident during her critical change of condition instead of going to another unit to perform a dressing change. The DON stated she felt the RN supervisor acted appropriately and was dealing with another emergent matter and the RN knew the primary nurse was available to care for the resident. -The DON was asked if the primary nurse that placed the oxygen mask on the resident should have stayed with the resident. The DON stated, yes. The DON acknowledged there should have been a care plan in place for the resident's use of oxygen. -The DON also stated the resident's last recorded pulse oximetry reading was 86% on 3.5 liters and that was not unreasonable. The DON then acknowledged at the time of the incident there were two types of oxygen masks in the building (both regular and non-rebreather). The DON stated she had educated the staff (nursing) after the incident regarding proper oxygen equipment usage. 4. Hospital Records a. Review of the resident's triage ER notes and history and physical (H & P) on her ER arrival 10/5/12, documented, in pertinent part, the resident was found at the facility by a family member to be minimally responsive and having difficulty breathing. Upon the arrival of the EMS (emergency medical services), she was found by EMS to be hypoxic and unable to respond appropriately to questions. The resident was documented to have severe symptoms upon (EMS) arrival (at the facility). The EMS reported to the ER staff the resident's oxygen saturation was at 70% when they arrived on scene and the resident was receiving 4L (liters) of oxygen via a non-rebreather mask (a device used to deliver a high flow of oxygen and contains a reservoir bag with a one-way valve to prevent exhaled air from returning to the bag, see; www.nursingcenter.com <http://www.nursingcenter.com>). The ER physician documented the resident presented with altered mentation and agonal respirations. The nursing assessment documented the resident arrived at 2:50 p.m. with dyspneic breathing of 6-8 breaths per minute and unresponsive to verbal stimulus; lethargic and with increased respiratory effort. Review of an ER vital sign sheet documented the resident required 10-15L (liters) of oxygen via non rebreather mask from the time she arrived to the ER until approximately 8:00 p.m. per the flow sheet. b. Attending Physician Report Review of an attending physician H & P dated 10/06/12 documented the following impressions: "...acute [MEDICAL CONDITION] ...I suspect that this patient was in a tenuous state from her underlying urinary tract infection and her concomitant respiratory issues ...I think the overall contributing factor to the [MEDICAL CONDITION] is urinary tract infection with some toxicity, but not [MEDICAL CONDITION] ..." "...acute on chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] with a history of severe [MEDICAL CONDITION] hypertension ...continue respiratory therapy protocol ..." C. Resident #2 Resident #2, age 70, was originally admitted to the facility on [DATE], according to the patient information sheet dated 11/16/12. She was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Residents status MDS: According to the minimum data set ((MDS) dated [DATE], resident #2 was independent with her bed mobility, transfers, ambulation (with the use of a cane), and toileting needs. She was continent of both bowel and bladder. She was usually understood and usually able to understand others. Resident #2 had a history of [REDACTED]. According to the brief interview for mental status (BIMS) dated 9/21/12, resident #2 had a cognitive status of being moderately impaired. Care plan: Care plan review revealed that resident #2 was care planned 7/13/10 for: -'Alteration in comfort' as evidenced by complaints of lower extremity discomfort, a history of lower extremity [MEDICAL CONDITION], and [MEDICAL CONDITION]. The care plan failed to indicate that resident #2 has a history of buttock pain, hip pain, or groin pain (see below). -'Activities of daily living' and required occasional supervision/cueing. The care plan failed to indicate that resident #2 had a history of [REDACTED]. (see below) -'Aggression and agitation' but did not have a history of inaccurately reporting pain issues 'Thought disorder' but no history of delusional or disorganized thinking when it came to reporting pain issues. (see below) 2. Fall 11/9/12. Resident incident /accident reports: According to resident #2's incident/accident report dated 11/9/12, the resident had an unattended fall in the facility TV room at 7:30 p.m. The resident was observed lying on her right side, she stated that she "hit her head" , and her "buttocks hurt." Resident #2 was alert and oriented times two out of three (person, place, and time), with no apparent injury noted. The incident report indicated that a message was left with the physician's answering services on 11/9/12 at 7:45 p.m. