Every finding on record at Health Center at Franklin Park

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of three medication carts.Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. Facility policy and procedureThe Medication Storage policy, dated 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.II. ObservationsOn 3/26/26 at 8:30 a.m. medication cart #2 on the second floor was observed with registered nurse (RN) #1. The following items were found:There was one umeclidinium-bromide (Incruse Ellipta) inhalation aerosol powder breath activated 62.5-25 micrograms (mcg) per actuation (mcg/act) inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident's name or the date the medication was opened for Resident #7.There were two bottles of polyethylene glycol-propylene glycol (Systane) 0.4 percent (%) ophthalmic (eye) drops stored in appropriately labeled medication boxes.-However, the individual medication bottles inside the boxes were not labelled with the resident's names or the dates the medications were opened for Resident #6 or Resident #7.There was one bottle of Biotene dry mouth moisturizing spray (artificial saliva) stored in an appropriately labeled medication box.-However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #7.There was one umeclidinium-vilanterol (Anoro Ellipta) inhalation aerosol powder breath activated 62.5-25 mcg/act inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the resident's name or the date the medication was opened for Resident #25.On 3/26/26 at 8:40 a.m. medication cart #1 on the first floor was observed with licensed practical nurse (LPN) #4. The following items were found:There was one bottle of morphine sulfate 20 milligram per milliliter (mg/ml) oral solution stored in an appropriately labeled medication box.-However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #28.There was one vial of insulin lispro injection solution stored in an appropriately labeled medication box.-However, the individual medication vial inside the box was not labelled with the resident's name or the date the medication was opened for Resident #18.III. Staff interviewsRN #1 was interviewed on 3/26/26 at 8:30 a.m. RN #1 said medications should be labelled inside their respective boxes. She said it was important for the medications to be labelled inside the boxes in case the box was damaged.LPN #4 was interviewed on 3/26/26 at 8:40 a.m. LPN #4 said it was important for medications to be labelled inside their respective boxes because the medication inside could become separated from its box. He said an unlabelled medication without its box could potentially cause a medication error.The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 3/26/26 at 1:33 p.m. The DON said medications should be labelled inside their respective boxes. She said it was important for the medications to be labelled inside the boxes in case the box was damaged. The DON said a damaged medication box could become an infection control risk. The DON and the ADON said an unlabelled medication without its box could potentially cause a medication error because the nursing staff would not know who the medication belonged to.IV. Facility follow-upDuring their respective interviews on 3/26/26 at 8:30 a.m. and at 8:40 a.m. (see staff interviews above), RN #1 and LPN #4 used a Sharpie marker and labeled the identified items in their medication carts with the residents' names and the dates the medications were opened.-However, the medications were not labeled in a manner consistent with professional standards until the concern was brought to the attention of the facility during the survey.

Based on observations and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for three of five emergency (crash) carts.Specifically, the facility failed to:-Ensure staff completed daily equipment checks;-Ensure expired items were removed from the crash cart;-Ensure missing items were replaced on the crash cart; and,-Ensure staff had knowledge of which electrical outlets were connected to the emergency backup generator. Findings include:I. Professional referenceAccording to [NAME], [NAME], May 2022, retrieved on 3/30/26 from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review,A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency.A crash cart is typically located in the setting of an unexpected medical emergency. This could include severe allergic reaction, cardiac or respiratory arrest, and conditions with an unexpected sudden deterioration of vital signs. This would require equipment located on the crash cart which would be used by a credentialed life support provider. While crash carts vary depending on location, the fundamentals for the crash cart will contain similar equipment.Although the organization of requirements for a crash cart is not generic, there is a fundamental standard which provides effortless access to emergency medical equipment. Note that all these organizational points are checked, dated, and signed by the staff member who performed the daily routine inventory and inspection.Top shelf/drawer: the top section typically has the most frequently used equipment employed in a resuscitation event, such as power cords and personal protective equipment.Side or rear: the oxygen cylinder should be secure on the side of the cart, with a full oxygen pressure level; a suction apparatus/charging battery for the portable use; a sharps container should be secure on cart; and, a rigid plastic/fiberglass backboard for chest compressions.Recommended equipment and medications: organization and location specific.Recommended maintenance: check expiration dates on equipment and medications per organization policy and replace as required.Schedule inventory check. The purpose of a crash cart inventory is to organize a schedule of when to check for expiration dates of equipment and supplies.Check that equipment is operating as required in the event of an emergency. In addition to recording who performed the inventory checks, with dates, times, and signatures. An alarming situation for the healthcare personnel requiring a crash cart is to find unusable equipment or expired medications in an emergency. Ensuring that an up-to-date, accurate, and truthful inventory record can avoid potential patient safety situations such as absence of equipment, equipment failure, expired or missing medication, and empty oxygen cylinders.The patient safety risk incident failure to rescue is perpetrated by healthcare professionals when they do not check cart accurately. Failure to follow standard or policy for checking equipment compromises patient safety and creates potential to harm patients.II. Facility policy and procedureThe Emergency Crash Cart and Automated External Defibrillators (AEDs) policy, dated 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It read in pertinent part, It is the policy of this facility to ensure that the facility will maintain at least one emergency cart per nursing care floor with additional carts added as deemed necessary in the case of the need for basic life support. In addition, the facility will ensure that at least one AED (automated external defibrillator - a portable, life-saving device used to treat sudden cardiac arrest), if available, is for use in the case of cardiac emergencies. Equipment/supplies used from the emergency crash cart are noted and replaced promptly. The emergency crash cart is checked every 24 hours and after every use. Missing or expired items are replaced, when applicable. Nursing staff should be familiar with the contents located on and within the emergency crash cart.III. Observations and staff interviewsThree of the facility's crash carts were observed on 3/24/26. The observations revealed the following:At 1:06 p.m. there was no stethoscope, crash cart check-off log or oxygen tank key (to turn on the oxygen tank) present in the dining room crash cart on the first floor.At 1:11 p.m. there was no stethoscope, backboard or medical grade extension power cord present in the dining room crash cart on the second floor. The crash cart was not near an electrical outlet that indicated it was connected to the backup generator. There was a clipboard which held crash cart checklists that were dated July 2023.An unidentified staff member was interviewed on 3/24/26 at 1:15 p.m. The staff member said there was one crash cart located on floors one, two and three. He said the crash carts were located in the dining room.At 1:20 p.m. there was no backboard present in the crash cart on the third floor.Certified nurse aide (CNA) #3 was interviewed on 3/24/26 at 1:23 p.m. CNA #3 said if the backboard was missing from the crash cart, she did not know where it might be.The same three crash carts were observed on 3/25/26. The observations revealed the following:At 2:10 p.m. there was no oxygen tank key present in the dining room crash cart on the first floor. There was a March 2026 crash cart check-off log, which revealed the cart was audited on 3/24/26 (during the survey), and a stethoscope present.-However, the stethoscope and the crash cart check-off log were not present in the initial observation of the cart on 3/24/26 (see observation above).At 2:14 p.m. there was a backboard, March 2026 crash cart check-off log which revealed the cart was audited on 3/24/26 (during the survey), and a stethoscope present in the dining room crash cart on the second floor.-However, the backboard, the March 2026 crash cart check-off log and the stethoscope were not present in the initial observation of the cart on 3/24/26 (see observation above). -There was still no medical grade extension power cord present in the crash cart.Additionally, the following expired supplies were found in the dining room crash cart on the second floor:There were two 20-inch length non-conductive connection tubes (connects the suction machine to the Yankauer suction tip) with expiration dates of 5/1/22 and 6/1/22. There was a Yankauer suction tip (a firm, rigid catheter used to clear oral secretions) with an expiration date of 9/5/22.At 2:21 p.m. there was a backboard present in the third floor crash cart.-However, the backboard was not present in the initial observation of the cart on 3/24/26 (see observation above).The second floor dining room crash cart was observed with registered nurse (RN) #1 on 3/25/26 at 2:28 p.m. RN #1 said it was the night nurses' responsibility to complete the crash cart log and ensure the crash cart had all of the required emergency supplies on a nightly basis. She said the nurse who checked the crash cart should have attempted to turn on the suction machine to make sure it worked properly. RN #1 said it was important for the backboard to be included with the crash cart because a firm, flat surface was needed beneath the resident in order to provide effective chest compressions.RN #1 said she did not know which electrical outlets were connected to the backup generator. She said she knew where the nearest outlet to connect the suction machine to electrical power in the dining room was located.The second floor dining room crash cart was observed again with the director of nursing (DON) on 3/25/26 at 2:40 p.m. The observation revealed the following:There were two 20-inch length non-conductive connection tubes with expiration dates of 5/1/22 and 6/1/22. There was a Yankauer suction tip with an expiration date of 9/5/22.The DON said she did not know if the outlets in the second floor dining room were connected to the emergency backup generator. She said it was important to have a backboard on the crash cart in order to give effective compressions during cardiopulmonary resuscitation (CPR). The DON said the first day she worked at the facility was the first day of the recertification survey. She said one of the first things she identified that needed to be updated in the facility were the emergency crash carts. The DON said effective immediately, the crash carts needed to be checked nightly by the charge nurses to ensure the oxygen tanks and suction machines functioned properly, missing equipment was replaced and expired supplies were removed from the carts. She said she would not expect to see expired equipment on the crash carts if they were audited consistently.The assistant director of nursing (ADON) was interviewed on 3/26/26 at 3:05 p.m. The ADON said there were a total of five crash carts in the facility. She said there was one crash cart on the third floor and there were two crash carts located on the first and second floors, respectively.-However, staff members were not clear on the number or locations of the emergency crash carts within the facility (see interview above).The DON was interviewed a second time on 3/25/26 at 3:57 p.m. The DON said she spoke to the maintenance director (MTD) and he was ordering a 15-foot electrical extension cord for the second floor dining room. She said she did not know if the electrical power cord the MTD ordered was a medical grade extension cord, but she said she would make sure it was. The DON said she contacted the facility's fire safety contractor to get an estimated date for project completion to make sure there were electrical outlets that were connected to the backup generator.The NHA provided a receipt for the 15-foot medical grade electrical extension cord on 3/25/26 at 7:54 p.m. She also provided communication from the electrical contractor, which said the contractor would be at the facility on 3/27/26 for identification and labelling of the facility's emergency electrical outlets.The DON was interviewed a third time on 3/26/26 at 9:50 a.m. The DON said the MTD notified her that the medical grade electrical extension cord would be delivered on 3/27/26. She said in the meantime, a heavy-duty extension cord had been placed in the second floor dining room crash cart. The DON said the MTD would exchange the heavy-duty extension cord for the medical grade extension cord when it arrived.-However, the crash carts were not maintained in safe operating condition until the concern was brought to the attention of the facility during the survey.

Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.Findings include: I. Professional referenceAccording to the National Certification Council of Activity Professionals (NCCAP) (2023), retrieved on 3/31/26 from www.nccap.org, an activity director must meet specific qualifications in education, certification and/or experience,The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the state in which practicing; and,-Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or,-Has two (2) years of experience in a social or recreational program within the last 5 (five) years, one of which was full-time in a therapeutic activities program; or,-Is a qualified occupational therapist or occupational therapy assistant; or,-Has completed a training course approved by the state.An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes completion of the activities component of the comprehensive assessment; contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident.II. Facility policy and procedure The Activities Director Qualifications policy and procedure, revised 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It read in pertinent part, The activities director, at a minimum, shall meet the following qualifications: licensed or registered by the state in which practicing and one or more of the following: eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or has two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program; or is a qualified occupational therapist or occupational therapy assistant; or has completed a training course approved by the state.III. Record review The key personnel list was provided by the NHA on 3/23/26 at 3:34 p.m. Review of the staff list revealed an activity director (AD). -However, the NHA was unable to provide documentation that the AD had been enrolled in or had taken the required courses to be considered a qualified activity director. -Additionally, the NHA was unable to provide documentation that the facility had employed an activity consultant to provide oversight to the activities department.Activity records for Resident #19 revealed the residents' records were completed by the AD.Cross-reference F679 for lack of meaningful activity programs. IV. Staff interviews The AD was interviewed on 3/26/26 at 12:31 p.m. The AD said she started working at the facility in September 2025 and this was her first activities position. She said she had never worked in a nursing facility prior to working in the facility. She said she knew she had to take a course to become a qualified AD, but she had not started the course yet. She said she did not have an activities consultant to help her. She said she was the AD and she was responsible for planning the activities calendar for the facility's residents. The NHA was interviewed on 3/26/26 at 3:05 p.m. The NHA said the AD did not fit the requirements for an AD. The NHA said she thought as long as the AD was enrolled in a course, the facility met the requirements. The NHA said she would work to ensure the AD was supported by an activities consultant while taking the AD qualification course.

Based on observations, interviews and record review, the facility failed to provide activities designed to support residents' physical, mental and psychosocial well-being were provided for one (#10) of four residents reviewed for meaningful activity programming activities out of 32 sample residents and on one of three units.Specifically, the facility failed to:-Offer and provide a personalized activity program for Resident #10;-Ensure Resident #10 was invited and encouraged to attend activities of the resident's preference; and,-Ensure a meaningful activities program was consistently provided to residents residing in the facility's secured dementia care unit.Findings include: I. Facility policy and procedure The Activities policy, revised 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It revealed in pertinent part, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident as well as support their physical, mental, and psychosocial well-being. Each resident's interest and needs will be assessed on a routine basis, including activity assessments to identify resident preferences and needed adaptations. Activities will include individual, small and large group activities as well as individualized activities. II. Failed to offer and provide a personalized activity program for Resident #10 and ensure the resident was invited and encouraged to attend activities of the resident's preference A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included dementia with agitation, frontotemporal neurocognitive disorder (affects behavior and ability to participate in care) and history of falling. The 1/2/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He required substantial assistance with eating, walking, bathing and dressing. B. Observations On 3/23/26 at 9:40 a.m. Resident #10 was sitting in a reclining chair by the nurses' station. There were several other residents next door in the common area who were participating in activities and some residents were watching television. Registered nurse (RN) #2 was at the nurses' station and did not offer to see if Resident #10 wanted to participate in activities. On 3/23/26 at 1:24 p.m. Resident #10 was sitting at the nurses' station napping while other residents were next door in the common area watching television. There were two staff members present at the nurses' station, including RN #2, who were seated nearby. -No staff members engaged with Resident #10 or offered activities to the resident. On 3/23/26 at 4:09 p.m. Resident #10 was sitting by the nurses' station in the recliner chair with periods of being asleep and awake. -No staff members engaged with Resident #10 or offered activities to the resident. On 3/24/26 at 8:48 a.m. Resident #10 was sitting at the nurses' station in a recliner while other residents participated in activities next door in the common area. Resident #10 was positioned next to the wall. The wall blocked his view of the common area and he was unable to participate passively in the activity. On 3/24/26 at 11:02 a.m. Resident #10 was sitting in the recliner chair near the nurses' station holding one of his shoes in his hand, with the other shoe positioned underneath his right thigh. There were several other residents in the room next to him who participated in activities using a balloon and hitting it back and forth with the activity staff. -No staff members engaged with Resident #10 or offered for the resident to participate in the balloon activity. During a continuous observation of Resident #10 on 3/24/26, beginning at 12:23 p.m. and ending at 3:25 p.m., the following was observed: At 12:23 p.m. Resident #10 was sitting in a recliner by the nurses' station with no engagement from staff, despite several staff members passing by him. At 12:37 p.m. activity staff members were observed taking residents from the common area outside for ice cream. Resident #10 remained in the recliner chair by the nurses' station. -No staff members offered to take the resident outside, bring him ice cream or interact with him. At 1:08 p.m. an unidentified staff member asked Resident #10 if he needed anything. The resident did not respond and continued to nap. At 1:34 p.m. certified nurse aide (CNA) #4 patted the resident on the leg and called his name. CNA #4 did not engage further with the resident and did not offer the resident in activities. At 1:57 p.m. Resident #10 was observed sitting in a recliner. CNA #2 was standing nearby, but did not interact with the resident. At 3:13 p.m. Resident #10 was observed pulling on his pajamas and intermittently extending and flexing his legs. No staff members interacted with the resident to determine if he needed anything. On 3/25/26 at 1:45 p.m. Resident #10's room was observed for bedside objects to provide spiritual comfort to resident, according to the care plan. There were no spiritual objects present in the resident's room (see care plan below). C. Record review The activities care plan, initiated 6/20/24 and revised 8/18/25, documented that Resident #10 had an activity deficit that may be related to dementia. It documented that he was friendly, could socialize with others when given enough time to respond and could passively participate in activities but needed assistance to and from group activities. It documented that he would need encouragement to participate in at least two group activities or one-to-one activity visits of his choice each week, he would remain relaxed and comfortable during activities, and verbalize enjoyment. Interventions included assisting him to activities of his choice and inviting, encouraging, reminding and escorting him to activities consistent with his interests. The spiritual needs care plan, initiated 1/21/25 and revised 1/15/26, documented that Resident #10 was unable to express his beliefs or feelings of religion. It documented that the chaplain engaged with him daily at the nurses' station. Interventions included arranging the resident's room to have at the bedside objects that provided the resident spiritual comfort. Review of the resident's March 2026 activity attendance record revealed Resident #10 had not attended any activities, except on 3/26/26, and there were no refusals of activities documented. D. Staff interviews Activity assistant (AA) #1 was interviewed on 3/25/26 at 11:38 a.m. AA #1 said she had worked at the facility for five months. She said activities appropriate for Resident #10 included sensory activities, such as puzzles, listening to music, watching movies, and exercise such as walking. She said these activities were provided daily, five times per week. AA #1 said when Resident #10 was sitting at the nurses' station, she would encourage him in the morning and tell him what activities were planned for the day. She said if the resident did not attend group activities, he received one-to-one activities visits on Thursdays for approximately 25 to 30 minutes, which included walking and going outside. She said Resident #10 was offered activities daily and often declined, and said refusals were documented in the activities attendance record (see above attendance record). She said she was the only activities staff member working on Mondays and was responsible for activities on all three floors, which made it difficult to manage activities. She said she brought residents from the second and third floors to the first floor for participation. The activity director (AD) was interviewed on 3/26/26 at 12:30 p.m. The AD said activity staff were assigned by floor, with one coordinator leading activities on the first floor in the main activity room and another coordinator going to each floor to encourage resident participation. The AD said a resident council meeting was held monthly and resident suggestions were incorporated into activities. The AD said the chaplain was on military duty this month and activities staff were responsible for providing updates to residents regarding changes in activities. The AD said appropriate activities for Resident #10 included listening to music, aromatherapy, engaging with fidget items, conversation and walking with assistance from restorative services. The AD said when Resident #10 was seated at the nurses' station, staff should approach him by greeting him, getting to his eye level and asking if he wanted to join an activity. The AD said one-to-one activities visits were provided weekly for the resident for approximately 20 to 30 minutes and included walking outside. She said a walking group was planned for the residents the following month (April 2026). The AD said staff were expected to invite each resident to activities and it was important to ensure residents were given choices because it made the residents feel cared for. The AD said staff were educated to document when activities were offered and when residents refused participation. The AD said the restorative aide was not present on Monday 3/23/26, which affected the level of resident engagement. CNA #5 was interviewed on 3/26/26 at 2:05 p.m. CNA #5 said she was with restorative therapy and had worked with Resident #10 extensively. CNA #5 said restorative services worked with Resident #10 on ambulation three times per day for approximately 15 minutes per session. She said sensory items, including a pop fidget (sensory toy with bubbles) and blanket device were provided for engagement for the resident. She said if sensory items were not provided, the resident would engage with his shoes instead. She said she had not worked in the facility this week until today (3/26/26) and she expected other staff members to offer comfort items and activities to residents when she was out of the building. III. Failed to ensure a meaningful activities program was consistently provided to residents residing in the facility's secured dementia care unit A. Resident interview and observation Resident #19 was interviewed on 3/23/26 at 3:00 p.m. in his room. Resident #19 said there were no activities and he wanted to go outside. Resident #19's room was observed and there was no activities calendar observed in the room. Resident #19 said he did not know when activities were scheduled. Resident #19 was shown the activities calendar in the hallway leading to the common area of the secured unit. Resident #19 said he did not know that was the activities schedule. B. Observations During a continuous observation of the facility's secured behavior and dementia care unit on 3/24/26, beginning at 11:55 a.m. and ending at 1:38 p.m., the following was observed. The activities calendar revealed that there was an event titled Celebrate Anything Day scheduled to begin at 12:30 p.m. No staff were observed gathering residents to attend the event. The residents were observed sitting in chairs in the television (TV) room and sitting at the dining room tables of the common area. The residents' eyes were open and staring straight ahead. -However, the scheduled activity did not occur (see observations below). At 12:08 p.m. AA #1 sat next to Resident #19, who was sitting in the unit's common area. AA #1 did not engage with any other residents in the common area. At 12:41 p.m. AA #1 offered for some residents to go outside for ice cream. AA #1 did not offer for all residents to go outside or to have ice cream. There were no leisure materials available on the tables, no leisure activities were offered to any of the residents and there were no organized group activities offered during the observation period. At 1:35 p.m. CNA #6 sat in a chair in the TV room and started leg exercises. CNA #6 tried to engage all residents sitting in the TV room. Several residents started to participate. During a continuous observation of the facility's secured behavior and dementia care unit on 3/25/26, beginning at 9:37 a.m. and ending at 11:08 a.m., the following was observed: The activities calendar revealed that there was an event titled House of [NAME] scheduled to begin at 10:15 a.m. No staff were observed gathering residents to attend the event. Six residents were observed sitting in chairs in the TV room and sitting at the dining room tables of the common area. -However, the scheduled activity did not occur (see observation below). At 10:52 a.m. AA #1 came to the secure unit and told CNA #6 that after lunch she would take some residents outside. There were no leisure materials available on the tables, no leisure activities were offered to any of the residents and there were no organized group activities offered during the observation period. C. Record review Resident council meeting minutes were reviewed from October 2025 through February 2026. The October 2025 resident council meeting minutes revealed residents requested one-on-one activity visits, to go to the art museum and a Hanukkah party. The November 2025 resident council meeting minutes revealed residents requested games, such as Hangman, Jeopardy and Family Feud. The minutes additionally revealed a request from residents to hire weekend activity help. The February 2026 resident council meeting minutes revealed residents requested more assistance for bingo and group activities. The March 2026 activities calendar was reviewed. It revealed activities started at 8:30 a.m. with news and brews, rummy, or chess and checkers. Other activities included dress like a movie character, air hockey and bingo. Each day of the week had at least two activities scheduled. -However, group and individual activities were not observed occurring in the secure dementia care unit. D. Staff interviews CNA #6 was interviewed on 3/26/26 at 12:26 p.m. CNA #6 said the activities department was responsible for carrying out the activities in the secure unit. She said activities staff came and asked almost everyone to attend group activities located in the other units. CNA #6 said besides the activities scheduled on the calendar, residents could go outside, dance to music, color and tie dye shirts. CNA #6 said independent activities to keep residents engaged included watching TV, specifically the news and spending time with other residents. The activities director (AD) was interviewed on 3/26/26 at 12:31 p.m. The AD said she started working at the facility in September 2025. She said she had three staff members plus herself in her department. She said she had two full-time activities staff members and one part-time staff member. She said her staff was scheduled to work either Sunday to Thursday or Tuesday to Saturday from 7:30 a.m. to 3:30 p.m or 8:00 a.m to 4:00 p.m. She said the evening activities were independent leisure activities because most residents were in bed and residents wanted activities to start early in the morning. The AD said she was fully staffed. The AD said she balanced activities for three units, including a secured unit carefully. She said when she had two staff schedules, she had one activities staff member leading the event while the other activities staff member was responsible for engaging with those residents not attending the activities. The AD said it was important for the support activities staff member to be on the third floor, the secure unit, because not a lot of the residents attended the group activities. The AD said the support activities staff member should go to the other floors to invite the residents. The AD said residents were informed about activities with the morning reminder and approximately 15 minutes to 30 minutes prior to the scheduled event, the activities staff should remind and gather the residents for the group activity. The AD said when residents sat idle in common areas, residents should watch television, read and play games, such as checkers, Uno and canasta. The AD said there were tools for residents to draw, complete crossword puzzles and do word searches. The AD said on 3/25/36 at 10:30 a.m. there was a House of [NAME] event and the support activities assistant should have invited residents on the secure unit to attend. The AD said she did not know why residents were not invited and she did not know why residents on the secured unit were not offered leisure activities.