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the MAR indicated [REDACTED]'as needed' pain medication on 11/9/12. Upon review of the back of the MAR, the 'as needed' medication was given to resident #2 at 8:30 p.m. for hip pain that the resident rated at 8/10 (10=unbearable pain). Review of the 11/12 MAR, prior to 11/9/12, revealed the resident consistently rated her pain at a 0 out of 10 and had not received any as needed pain medication. 3. Failures to thoroughly assess resident's change of condition following her fall on 11/9/12 and as new symptoms were documented. a. Lack of a comprehensive initial assessment after a fall Although the resident's fall was unwitnessed, the resident stated she hit her head, and the resident complained of buttocks pain, review of the nurses note revealed no comprehensive assessment of the resident's initial condition following the incident, specifically, physical assessment of the resident's buttocks, hip, and head, including detailed neurological findings, as well as an assessment of the resident's pain which had been documented in the incident report and MAR (see above). Specifically: A nurses note by the LPN dated 11/9/12 at 8:30 p.m. indicated that resident #2 had a slightly elevated temperature, elevated respirations, and an elevated blood pressure. The nursing note read that at 7:30 p.m., the certified nurse aide (CNA) had reported to the LPN that resident #2 fell in the TV room. The registered nurse (RN) supervisor was notified and assessed resident #2 range of motion, and neurological status; both were noted to be at the resident's baseline. The resident reported hitting her head. Neurological assessments for resident # 2 dated 11/9/2012 were not available when requested of the Director of Nurses (DON) on 11/28/12 at approximately 2:30 p.m. b. Lack of ongoing assessments after fall 11/9/12 Review of the nursing notes for 11/9/12 revealed no further assessment of the resident's "buttock" and or hip pain being documented after resident was medicated with as needed medication at 8:30 p.m. However; resident was on scheduled pain medications given at 8:00 a.m., 12:00 p.m., and 6:00 p.m. 11/10/12 Another nurses note dated 11/10/12 (with no time indicated), stated that resident #2 continued with an elevated blood pressure, and she was on incident follow up after an unwitnessed fall. Resident #2 was medicated for coccyx pain once with positive results. Resident #2 was up for lunch and to the bathroom with her walker. Range of motion was within normal limits, but a bit stiff, the resident denied pain or discomfort at that time. The nurses note failed to indicate whether or not the nurse used the resident's scheduled medications or her as needed pain medication but the MAR indicated [REDACTED]. Another nurses note dated 11/10/12 at 4:30 p.m. stated that resident #2 continued with an elevated blood pressure, and she was on incident follow up after an unwitnessed fall. The resident was moving/walking slowly today, asking for assistance to stand up. Resident #2 was pushing her call light and turning it off continuously throughout the day. Resident complained of pain to her "crotch" or "groin" prior to her scheduled pain medication. Once resident #2 was medicated with pain medications, she stated "its feeling better" . The pain assessment on the MAR indicated [REDACTED]. Despite documentation of the onset of additional new symptoms (asking for assistance to stand, pushing call light throughout the day, complaining of pain), there was no documentation that the resident's status, buttocks, hip and head, as well as complaints of pain were comprehensively assessed. There was no documentation that the physician was notified regarding the resident's complaint of groin pain. 11/11/12: According to incident report dated 11/11/12 at 6:15 a.m. resident #2 was in her room, unattended, and weak prior to her fall. Resident #2's roommate went to the nurses station to report that her roommate was on the floor. Resident #2 stated she thought it was time to get up and she was feeling weak. The resident was noted to have a hematoma to her left hip possibly from a fall on 11/9/12, and [MEDICAL CONDITION] noted in bilateral lower extremities. An x-ray was obtained at the facility on 11/11/12 at 1:00 p.m. and indicated a "likely left femoral neck fracture." Resident was sent to the hospital for evaluation and treatment. 4. Staff interviews The RN supervisor was interviewed on 11/28/12 at 12:35 p.m. She stated that if a resident had fallen on a previous day and was complaining of groin pain and it was persistent, she would expect the LPN to monitor and assess the resident. If the resident was not responding to treatment she would then expect the LPN to call the RN supervisor to assess the resident. The DON was interviewed at approximately 2:30 p.m. on 11/28/12. The DON stated with a new onset of pain after a fall, she would have expected the nurse to investigate the change further, notify and discuss with the nursing supervisor, and to have notified the physician if the change was new and unusual. The DON agreed that she would expect the RN supervisor to enter a note in the resident's chart, if the RN supervisor completed an assessment on the resident.