Based on record review and interviews, the facility failed to ensure two (#28 and #55) of five residents were free from chemical restraints out of 32 sample residents.Specifically, the facility failed to: -Ensure Resident #28's representative was informed of the facility's decision to implement a gradual dose reduction (GDR) after the pharmacist and the physician recommended a GDR of the resident's Zyprexa (antipsychotic medication);-Ensure Resident #55's antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary team (IDT); and, -Ensure Resident #55's care plan included resident-specific non-pharamacological care approaches for the resident's behaviors.Findings include: I. Facility policy and procedure The Gradual Dose Reduction (GDR) of Psychotropic Drugs policy, revised on [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 11:47 a.m. It read in pertinent part, Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs. Gradual Dose Reduction refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. Opportunities during the care process to consider whether medications should be continued, reduced, discontinued, or otherwise modified included during the monthly medication regimen review by the pharmacist, when the physician or prescribing practitioner evaluates the resident's progress, and during the quarterly MDS (minimum data set) assessment review by the interdisciplinary team (IDT). II. Failed to ensure Resident #28's representative was informed of the facility's decision to implement a gradual dose reduction (GDR) after the pharmacist and the physician recommended a GDR of the resident's Zyprexa (antipsychotic medication) A. Resident status Resident #28, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included dementia unspecified severity with other behavioral disturbance, bipolar disorder, and weakness. The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. She was dependent on staff for assistance with toileting, bathing and dressing. The MDS assessment indicated the resident did not exhibit verbal or physical behavior toward others, reject care or wander. B. Resident #28's representative interview Resident #28's representative was interviewed on [DATE] at 9:56 a.m. Resident #28 said the facility did not discuss decreasing the dose of the resident's antipsychotic medication, Zyprexa, during the resident's care conference on [DATE]. Resident #28's representative was interviewed a second time on [DATE] at 2:22 p.m. The representative said if the pharmacist and the physician recommended a dose reduction of the resident's medication, she would agree to decrease the dose. She said she would wait for the facility to contact her. She said she often visited Resident #28 and the resident was very sleepy. She said the last time she visited her was on [DATE], and the resident was very sleepy and it could have been due to her Zyprexa. C. Observations On [DATE] at 8:48 a.m. Resident #28 was sleeping in her bed in her room. On [DATE] at 11:02 a.m. Resident #28 was sleeping in her bed in her room. On [DATE] at 12:23 p.m. Resident #28 was sleeping in her bed in her room. D. Record review The [DATE] CPO revealed the following physician's orders: Olanzapine (Zyprexa) oral tablet 10 milligrams (mg) by mouth in the evening for dementia, ordered [DATE]. Review of the [DATE] consultant pharmacist recommendation revealed the pharmacist recommended a GDR of olanzapine from 10 mg to 7.5 mg for Resident #28. The physician agreed with the recommendation on [DATE] and documented for staff to confirm the GDR with the resident's representative prior to implementation. Review of the [DATE] physician progress note documented the facility consultant pharmacist requested a Zyprexa (olanzapine) GDR for Resident #28. The physician documented Resident #28 had no recent behaviors on the current medication regimen and staff were to reach out to the resident's representative to discuss the GDR. Review of the [DATE] and [DATE] physician progress notes revealed the resident remained on Zyprexa (olanzapine) with no recent behaviors and staff were to reach out to the Resident #28's representative to confirm the changes prior to implementing the GDR of the medication. Review of the [DATE] care conference revealed Resident #28's medication was reviewed and no changes were identified. -However, the resident's representative said the GDR of the resident's olanzapine medication was not discussed with her in the care conference (see resident's representative interview above). -There was no documentation in Resident #28's electronic medical record (EMR) to indicate the resident's representatives were informed of the olanzapine GDR. -A second review of Resident #28's [DATE] CPO on [DATE] revealed the physician's orders were updated to decrease olanzapine to 7.5 mg by mouth in the evening, ordered [DATE] (over a month after the pharmacist and the physician recommended the GDR and directed staff to speak with the resident's representative about it). E. Staff interviews The social services director (SSD) was interviewed on [DATE] at 10:02 a.m. The SSD said she had worked at the facility for three years. She said during the care conference for Resident #28 on [DATE], both of the resident's representatives were present and the team should have reviewed the resident's medications. She said she reviewed the Medical Orders for Scope of Treatment (MOST) form and the director of nursing (DON) or the assistant director of nursing (ADON) was responsible for communicating medication changes and dose reductions to the representatives. She said the issue with not discussing the medication reduction with the representatives was that the resident would have benefited from a dose reduction and she said she would speak with the ADON regarding this. The ADON was interviewed on [DATE] at 10:09 a.m. The ADON said nursing staff was responsible for sending the pharmacist's recommendation for a GDR to the physician and once the physician agreed, the orders for the dose reduction were implemented. She said nursing staff was supposed to contact the resident's representative regarding Resident #28's GDR of olanzapine so they could make a decision. She said the previous DON should have discussed the GDR during the care conference on [DATE]. She said she could not participate in the care conference on [DATE]. She said it was important the medication be reduced because the physician had determined the dose should be decreased and it could be dangerous for the resident if she was not receiving the right dose. The DON was interviewed on [DATE] at 10:20 a.m. The DON said she started working at the facility on [DATE]. She said the facility tracked dose reductions through pharmacy recommendations, implementation and follow-ups with the physician. She said the pharmacy recommendation for reduction of Resident #28's olanzapine was not followed through on and staff education would be provided to ensure recommendations were tracked and followed through. She said after the pharmacist recommended a dose reduction, the resident's family needed to be notified. She said the facility would do more to collaborate to ensure family notification about GDRs occurred. She said she would call Resident #28's representative to determine what decision would be made about reducing the resident's olanzapine. Certified nurse aide (CNA) #1 was interviewed on [DATE] at 11:09 a.m. CNA #1 said Resident #28 had no behaviors except during care when being changed. She said the behaviors did not occur frequently and happened once in a while. She said the resident became agitated, threw her arms and calmed down with reassurance. She said she would report the behavior to the nurse and the nurse would document it. III. Failed to ensure Resident #55's antipsychotic medication was appropriately monitored and reviewed by the IDT and the resident's care plan included resident-specific non-pharamacological care approaches for the resident's behaviors A. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included Alzheimer's disease, dementia with mood disturbances, hypertensive heart disease (heart disease caused by long term high blood pressure), major depressive disorder, insomnia, and post traumatic stress disorder. The [DATE] MDS assessment revealed the resident was cognitively impaired with a BIMS of nine out of 15. He used a walker. He was independent with eating and he required supervision with oral hygiene. He required substantial assistance with toileting and showering. He required moderate assistance with personal hygiene. The resident did not exhibit verbal or physical behavioral symptoms toward others, reject care or wandered during the assessment look-back period. The MDS assessment revealed the resident was depressed and had post-traumatic stress disorder. The MDS assessment revealed the resident was prescribed an antidepressant medication. B. Record review The wandering and elopement care plan, initiated [DATE] and revised [DATE], revealed Resident #55's family disclosed he had a history of leaving familiar settings. Interventions included clearly identifying Resident #55's room, engaging Resident #55 in purposeful activities and scheduling time for regular walks and appropriate activities. The cognition care plan, initiated [DATE] and revised [DATE], revealed Resident #55 was at risk for altered cognition due to dementia with agitation that caused poor safety awareness. Interventions included participating in daily care and decision making as able, contacting family for decision-making assistance and engaging the resident in frequent conversations using reminiscence, life review and validation. The mood care plan, initiated and revised [DATE], revealed Resident #55 liked to talk about his life and would tear up talking about his spouse. Interventions included family support and involvement and providing comfort. The [DATE] CPO revealed the following physician's orders: Sertaline (an antidepressant medication) 100 mg. Take one tablet by mouth one time a day for dementia with mood disturbance, post traumatic stress disorder and depression, ordered [DATE]. Trazodone (an antidepressant medication) 100 mg. Take one tablet by mouth at bedtime for insomnia, ordered [DATE]. Seroquel (an antipsychotic medication) 12.5 mg. Take one tablet by mouth for dementia with behaviors and agitation. Try to give as close to 3:00 p.m. as possible to prevent sundowning symptoms in the late afternoon, ordered [DATE] and discontinued [DATE]. Risperidone (an antipsychotic medication) 0.5 mg. Take one tablet by mouth at bedtime for dementia with behaviors, ordered [DATE] and discontinued [DATE]. Seroquel 12.5 mg. Take one tablet by mouth two times a day for dementia with behaviors and agitation, ordered [DATE]. Monitor hours of sleep related to trazodone use, ordered [DATE]. Alert for and notify the physician if any of the following occur: increased fatigue, sleep disturbance, anxiety, restlessness, nausea, headache, dizziness, tardive dyskinesia and suicidal ideations. If yes, list and notify the physician, twice a day for antidepressant medication, ordered [DATE]. Monitor the resident for increased Sertaline two times a day for depression, ordered [DATE]. Monitor and chart on the resident for reactions to starting on Seroquel two times a day for dementia with behaviors and agitation, ordered [DATE] and discontinued [DATE]. Monitor and chart on the resident for reactions to starting Risperdal two times a day related to dementia with mood disturbances, ordered [DATE] and discontinued [DATE]. Monitor and on chart the resident for behaviors for 14 days due to a medication change from Risperdal to Seroquel two times a day for behaviors, ordered [DATE] (during the survey). The [DATE] social services note revealed Resident #55's mood, psychosocial well-being and psychoactive medication were reviewed by the physician, the DON and social services. -However, there was no documentation of what specifically was reviewed and what decisions were made. The [DATE] consultant pharmacist's recommendation to the physician regarding Resident #55's sertraline medication revealed practice guidelines for major depression for sertraline in primary care recommended continuing the same dose for four to nine months following the acute phase. A trial dose reduction might be reasonable. The resident had been using 75 mg four times a day since [DATE]. If the medication therapy was required to prevent future depressive episodes, the pharmacist requested for the physician to document that in the progress notes. In response to the pharmacist's recommendations, the physician checked the box on the form to continue Resident #55's antidepressant therapy and a dose reduction was contraindicated. The physician documented the medication could be discussed at the psychopharmacology meeting as the physician was not sure when the resident's previous gradual dose reductions were. -However, the physician signed the form on [DATE], two months after the pharmacist's recommendation for a GDR of Resident #55's sertraline medication. The [DATE] social services note revealed Resident #55's mood, psychosocial well-being and psychoactive medication reviewed by the physician, the DON and social services. -However, there was no documentation of what was specifically reviewed and what decisions were made. The [DATE] physician's note revealed Resident #55 went to the emergency room on [DATE] for agitation and threats towards staff members. A behavioral health services referral was placed on [DATE], though the physician documented there were no notes from the behavioral health services provider in the resident's EMR The resident's sertraline was increased from 75 mg daily to 100 mg daily to try and help with some behaviors, but nursing staff had stated the resident's behavior and sundowning were consistently getting worse and a medication change did not make a difference. The physician called behavior health services to discuss a couple of options. Behavioral health services agreed the resident's symptoms seemed most consistent with sundowning behaviors and recommended a very low dose of Seroquel to start as the resident had never had the medication before. The physician discussed with nursing to start the medication while the facility's behavioral health services team established care with the resident. The [DATE] behavior note, documented at 3:50 p.m., revealed Resident #55 started yelling and screaming he wanted to go home. The resident went to the phone room and called 911. The nurse was able to talk to the operator and explained the situation to her. The resident went to his room, closed the door and started yelling for help to call the police. The resident went to the TV room and started pushing furniture and threw anything he could lay his hands on. He calmed down at 4:30 p.m. The [DATE] psychiatric evaluation note revealed staff reported Resident #55 was difficult to redirect, was exit-seeking and verbally or physically aggressive when staff tried to redirect him. He was started on a low dose of Seroquel for increased behaviors and aggression in the afternoon. The [DATE] nurse note revealed Resident #55 was crying and told the nurse his wife died. He started yelling for help to go to the hospital or call the police to take him home. He went to the elevator and blocked the entrance, saying if 911 or the police was not called, he would not move out of the way. The DON was notified. She came with another CNA and an admissions staff member, but they were unable to redirect the resident. The resident refused to talk to his family. He tried to put himself on the floor but two staff members held him to ease him to the floor. After a while, he was helped up and was redirected to sit in the TV room. The [DATE] behavior note revealed Resident #55 was observed between 1:00 p.m. to 3:30 p.m., very agitated and exit-seeking. The resident stood in front of the big elevator for about 30 minutes. The resident pounded on the wall yelling and screaming, looking for his wife and son. He could not be redirected. The [DATE] psychiatric note revealed the resident continued to present with delusions of being in a hotel, irritability and was difficult to redirect. Recommendations included titrating his risperidone medication as needed, as titration had been shown to have some beneficial efficacy with dementia behaviors. The reason for the psychiatrist's visit was the resident's agitation. The resident was evaluated in the hallway standing by the nurse's station. He was irritable and minimally cooperative throughout the session. He presented with a dysphoric (profound sense of unease, unhappiness and dissatisfaction) mood and restricted affect. He appeared to have a current delusion that he was waiting for the police to arrive because they would not let him into his hotel room. The psychiatrist attempted to reorient the resident to the situation with no benefit. The resident said he was waiting for his wife because they needed to go to the car show. The psychiatrist attempted to redirect the resident to assessment questions with no benefit. The resident appeared fixated on the notion his wife was still alive and he was meant to be at a car show. The [DATE] behavior note revealed Resident #55 was very agitated between 1:00 p.m. to 4:00 p.m. and was looking for his son and wife. The resident wandered, looking for a place to exit the unit. He looked through the windows to find his car in the parking lot so he could drive away. The resident was found at the nurses' station two times using the phone and tried to pull the fire alarm. At 4:00 p.m. he calmed down after a shower. The [DATE] morning behavior note revealed Resident #55 called 911 saying he wanted to get out of the facility. The police called and were told the resident often did this, but the resident's representative wanted him to stay at the facility. After a number of attempts calling 911, the resident went to his bedroom. The [DATE] behavior note revealed Resident #55 continued on monitoring for Risperdal use with no adverse reactions noted. The resident was observed between 6:30 a.m. and 7:00 a.m. yelling and screaming for help but staff could not tell what he wanted and the resident was not redirectable. After dinner, the resident asked for a phone to call his wife to come pick him up. He yelled and it took 30 minutes to redirect him. The [DATE] afternoon behavior note revealed after dinner, the resident went to his room put on a jacket and returned to the dining room and started to shout that he wanted to call his wife so he could go home. The resident was not redirectable at that time and the floor nurse came to assist him. The [DATE] nurse note revealed Resident #55 was agitated with confusion around 8:00 p.m. The nurse informed the house supervisor who came to intervene but was unsuccessful. The supervisor called the resident's representative who spoke with the resident at length with no impact. The supervisor called the ADON who suggested giving the resident an additional dose of risperidone 0.5 mg to control the resident's behavior, but the offer was rejected by the resident. The [DATE] nurse note revealed the resident was agitated and reported to staff he did not like to stay here and wanted to go out. Staff tried to redirect the resident but the resident was more agitated and activated the emergency door alarm five times. Staff provided one-on-one care but the resident tried to hit staff with his walker and tried to break the facility window with his oxygen tank. Staff tried to notify the physician for more than 45 minutes but were unsuccessful. Staff called the medical director for a physician's order to send the resident to the hospital for further evaluation. The [DATE] nurse note revealed Resident #55 returned from the emergency room and he was in a confused state and said where is my wife and why am I here. Staff redirected the resident multiple times. The [DATE] behavior note revealed Resident #55 was on monitoring for medication changes from Risperdal to Seroquel with behaviors noted between 4:00 p.m. to 5:20 p.m. The resident stated the building belonged to him and he wanted everyone out of the building, especially two residents he pointed to. He was very difficult to redirect. The SSD came and took the resident to her office for about 15 minutes and brought him back. The resident was quiet for about 10 minutes and then started yelling for everyone to get out of the building. The resident went to his room and the nurse talked to him for about five minutes and brought him back to the TV room. He saw the residents in the TV room watching TV and he turned the TV off and went back to his room. -A review of Resident #55's EMR revealed there was no documentation of what specific interventions were offered and if the interventions were effective when the resident was exhibiting behaviors. -A review of Resident #55's EMR revealed there were no person-centered non-pharmacological interventions documented for dementia, depression and insomnia. -A review of Resident #55's EMR revealed there was no documentation on what behaviors the facility was specifically monitoring for Resident #55 and what interventions were identified to help Resident #55 if he exhibited any behaviors. -A review of Resident #55's EMR revealed there was no documentation to indicate the IDT reviewed the resident's use of sertraline to determine if the continued use of the medication was justified and if a GDR of the medication was indicated. C. Staff interviews CNA #6 was interviewed on [DATE] at 12:15 p.m. CNA #6 said she was familiar with Resident #55. She said his behaviors escalated when he could not talk to his family. CNA #6 said his family took his personal phone away because he called them every two minutes. She said Resident #55's wife was dead but he did not remember and wanted to talk to her. CNA #6 said checkers, eating ice cream and drinking coffee helped de-escalate his behaviors. She said another way to help de-escalate his behavior was when she talked to him about his plans for tomorrow. She said talking about tomorrow helped relax Resident #55. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 10:35 a.m. LPN #2 said he knew what behaviors to monitor based on what the resident needed. He said he knew what de-escalated a resident's behavior by talking to the resident to learn what caused their current behavior. He said it was important to remember most residents would not remember what he said, so it was important to not say he already answered the resident's question. LPN #2 said he did not document every behavior, but if it was a behavior out of the ordinary, such as an aggressive behavior, he wrote a progress note. LPN #2 said he was familiar with Resident #55. He said he was one of the residents who did not remember what he said and Resident #55 asked about his son. He said he would meet the resident where he was to help not escalate his behaviors. The DON was interviewed on [DATE] at 3:50 p.m. She said the IDT was responsible for determining what resident behaviors needed to be monitored. She said it started before the resident was admitted to the facility by reviewing the referral admission packet and reviewing clinical notes, including the clinical diagnoses and behavior notes. The DON said she reviewed the physician's orders to see if there were psychotropic medications or if there were orders to monitor behaviors. The DON said interventions were determined by monitoring the resident when they were first admitted to the facility or first started a psychotropic medication. She said from there, the IDT care planned what behaviors were monitored and what interventions to use. The DON said residents who were on psychotropic medications were reviewed by the IDT in the first month they started the medication, quarterly and as needed. She said the IDT reviewed how long the resident was on the medication, what behaviors the resident had, their sleeping patterns, their nutrition status, if a GDR was appropriate, and if they had signs of tardive dyskinesia (a medication-induced movement disorder characterized by involuntary repetitive movements most often in the face). The DON said non-pharmacological interventions should be offered before a resident started any new medication. The DON said interventions should be documented in the care plan. The DON said she was new and was not familiar with Resident #55.

Based on observations, record review and interviews, the facility failed to ensure received services and assistance to prevent a reduction in range of motion for two (#6 and #10) of four residents reviewed for range of motion out of 32 sample residents. Specifically, the facility failed to: -Ensure preventative measures were put into place for Resident #6's bilateral hand contractures; and, -Ensure preventative measures were followed for Resident #10 to prevent further body misalignment.Findings include: I. Facility policy and procedure The Restorative Care policy and procedure, revised 3/24/26, was provided by the nursing home administrator (NHA) on 3/31/26 at 11:47 a.m. It read in pertinent part, Residents will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services include passive or active range of motion, splint or brace assistance, and bed mobility training and skill practice. Potential candidates for restorative nursing services may be identified through physical assessments, MDS (minimum data set) assessments, specialized rehabilitation assessments, or in-house referrals prompted by unusual occurrences or events. The restorative nurse is responsible for maintaining a current list of residents requiring restorative nursing services and ensuring that all elements of each resident's program are implemented. Each resident's restorative nursing plan will include the problem, need, or strength the restorative tasks are intended to address; the type of activities to be performed; the frequency and duration of activities; and measurable goals with target dates. The discharging therapist, restorative nurse, or designated licensed nurse will communicate the provisions of the resident's plan to the appropriate restorative aide and provide any necessary training to carry it out. Restorative aides will implement the plan for the designated length of time, performing the assigned activities and documenting them on the Restorative Aide Documentation Form or another facility-designated form. The restorative nurse, or designated licensed nurse, will provide oversight of the restorative aide's activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly, documenting the outcomes accordingly. II. Failed to ensure preventative measures were put into place for Resident #6's bilateral hand contractures A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included paranoid schizophrenia, dementia with agitation, depression, delusional disorders and catatonic disorder. The 3/26/26 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. She was dependent on others for oral hygiene, toileting, showering and upper and lower dressing. The MDS assessment revealed the resident had received no physical or occupational therapy services during the assessment look-back period. B. Resident #6's representative interview Resident #6's representative was interviewed on 3/24/26 at 2:04 p.m. The representative said he was frustrated with the facility because Resident #6 had started to have contractures (the permanent, often painful shortening of muscles, tendons, or skin, causing rigid joint stiffness and limited motion) in both hands in November 2025. He said the contractures were due to a muscle spasm related to the medications she took. He said he had asked the facility if they could place a brace or even a towel in between her hands to prevent the contractures from getting worse. He said the facility said she could not use a brace or towel because they were concerned the resident might swallow the supplies. The representative said he thought the facility gave up on Resident #6's contractures because in order to put a brace or a towel in between her fingers and palm, it needed to be done slowly because the contractures caused her so much pain. He said no one had talked to him or another resident representative about what the facility was doing to prevent the resident's contractures from getting worse. He said it had been a nightmare for him and the other resident representatives. C. Resident observation On 3/24/26 at 1:44 p.m. Resident #6 was lying in her bed in her room. She was unable to answer any questions. Both of the resident's right and left hands were contracted. Her left fingers were almost touching the palm of her left hand with about one inch of space between her fingers and her palm. Her fingers on her right hand were touching the palm of her hand. The resident was not wearing hand splints on either hand. On 3/25/26 at 9:36 a.m. Resident #6 was lying in her bed in her room. Resident #6 did not have a brace or splint on either hand. D. Record review The pain care plan, initiated 4/8/25 and revised 6/3/25, revealed Resident #6 had the potential for pain related to a history of global decline in function, impaired mobility, contractures and osteoarthritis. Interventions included non-medication pain relief techniques and implementing relaxation techniques to assist with pain control. -The care plan failed to indicate if passive range of motion was being utilized as an intervention for Resident #6's contracted hands. -A review of Resident #6's Kardex (an abbreviated care plan) and March 2026 CPO failed to indicate if the resident was receiving passive range of motion for her contracted hands. The 11/24/25 occupational therapy (OT) discharge summary indicated the OT's recommendations included passive range of motion with the resident's upper and lower extremities. -However, there was no documentation in Resident #6's electronic medical record (EMR) to indicate that passive range of motion was offered was provided to the resident from 11/24/25 to 3/26/26. E. Staff interviews Certified nurse aide (CNA) #7 and licensed practical nurse (LPN) #3 were interviewed together on 3/26/26 at 11:55 a.m. CNA #7 said CNA#5 was responsible for carrying out restorative nursing programs. LPN #3 said nurses or CNAs could perform passive range of motion with residents, depending on what type of passive range of motion was ordered. CNA #7 said it depended on what was listed on the Kardex and if it was a task for a CNA to carry out during the shift. CNA #7 said passive range of motion was documented in the tasks in the resident's EMR. CNA #7 said if a resident refused restorative care, she tried to redirect and try again. CNA #7 said if the resident still refused, she informed the nurse and the nurse and the CNA worked together to complete the task. LPN #3 said physical therapists (PT) or OTs were responsible for placing a brace or a splint on a resident when the resident received therapy. LPN #3 said once the resident was discharged from PT or OT services, the restorative nurse aide was responsible for performing range of motion. LPN #3 said if the restorative nurse aide was not working, nursing staff could place or remove the brace or splint. LPN #3 said he knew which residents had a restorative nursing plan because it showed up for the restorative nurse aide on their tasks and they were responsible to sign off on it once they completed it. LPN #3 said if a resident refused restorative care, then CNAs and nurses would document the refusal. CNA #7 and LPN #3 said they were familiar with Resident #6. They both said she never refused care. CNA #7 said Resident #6 would yell during care but that was her normal behavior and the staff who knew Resident #6 knew that was her normal behavior and she was not refusing care. LPN #3 said he was not able to remember how long Resident #6 had had contractures in her hands but thought it began occurring in November 2025. LPN #3 and CNA #7 said Resident #6 accepted care from staff who she was familiar with. LPN #3 and CNA #7 said sometimes if they told Resident #6 to relax her hands that helped with her contractures. LPN #3 and CNA #7 said they did not see restorative nursing for Resident #6 and they did not know the last time she received passive range of motion. The director of nursing (DON) was interviewed on 3/26/26 at 4:00 p.m. The DON said the restorative CNA was responsible for carrying out restorative nursing five days a week. The DON said on the days the restorative CNA did not work, the floor CNAs were responsible. The DON said passive range of motion was part of restorative nursing when PT or OT discharged the resident from therapy and wrote a restorative program in order to not lose the strength the resident gained from therapy. The DON said the director of rehabilitation (DOR) was responsible for writing the restorative programs for the residents. The DON said the restorative CNA was responsible for placing the brace or splint on a resident. The DON said there was usually a physician's order for the brace or splint so the nurses made sure the brace or splint was placed. The DON said since she had only been working in the facility for four days, she was learning the processes. The DON said she talked to the DOR and they needed to come up with a plan on which residents were on a restorative plan. The DON said she did not ask the DOR for a list of residents who were on a restorative plan. The DON said the restorative CNA should document the restorative tasks in the resident's EMR when restorative care was provided. The DON was interviewed a second time on 3/26/26 at 5:22 p.m. The DON said she talked to CNA #5. She said CNA #5 said Resident #6 was on a restorative nursing program for passive range of motion but she was not currently on the restorative nursing list. The DON said CNA #5 said Resident #6 did not refuse care. She said Resident #6 would be added to the restorative nursing list. The DOR was interviewed on 3/26/26 at 5:35 p.m. The DOR said she was notified to evaluate a resident for therapy based on a physician's order from nursing staff or from a physician. The DOR said if a resident refused an assessment, she documented and then talked to nursing staff to see what worked for them so the resident would accept care. She said she documented the refusal and reattempts in a progress note or as a therapy evaluation. The DOR said she communicated with nursing staff and family during a care conference. The DOR said a resident was discharged from therapy services when a resident reached their maximum potential. The DOR said she completed a discharge summary at that time. The DOR said she communicated the discharge plan to nursing during the morning meeting and restorative nursing started after therapy services ended. She said that was how it worked for most residents, but each resident was different and the restorative plan was specific for each resident. The DOR said passive range of motion would not be part of restorative or functional nursing plan when she expected the resident to refuse or if the resident was bed bound and she wanted nursing to provide some sort of motion for the resident. The DOR said she measured if a resident's contractures were getting better or worse based on the resident's stiffness and positioning. She said if the resident had a decline in self care, that was one way to measure if contractures were worsening. The DOR said she was familiar with Resident #6. The DOR said the resident started having contractures about six months ago. She said passive range of motion should be offered to the resident three to four times a week. She said Resident #6 did not have a splint or brace because of her behaviors and aggressiveness. III. Failed to ensure preventative measures were followed for Resident #10 to prevent further body misalignment A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included dementia with agitation, frontotemporal neurocognitive disorder (affects behavior and ability to participate in care) and history of falling. The 1/2/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He required substantial assistance with eating, walking, bathing and dressing. B. Observations On 3/23/26 at 9:40 a.m. Resident #10 was sitting in a reclining chair by the nurses' station with the recliner fully extended in a reclined position. The resident's neck was tilted to the left without a pillow or cushion to support his neck. Registered nurse (RN) #2 was sitting at the nurses' station but did not offer to reposition the resident's neck or provide him any supportive devices. On 3/23/26 at 1:24 p.m. Resident #10 was at the nurses' station in the recliner and was napping. The resident was in the same position as observed earlier in the morning, with his neck tilted to the left without a pillow or cushion to support his neck. Two unidentified staff members were present at the nurses' station but did not provide the resident with any support for his neck. On 3/23/26 at 4:09 p.m. Resident #10 was by the nurses' station in the recliner chair in a fully extended position. The resident had periods of being asleep and awake and he was heard saying something that could not be understood while his eyes remained closed. His neck remained tilted to the left without a pillow or cushion to support his neck. On 3/24/26 at 8:48 a.m. Resident #10 was sitting in a reclining chair by the nurses' station with the recliner fully extended in a reclined position. His head was tilted to the left side and no staff members provided assistance with repositioning the resident's neck. During a continuous observation on 3/24/26, beginning at 12:23 p.m. and ending at 3:25 p.m., the following was observed: At 12:23 p.m. Resident #10 was observed sitting in a recliner by the nurses' station with the recliner fully extended in a reclined position. -The resident's neck was not supported with a pillow or cushion. At 1:08 p.m. an unidentified staff member asked the resident if he needed anything. The resident did not respond and continued to nap. His neck remained tilted to the left without a pillow or cushion to support his neck. -However, the unidentified staff member did not offer to provide the resident with support for his neck. At 1:34 p.m. CNA #4 patted Resident #10 on the leg and called his name but did not attempt to reposition the resident's neck or provide a pillow for support. At 1:57 p.m. Resident #10 was observed sitting in a recliner with his head significantly tilted to the left, resting close to his shoulder, and he was unable to maintain an upright head position. CNA #2 was standing nearby and did not provide repositioning or offer a pillow for support. At 3:16 p.m. CNA #2 and another unidentified staff member assisted Resident #10 to stand using a gait belt and ambulated with him down the hall. The resident was unable to maintain his neck in an upright position when ambulating. The CNAs provided care for the resident and returned the resident to the recliner at 3:24 p.m. The resident's neck continued to be tilted to the left. -CNA #2 and the unidentified staff member did not provide a pillow to support the resident's neck once they returned him to the recliner. On 3/25/26 at 9:44 a.m. Resident #10 was sitting in a recliner by the nurses' station with a small pillow in place to support his neck. C. Record review The pressure ulcer care plan, initiated 1/15/24, documented Resident #10 had a potential for pressure ulcer development related to severe dementia and incontinence. Pertinent interventions included implementation of proper body positioning with supportive pillows, cushions, and positioning devices to reduce pressure points and maintain joint alignment. D. Staff interviews RN #2 was interviewed on 3/26/26 at 11:51 a.m. RN #2 said staff were supposed to support Resident #10's head while he was sitting in the recliner by using a pillow or a rolled towel to keep the resident's head in proper alignment. He said a few weeks ago he assessed the resident's neck and tried to use a rolled towel to prevent further decline, and sometimes the resident was resistant to the towel. He said he did not document the resident's refusals because putting a towel was not ordered and he just wanted to help the resident. RN #2 said restorative therapy had worked with Resident #10 two to three times each week, including walking with him. He said therapy did not provide services the week of the survey because they were not in the building. RN #2 said staff followed the residents' care plans and electronic medication administration records (eMAR), and if interventions were not completed they would report concerns to the DON. RN #2 said Resident #10 did not refuse care and staff would encourage and explain repositioning to ensure the resident's compliance with positioning needs. CNA #4 was interviewed on 3/26/26 at 1:53 p.m. CNA #4 said restorative therapy assisted Resident #10 with walking and exercises. She said the staff placed a pillow daily to support the resident's head while he was sitting in the recliner and he was comfortable with the placement of the pillow. She said if staff were not busy, they checked and repositioned the resident approximately every two hours. She said staff would also assist him to walk and transfer him to a chair. She said staff reminded each other to reposition Resident #10 as needed for his overall well-being and said repositioning could be missed at times when they were busy. CNA #5 was interviewed on 3/26/26 at 2:05 p.m. CNA #5 said she worked with Resident #10 with restorative therapy and services included ambulation three times per day for approximately 15 minutes per session and range of motion (ROM) exercises twice per day for 10 to 15 minutes. She said body positioning interventions included placing a pillow to support the resident's head and neck, especially while he was sleeping in the recliner. She said lack of proper support would cause the resident's neck muscles to become sore and uncomfortable.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in two of three units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure resident glucometers were cleaned in a sanitary manner; and, -Ensure gloves were worn while administering an insulin injection. Findings include: I. Failure to clean rooms in a sanitary manner and follow disinfectant surface contact times A. Professional reference According to The Centers for Disease Control (CDC) Environment Cleaning Procedures (5/4/23), retrieved on 2/29/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas. Never leave soiled mop heads and cleaning cloths soaking in buckets. B. Manufacturer's recommendations According to Sunburst Chemicals Sunburst No-Bac Cleaner/Disinfectant/Sanitizer, retrieved on 2/29/24 from https://support.sunburstresults.com/wp-content/uploads/sites/2/2018/09/Sunburst-No-Bac_Spec-Sheet_V8_Haz-1.pdf, Sunburst No-Bac is an effective multipurpose cleaner/disinfectant/sanitizer when used at one ounce per gallon of water. Disinfectant against Pseudomonas, Shigella, Campylobacter, Ecterobacter, Streptococcus, Vancomycin Resistant Enterococcus (VRE), Methicillin Resistant Staphylococcus Aureus (MRSA), Listeria, Salmonella, Escherichia coli, Klebsiella, Norovirus, Hepatitis B, Hepatitis C, HIV, Coronavirus, Influenza, Herpes Simplex. According to Sunburst Chemicals Sunburst Essential Specifications for Sanitizers, Disinfectants and Test Strips, retrieved on 2/29/24 from https://www.sunburstresults.com/wp-content/uploads/2020/07/Essential-Specifications-for-Sanitizers-Disinfectants-and-Test-Strips-Final-7.28.20.pdf, Sunburst No [NAME] dilution of one ounce per one gallon requires a 10 minute contact time as a disinfectant. C. Facility policy and procedure The Step by Step Guide for Cleaning Rooms policy and procedure was provided by the housekeeping supervisor (HSKS) on 2/27/24 at 11:37 a.m. It read in pertinent part, Spray all high touch surfaces and let sit over two minutes. Leave spray disinfectant on the sink so we have a consistent visual. Begin cleaning the wash area first top to bottom inside sink last. Clean bathroom top to bottom inside bowl last. D. Observations On 2/27/24 at 11:00 a.m., housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER] HSK #1 donned gloves and sprayed the high touch surface areas, door handles, light switches and railings in the room and then sprayed the toilet in the bathroom. She proceeded to spray the front of the dressers and bedside table. She immediately wiped down the front of the chest of drawers and the top of the bedside table. -HSK #1 did not wait the required dwell time of two minutes before wiping off the disinfectant spray. -HSK #1 did not change gloves or perform hand hygiene before moving from a low area to a high area. HSK #1 set the bottle of spray disinfectant on the floor, wiped the inside of the sink, the sink fixtures and then the counter top. She set the bottle of cleaner on a dirty area. -HSK #1 wiped a dirty area and proceeded to a higher clean area without changing gloves or performing hand hygiene. HSK #1 wiped the top of the toilet, the toilet set, top of the toilet bowl and then the bottom of the toilet. She picked up the spray disinfectant off the floor. She proceeded to the housekeeping cart and touched items on the housekeeping cart with the same gloves she had just cleaned the toilet with. -HSK #1 did not change her gloves or perform hand hygiene after cleaning the bathroom, picking up the disinfectant off of the floor and touching the housekeeping cart. -HSK #1 did not clean the inside of the toilet bowl. HSK #1 mopped the resident's room and then mopped the bathroom. She placed the soiled mop head in the mopping cleaning solution and left it to soak. E. Staff interviews HSK #1 was interviewed on 2/27/24 at 11:15 a.m. HSK #1 said when spraying the disinfectant onto surfaces, the surface should remain visibly wet for two minutes before wiping. She said all surfaces should be wiped from top to bottom. She said gloves should be changed and hand hygiene performed if cleaning required returning to a top surface. HSK #1 said after cleaning the bathroom, gloves should be removed and hand hygiene performed before touching clean surfaces. She said the disinfectant bottle should not be placed on the floor because it was a dirty surface area. The HSKS was interviewed on 2/27/24 at 11:38 a.m. The HSKS said top surfaces and high touch surfaces were sprayed first and should remain visibly wet for two minutes before being wiped. She said high surfaces should be wiped first and proceed to lower dirtier surfaces. She said after dirty areas were cleaned, gloves should be removed and hand hygiene before cleaning high or clean areas. She said gloves should be changed and hand hygiene should be performed after cleaning the bathroom and before touching clean items. The HSKS said the disinfectant bottle should not be placed on the floor. II. Failure to clean resident glucometers A. Manufacturer's guidelines According to Assure Platinum Blood Glucose Meter manufacturer cleaning and disinfecting guidelines (2023), retrieved on 2/29/24 from https://www.arkrayusa.com/english/diabetes_management/professional_products/assure/assure_platinum.html, Disinfecting the glucometer can be accomplished with an EPA (Environmental Protection Agency) registered disinfectant detergent or germicide that is approved for healthcare settings. In accordance with CDC guidelines, we recommend that the Assure Platinum glucometer be cleaned and disinfected after each use for individual resident care. B. Facility policy and procedure The Glucometer Disinfection policy and procedure, undated, was provided by the NHA on 2/27/24 at 12:35 p.m. It read in pertinent part, Single resident use: Glucometers will be cleaned and disinfected once a day according to manufacturer's instructions. The glucometers will be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA) registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. C. Observations On 2/26/24 at 7:15 a.m., registered nurse (RN) #1 took a labeled designated glucometer for Resident #51 from the medication cart to check the resident's morning glucose level. He disposed of Resident #51's test strip that contained blood and the used lancet into the sharps container. RN #1 returned the glucometer to the medication cart. -RN #1 did not clean Resident #51's glucometer before returning it to the medication cart. On 2/2724 at 8:30 a.m., licensed practical nurse (LPN) #2 took a labeled designated glucometer for Resident #20 from the medication cart to check Resident #20's morning glucose level. He disposed of Resident #20's used test strip that contained blood and the used lancet in the sharps container. LPN #2 returned the glucometer to the medication cart. -LPN #2 did not clean Resident #20's glucometer before returning it to the medication cart. D. Staff interviews LPN #2 was interviewed on 2/26/24 at 8:55 a.m. LPN #2 said glucometers were cleaned once a day or once a shift. He said alcohol wipes were used to clean the glucometers. RN #1 was interviewed on 2/26/25 at 9:00 a.m. RN #1 said glucometers should be cleaned after every use. He said alcohol wipes were used to clean the glucometers. He said he did not clean the glucometer after he used it to obtain Resident #51's morning glucose level. The director of nursing (DON) was interviewed on 2/26/25 at 9:04 a.m. The DON said glucometers should be cleaned after every use. She said the Sani Cloths (disinfectant wipes) should be used and the glucometers should be wet for two minutes to kill bacteria and any blood borne pathogens. III. Failure to wear gloves when administering insulin A. Professional reference According to the CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Part III: Precautions to Prevent Transmission of Infectious Agents July 2023, retrieved on 2/29/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/Isolation-guidelines-H.pdf, Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions, except sweat, non intact skin and mucous membranes may contain transmissible infectious agents. These include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluid must be handled in a manner to prevent transmission of infectious agents (wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). B. Observations On 2/27/24 at 8:45 a.m., LPN #2 drew up Lispro insulin 12 units to be administered to Resident #20. LPN #2 wiped off Resident #20's abdomen with alcohol and administered the insulin. -LPN #2 did not put on gloves before the administration of the insulin injection. C. Staff interviews LPN #2 was interviewed on 2/27/24 at 8:55 a.m. He said hand hygiene should be performed and gloves should be worn before administering any injection. He said this was to prevent potential contamination with blood from the injection. The DON was interviewed on 2/27/24 at 9:05 a.m. The DON said hand hygiene was to be performed and gloves were to be worn with the administration of any injection to prevent infection from blood borne pathogens and causing cross contamination.

Based on observations, record reviews and interviews, the facility failed to ensure two (#60 and #24) of three residents reviewed for unnecessary medications out of 23 sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to: -Ensure Resident #60 and Resident #24 were adequately monitored and documented side effects of anticoagulant medication; and, -Establish pain parameters for pain medications for Resident #24. Findings include: I. Professional reference According to Vallerand and Sanoski, 2021 [NAME]'s Drug Guide for Nurses, seventeenth edition, page 176, Apixaban (Eliquis), classification therapeutic: anticoagulants. Assessment: Assess patient for symptoms of stroke, DVT (deep vein thrombosis), PE (pulmonary embolism), bleeding, or peripheral vascular disease periodically during therapy. Patient teaching: Inform patient that they may bruise and bleed more easily or longer than usual. Advise patient to notify health care professional immediately if signs of bleeding (unusual bruising, pink or brown urine, red or black, tarry stools, coughing up blood, vomiting blood, pain or swelling in a joint, headache, dizziness, weakness, recurring nosebleeds, unusual bleeding from gums, heavier than normal menstrual bleeding, dyspepsia, abdominal pain, epigastric pain) occurs or if injury, especially head injury. II. Facility policy and procedure The Unnecessary Drugs-Without Adequate Indication for Use policy, undated, was provided by the nursing home administrator (NHA) on 2/27/24 at 12:35 p.m. It read in pertinent part, It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: Adequate monitoring for efficacy and adverse consequences, preventing, identifying and responding to adverse consequences. III. Resident #60 A. Resident status Resident #60, age less than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included malignant neoplasm of kidney (cancer), chronic obstructive pulmonary disease (inflammatory lung disease), neoplasm (abnormal growth of tissue) of lung and bone. The 1/23/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required no assistance for functional activities such as bed mobility, transfers, toilet transfers, walking, and shower transfers. The assessment indicated the resident was receiving an anticoagulant medication. B. Resident observation and interview Resident #60 was observed on 2/21/24 at 1:54 p.m. She had three small bruises on her right arm. Resident #60 was observed on 2/26/24 at 2:40 p.m. She had skin tears on both arms with band-aids on each arm. Resident #60 said the skin tears occurred when she bumped her arms on the door handle. She said sometimes she got nose bleeds and she said her last one was about a week ago. C. Record review Review of Resident #60's comprehensive care plan, initiated 10/20/23, revealed there was no care plan focus to monitor for anticoagulant medication use. The February 2024 CPO documented the following physician's order: Apixaban oral tablet 5 mg (milligrams). Give one tablet by mouth two times a day for PE (pulmonary embolism) (blood clot in the lungs). The start date of the order was 10/18/23 -Review of Resident #60's electronic medical record (EMR), including the medication administration records (MAR), revealed there was no documentation to indicate the resident was being monitored for side effects of an anticoagulant medication including signs and symptoms of increased bleeding. D. Staff interviews Registered nurse (RN) #2 was interviewed on 2/27/24 at 12:26 p.m. RN #2 said if a resident was on an anticoagulant medication she would monitor for bruising, bleeding, especially if they should cut themselves. She said she would watch for coffee ground emesis (vomit which looks like coffee grounds) which could indicate internal bleeding. RN #2 said it should be on the care plan if a resident was on an anticoagulant. She said she would document the monitoring on the MAR when she administered the medication. RN #2 said she did a weekly skin assessment on residents and would monitor for bruising. She said she would monitor residents on anticoagulants for nose or gum bleeding because any abnormal bleeding would be a concern. The director of nursing (DON) was interviewed on 2/27/24 at 1:49 p.m. She said if a resident was on an anticoagulant medication the nurses should monitor for signs of bleeding. The DON said there should be a physician's order in the EMR for monitoring when a resident was on an anticoagulant medication. The DON said there should be a care plan to monitor residents who were on an anticoagulant. The DON said it was important to monitor due to risk of bleeding since it was a blood thinner that could cause a brain bleed if a resident hit their head. The DON confirmed that Resident #60 was taking the anticoagulant medication Apixaban. She said the resident should have had an order to monitor for side effects of the medication, such as signs of bleeding. The DON said the resident's anticoagulant medication use and monitoring should have been on the resident's care plan. 47350 IV. Resident #24 A. Anticoagulant monitoring 1. Resident status Resident #24, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 CPO, diagnoses included cancer of the left kidney and deep tissue injury (DTI) of the left heel. The 1/16/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial/maximal assistance with transfers, toileting, required partial/moderate assistance with personal hygiene and was independent with eating and bed mobility. 2. Record review Review of Resident #24's comprehensive care plan, initiated 10/13/23, revealed there was no care plan focus to monitor for anticoagulant medication use. The February 2024 CPO revealed a physician's order for Eliquis (Apixaban) 5 mg twice a day for pulmonary embolism, start date 1/24/24. -Review of Resident #24's EMR, including the MAR, revealed there was no documentation to indicate the resident was being monitored for side effects of an anticoagulant medication including signs and symptoms of increased bleeding 3. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 2/27/24 at 1:00 p.m. LPN #3 said if a resident was on an anticoagulant medication the resident should be monitored for signs and symptoms of bleeding. She said if bleeding was noted it was put in a nursing progress note. She said the facility did not have anticoagulant monitoring documentation on the MAR or another formally designated area in the EMR. She said Resident #24 should be monitored for bleeding as he was on an anticoagulant. The DON was interviewed on 2/27/24 at 1:49 p.m. The DON confirmed that Resident #24 was taking the anticoagulant medication Apixaban. She said the resident should have had an order to monitor for side effects of the medication, such as signs of bleeding. The DON said the resident's anticoagulant medication use and monitoring should have been on the resident's care plan. B. Pain parameters 1. Professional reference According to Queremel [NAME], D. A., [NAME], D.D. (July 3, 2023), Pain Management. Stat Pearls. National Library of Medicine, retrieved on 3/6/24 from https://www.ncbi.nlm.nih.gov/books/NBK560692/, Acetaminophen: Mild to moderate pain, moderate to severe pain (as adjunctive therapy to opioids). Opioids are recognized as the most effective and widely used drugs in treating severe pain. 2. Record review Resident #24's pain care plan, initiated on 10/15/23 and revised on 1/31/24, indicated the resident had chronic pain related to cancer. Interventions included music therapy and adequate scheduled pain medication. -A review of the pain care plan failed to reveal person-centered interventions for the administration of as needed pain medications. The February 2024 CPO revealed a physician's order for Morphine sulfate 20 mg/milliliter (ml), give 0.25 ml every five hours as needed for pain or shortness of breath, ordered 2/14/24. -A review of the February 2024 CPO did not reveal a pain assessment parameter for the administration of the as needed morphine. 3. Staff interviews RN #2 was interviewed on 2/27/24 at 2:35 p.m RN #2 said before administering an as needed pain medication a pain assessment, including pain level, quality and location of pain should be done. She said non-pharmacological interventions should be offered first. She said the pain assessment helped determine what type of pain medication to be administered based on the ordered parameters. She said if there were no parameters ordered the physician should be contacted and the order clarified. The DON was interviewed on 2/27/24 at 1:50 p.m. She said pain should be assessed before the administration of any as needed pain medication. She said the pain medication should be administered based on the ordered parameters. She said pain parameters should be in place before any pain medication was administered. She said this was important for Resident #24 before the morphine was administered so his pain was controlled and he was comfortable, but also to keep him from becoming too sedated.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#21) of three residents out of 23 sample residents investigated for abuse. Specifically, the facility failed to report two allegations of verbal abuse of unidentified residents by Resident #21 to local law enforcement and the State Agency on 9/21/23 and 1/7/24. Cross reference F610 for failure to investigate an alleged violation Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 10/30/23, was provided by the nursing home administrator (NHA) on 2/22/24 at 8:37 a.m. The policy revealed in pertinent part, Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or other but has not yet been investigated and, if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Verbal abuse means the use of oral, written or gestures communication or sounds that willfully includes disparaging and derogatory terms ro resident or their families, or within hearing distance regardless of their age, ability to comprehend or disability. The facility will designate an abuse prevention coordinator in the facility who is responsible for reporting allegations of suspected abuse, neglect or exploitation to the state survey agency and other officials in accordance with state law. II. Record review A review of Resident #21's progress notes revealed the following: A 9/22/23 behavior note, written at 10:43 a.m., documented that on 9/21/23, Resident #21 became agitated with another resident and escalated to yelling at him and arguing. During the argument Resident #21 told the other resident, I'm going to kill you several times. His aggression de-escalated when the other resident was redirected to another area away from him. A 1/7/24 behavior note, written at 2:17 p.m., documented Resident #21 told another resident he was going to kill them and cut their head off. Staff tried to intervene and redirect but the resident was calling staff names. -There was no evidence that the resident to resident verbal altercations documented in the progress notes on 9/22/23 or 1/7/24 was reported to the State Agency. III. Staff interviews The director of nursing (DON)was interviewed on 2/27/24 at 11:00 a.m. The DON said when a resident exhibited a behavior, the DON or the NHA needed to be informed by staff because the behavior could be an actual threat, a joke or post-traumatic stress disorder (PTSD). The NHA was interviewed on 2/27/24 at 1:52 p.m. The NHA said the facility investigated the incidents with Resident #21 but did not report them. The NHA said if Resident #21 would have hit someone the event would have been reportable. The NHA said the facility did not report the incident because the yelling was a behavior Resident #21 had. He said the facility determined it was a behavior by talking to the facility staff but said she did not document those staff conversations.

Based on observation, interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#30) of three residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to protect Resident #165 from physical abuse from Resident #30. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 10/30/23, was provided by the nursing home administrator (NHA) on 2/22/24 at 8:37 a.m. The policy revealed in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; and the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. II. 10/25/23 incident between Resident #30 and Resident #165 A. Facility investigation The 10/25/23 investigation summary documented Resident #165 was found wandering and the charge nurse redirected Resident #165 to his room. Fifteen to 20 minutes later, Resident #30 approached the charge nurse and asked if the charge nurse would get the man laying in his bed out of his room. The charge nurse noticed Resident #30 appeared agitated and the charge nurse asked Resident #30 what he did. The charge nurse went to Resident #30's room and found Resident #165 laying in Resident #30's bed with blood coming from his face and Resident #165 was unable to move. The conclusion of the internal investigation documented the following: Resident #30 and Resident #165 continued to have one-to-one checks. Both residents suffered from severe dementia and were unable to recall time and place. Nursing staff were educated on ensuring wandering residents were being supervised. Resident #165 was moved closer to the nurses station and one-to-one checks were conducted and documented by staff and were to be ongoing. -The investigation failed to include documentation of how or when staff monitored residents to prevent them from entering Resident #30's room on 10/25/23. -The documentation for nursing staff education and staff interviews were requested during the survey and were not provided. III. Resident #30 A. Resident status Resident #30, age 85, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia, weakness, presence of artificial left eye and glaucoma of the right eye. The 1/30/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He ambulated independently and needed set up help only with personal hygiene and eating, and supervision with bathing. He was independent with all other activities of daily living. B. Resident interview Resident #30 was interviewed on 2/27/24. Resident #30 said he got into it with a guy when his room used to be down the hall but he moved to this room (as he gestured to his room) and said he liked his current room better. C. Record review The incident progress note written on 10/25/23 at 6:53 p.m. documented in pertinent part, At 3:29 p.m. this nurse (LPN #1) was standing by the medication cart and saw Resident #30 coming and LPN #1 approached and Resident #30 told LPN #1 there was somebody in his room so LPN #1 should go and get him out. LPN #1 asked Resident #30 'Did you do anything to him?' and Resident #30 replied 'He came into my room and I told him to get but he punched me and I beat the hell out of him.' LPN #1 saw Resident #165 went to Resident #30's room and saw resident #165 lying on the bed with cuts and blood on his head and arms. There was also blood on the bed. Broken glasses were also found on the bed and floor. Resident #30's behavior care plan focus, initiated 12/31/16 and revised 2/17/21, documented Resident #30 had impaired cognitive function and impaired thought processes related to his diagnosis of dementia with behaviors and a history of alcohol dependence. Resident #30 was very territorial due to his history of homelessness and protective of his personal items and space. He could become agitated by using abusive language and volume if he felt out of control of his environment. He usually verbalized his concerns to staff. Pertinent care plan interventions included attempting to keep others out of the resident's personal space, respecting his boundaries and assisting others out of his personal space (initiated 10/6/20) and placing the resident in a private room to decrease the potential of his personal environment being interrupted (initiated 3/6/17). Resident #30's psychosocial care plan focus, initiated 5/22/19 and revised 2/12/24, documented he was at risk for psychosocial decline related to past trauma. Resident #30 reported assault in 2015 prior to his admission and he was attacked and stabbed numerous times. Pertinent interventions included to approach Resident #30 from the front, announce yourself and explain your purpose and maintain personal space (initiated 5/22/19). -Resident #30's care plan was not updated after the 10/25/23 altercation. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/27/24 at 10:22 a.m. CNA #1 said Resident #30 had had other residents go into his room. CNA #1 said facility staff should monitor the residents and follow the residents if needed when the residents left the common area to go to their rooms. LPN #1 was interviewed on 2/27/24 at 10:30 a.m. LPN #1 said most of the time staff were present in the hallways where resident rooms were and in the common room and staff were moving around to ensure both areas were visible to them. LPN #1 said staff kept an eye on Resident #30's room. He said the facility did not currently have residents who wandered. LPN #1 said Resident #30 did not like people in his room but he got along with the resident in the room next to his. LPN #1 said staff should knock on Resident #30's door and let him come to the door before entering his room. The director of nursing (DON) was interviewed on 2/27/24 at 11:00 a.m. The DON said a CNA was stationed at the nurses' station when the residents were not all in the common room. The DON said if all the residents were in the common room there should be a CNA in that room to watch the residents. He said this was to help keep residents from wandering into other residents' rooms.

Based on observations, record review and interviews, the facility failed to ensure the environment remained as free of accident hazards as is possible, and ensure each resident received adequate supervision for six residents who resided on the secure unit out of 23 sample residents. Specifically, the facility failed to ensure Resident #59's private sitter, who was hired by the resident's family, did not provide assistance to other residents who resided on the secure unit. Findings include: I. Observations and interviews The private sitter (PS) #1 was interviewed on 2/21/24 at 11:25 a.m. PS #1 said he did not work at the facility and was a private sitter for a resident. PS #1 said Resident #59's family asked him to be a private sitter for Resident #59. On 2/21/24 At 11:50 a.m., PS #1 was observed during mealtime in the secured unit. An unidentified resident was seated and a lunch plate was set on the table in front of her. The resident had not taken a bite of her food. PS #1 was observed lifting the unidentified resident's fork with food to her mouth to attempt to offer her food. The resident refused to take a bite. PS #1 attempted a second time to feed the unidentified resident by lifting her fork with food to her mouth. The resident again refused to take a bite. -PS #1 did not ask facility staff if the unidentified resident had swallowing difficulties. -Facility staff did not intervene when PS #1 attempted to assist the unidentified resident with eating. On 2/21/24 at 11:59 a.m., Resident #14 asked PS #1 to open a door to the bathroom in the common area on the secure unit. PS #1 asked Resident #14 if he could use the bathroom by himself and Resident #14 said yes. PS #1 opened the bathroom door and Resident #14 wheeled himself into the restroom in his wheelchair. -PS #1 did not ask facility staff if Resident #14 was safe to use the bathroom by himself. -Facility staff did not intervene when PS #1 opened the bathroom door for Resident #14. On 2/22/24 at 10:54 a.m., PS #1 was leading resident activity chair exercises in the common area for four seated residents. Certified nurse aide (CNA) #2 observed PS #1 leading the activity. -CNA #2 did not intervene despite observing PS #1 leading the activity. CNA #1 was interviewed on 2/26/24 at 12:14 p.m. CNA #1 said PS #1 was a private caregiver for Resident #59 and was at the facility for just a few hours during the day. CNA #1 said PS #1 had cared for Resident #59 prior to the resident's admission to the facility and the resident's wife wanted PS #1 to continue assisting the resident after he was admitted to the facility. II. Record review A progress note written by the director of nursing (DON) on 11/17/23 at 10:22 a.m. revealed Resident #59's spouse had approached the DON said she would love to bring in a companion/sitter for Resident #59 because she wanted to take a break from coming to the building daily. Resident #59's spouse was informed the resident did not need a sitter, however, Resident #59's spouse insisted that a sitter would make her feel better. PS #1 was to come in three days a week for four hours a day on Tuesdays, Wednesdays and Thursdays. III. Staff interviews The nursing home administrator (NHA) was interviewed on 2/22/24 at 3:14 p.m. The NHA said PS #1 was not employed at the facility and was a private caregiver. The NHA said she was not aware PS #1 had attempted to feed other residents. The NHA said staff did not have to be a CNA to assist residents with eating, however, she said someone who assisted residents with eating needed training prior to assisting a resident. IV. Facility follow up The NHA provided follow up on 2/26/24 at 4:30 p.m. She said PS #1 worked for a nurse staffing agency and was a CNA.The NHA said she told PS #1 he was not to provide care to any facility residents other than Resident #59.

Based on observations, record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for pressure ulcers out of 23 sample residents received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure Resident #24 did not experience a worsening of a shear/friction injury, which the resident was readmitted to the facility with, to an unstageable pressure injury. 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 2/28/24, 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. According to Al [NAME], A. M., Manna, B. (April 19, 2023). Wound Pressure Management. Stat Pearls. National Library of Medicine. Retrieved on 3/4/24 from https://www.ncbi.nlm.nih.gov/books/NBK532897/, Proper repositioning is essential in maintaining skin integrity and is needed in patients who are unable to do this for themselves. The most effective way of repositioning is to move the patient every 2 (two) hours so that the ischemic (reduced blood flow) areas can recover. II. Facility policy and procedure The Pressure Injury Prevention and Management policy and procedure, reviewed February 2023, was provided by the nursing home administrator (NHA) on 2/27/24 at 12:35 p.m. It read in pertinent part, After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. [NAME] or routine care interventions could include, but are not limited to: Redistribute pressure (such as repositioning. Protecting and/or offloading heels); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate pressure redistributing support surfaces; Provide non irritating surfaces; and Maintain or improve nutrition and hydration status, where feasible. III. Resident #24 A. Resident status Resident #24, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included cancer of the left kidney and DTI (deep tissue injury) of the left heel. The 1/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief for mental status score (BIMS) score of 15 out of 15. He required substantial/maximal assistance with transfers, toileting, required partial/moderate assistance with personal hygiene and was independent with eating and bed mobility. The assessment indicated he had no unhealed pressure ulcers, had moisture associated skin damage (MASD) and was at risk for developing pressure ulcers. The 1/26/24 change of condition MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He was dependent with personal hygiene, transfer, toileting, required setup assistance with eating and was independent with bed mobility. The assessment indicated he had one unhealed suspected DTI injury upon reentry, MASD and was at risk for developing pressure ulcers. B. Observations On 2/22/24 at 2:00 p.m., Resident #24 was observed lying on his back on an air mattress with bilateral heel boots in place. On 2/27/24 at 10:30 a.m., Resident #24 was assisted to his side by one staff member and his incontinence brief was removed. The wound physician removed a dressing from the resident's left buttock, revealing a wound. The wound bed was covered by a large amount of eschar (brownish black tissue). The wound measurements were 5.5 centimeters (cm) by 4.5 cm. C. Record review The skin integrity care plan, initiated on 1/25/24, indicated Resident #24 had a DTI to the left heel and was at risk for further skin breakdown due to immobility. Interventions included assisting with turning and repositioning every four hours and as necessary, monitor pain every shift, observing for placement of an intact dressing every shift, observing skin with care for redness, rash, irritation, skin tears, bruises and nursing to follow up with a physician as needed, observing wounds for signs of infection and following up with the nurse practitioner or physician for concerns. -The care plan failed to include documentation of the resident's sacral wound. The hospice care plan, initiated on 2/9/24, indicated the resident was receiving hospice services for cancer of the left kidney. Interventions included collaborating with the hospice team for needed treatment, medication or supplies, collaborating with the hospice team regarding changes of condition or behaviors and reviewing care plan quarterly with family and hospice to ensure proper treatment. Further review of the comprehensive skin integrity care plan revealed interventions for a pressure relieving device to bed and chair, initiated on 10/23/23 and assist with repositioning every four hours, initiated on 1/25/24. The February 2024 CPO documented the following physician's orders: Weekly skin assessments, ordered 10/18/23. Apply house barrier cream to the buttock/coccyx area twice a day, ordered 1/3/24. Referral for hospice services, ordered 1/12/24 reordered 1/31/24. Right buttock wound, apply calazime cream to the wound, apply a sacral bordered foam dressing change every day and as needed, ordered 1/25/24. -The order documented right buttock wound, however, Resident #24's wound was on the left buttock. Right buttock shearing wound cleanse with wound cleanser, apply medihoney and cover with foam dressing every day, ordered 2/8/24. -The order documented right buttock wound, however, Resident #24's wound was on the left buttock. -Review of the February 2024 CPO failed to reveal an order for an air mattress or repositioning program. The 1/26/24 Braden Scale Assessment (a tool used to predict the risk of pressure ulcers) indicated Resident #24 was at a moderate risk for developing pressure ulcers. Review of the certified nurse aide (CNA) documentation for the turning and repositioning of Resident #24 revealed the resident was scheduled to be repositioned at 2:00 a.m., 5:00 a.m., 10:00 a.m, 1:30 p.m. 4:00 p.m. and 8:00 p.m. The CNA documentation from 2/1/24 to 2/26/24 revealed the following: -On 2/2/24 there was no documentation of repositioning of the resident at 8:00 p.m.; -On 2/3/24 there was no documentation of repositioning of the resident at 2:00 a.m., 5:00 a.m. or 8:00 p.m.; -On 2/4/24 there was no documentation of repositioning of the resident at 2:00 a.m. or 5:00 a.m.; -On 2/7/24 there was no documentation of repositioning of the resident at 5:00 a.m.; -On 2/13/24 there was no documentation of repositioning of the resident at 8:00 p.m.; -On 2/14/24 there was no documentation of repositioning of the resident at 2:00 a.m. and 5:00 a.m.; -On 2/17/24 there was no documentation of repositioning of the resident at 1:30 p.m. and 4:00 p.m.; -On 2/20/24 there was no documentation of repositioning of the resident at 8:00 p.m.; -On 2/21/24 there was no documentation of repositioning of the resident at 2:00 a.m. and 5:00 a.m.; -On 2/22/24 there was no documentation of repositioning of the resident at 2:00 a.m. and 5:00 a.m.; -On 2/24/24 there was no documentation of repositioning of the resident at 2:00 a.m., 5:00 a.m. and 4:00 p.m.; and, -On 2/25/24 there was no documentation of repositioning of the resident at 2:00 a.m. and 5:00 a.m. -A comprehensive review of the repositioning documentation revealed repositioning schedule times between three to five hours. It revealed a lack of documentation of times of four or more hours. Review of the wound care physician notes revealed the physician initially evaluated Resident #24's wounds on 1/30/24 and continued to provide weekly wound care visits. -However, the wound physician's initial visit note on 1/30/24 only included documentation for the resident's left heel DTI and failed to reveal any documentation for the sacral buttock wound. The wound physician's 2/6/24 visit note documented the following: The sacral wound was documented as a shearing friction wound. The measurements were 4 cm by 4.2 cm by 0.1 cm. There was a moderate amount of serous (yellow fluid) drainage. The wound bed had 100% granulation (pink in color and indicates wound healing). The wound physician's 2/13/24 visit documented the following: The sacral wound was documented as a shearing friction wound. The measurements were 4.2 cm by 4.0 cm by 0.2 cm. The wound was documented with muscle exposed. Wound bed had 25% granulation, 50% slough (yellow white material) and 25% epithelialization (pink white in color) There was no change in the wound progression. The wound physician's 2/20/24 visit documented the following: The sacral wound was documented as a shearing friction wound. The measurements were 5 cm by 5 cm by 0.2 cm. The wound bed had 50% granulation, 25% slough and 25% epithelialization. The wound was documented as improving. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 2/27/24 at 1:00 p.m. LPN #3 said residents who were dependent or had issues with pressure wounds should be repositioned every two hours. She said when a resident had a new wound or skin issue the wound care team including the director of nursing (DON) and wound physician were notified. She said interventions would then be put into place, including frequent repositioning, air mattresses, nutritional consults and wound care consults. She said the facility did not have a repositioning program and nurses would have an informal discussion with certified nurse aides (CNA) on who needed to be repositioned frequently. She said Resident #24 should be repositioned at least every two hours. The wound physician was interviewed on 2/27/24 at 10:35 a.m. The wound physician said Resident #24's sacral wound had deteriorated and was unstageable. He said Resident #24's pressure wounds may have been unavoidable due to his comorbidities, however, he said there were interventions the facility should have in place which could help further deterioration and promote healing of the wound. He said Resident #24 had an incontinence brief and multiple layers between the resident and the air mattress which could trap moisture against the skin and cause further skin breakdown. The wound care physician said Resident #24 should be repositioned frequently to help promote blood flow to the wound and promote healing. The DON was interviewed on 2/27/24 at 2:25 p.m. The DON said when a resident was identified to be at risk for a pressure ulcer or had an existing pressure ulcer they should be repositioned every two hours. She said there was not a formal repositioning program in place at the facility but CNAs documented when Resident #24 was positioned.

Based on record review and interviews, the facility failed to investigate an allegation of abuse for one (#21) of three residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to ensure two incidents of verbal abuse of unidentified residents by Resident #21 on 9/21/23 and 1/7/24 were thoroughly investigated and documented in a timely manner. Cross-reference F609 for failure to report an alleged violation. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 10/30/23, was provided by the nursing home administrator (NHA) on 2/22/24 at 8:37 a.m. The policy revealed in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. II. Resident #21 A. Resident status Resident #21, age 68, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included Parkinsonism (tremors and rigidity), dementia and post traumatic stress disorder (PTSD). The 2/13/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He needed moderate assistance with dressing, and substantial assistance with dressing and bathing and set up only for eating. He was independent with mobility of short distances but needed supervision for distances of 150 feet. The assessment documented the resident had behaviors directed at others such as threatening or screaming and other behaviors not directed at others such as screaming and pacing. B. Record review Review of Resident #21's care plan, initiated on 10/6/2020 and revised on 2/27/24 (during the survey), revealed the resident had a history of using profane language to staff and peers when he was frustrated and irritable. This could often stem from loneliness, depression and boredom which could present as social withdrawal, anhedonia (lack of interest) and increased sleeping. He did not have any specific triggers, sometimes his behavior was due to additional stimuli or a result of thinking others were talking to him when they were not. Pertinent interventions initiated 10/6/2020 included: Facilitate access to Resident #21's supports such as his sister; engage in conversations with him about his sister, assist him in calling his sister on the phone and schedule visits, if Resident #21 was using profane language do not engage in power, allow for time and space to vent; redirect him to a different area such as the patio; monitor target behavior that included declining brief changes, and being uncooperative with staff during cares; provide a structured schedule of activities that was cognitively stimulating, socially engaging and physically active to decrease boredom and increase social interaction opportunities and adapt activities so the activities were consistent with his skill level and abilities. -The care plan was not updated with new interventions following the verbal abuse allegations on 9/21/23 and 1/7/24. A review of Resident #21's electronic medical record (EMR) revealed the following progress notes: A 9/22/23 behavior note, written at 10:43 a.m., documented that on 9/21/23 Resident #21 became agitated with another resident and escalated to yelling at him and arguing. During the argument, Resident #21 told the other resident, I'm going to kill you several times. His aggression de-escalated when the other resident was redirected to another area away from him. A 1/7/24 behavior note, written at 2:17 p.m., documented Resident #21 told another resident he was going to kill them and cut their head off. Staff tried to intervene and redirect but the resident was calling staff names. III. Verbal abuse incidents and investigations A. 9/21/23 incident The investigation for Resident #21's verbal abuse incident on 9/21/23 was provided by the NHA on 2/22/24 at 1:15 p.m. The investigation documented the following information: On 9/21/23 Resident #21 became agitated with another resident and escalated to yelling at him and arguing. During the argument, he told the other resident, I'm going to kill you several times. His aggression de-escalated when the other resident was redirected to another area away from him. Witnesses: Activities director. The witness stated that she overheard, I'm going to kill you from resident Resident #21, the resident calmed down after being redirected. During the clinical meeting, it was identified that Resident #21 was yelling at another resident in the dining room. Investigation findings from other staff observed residents eating and participating with no adverse effects and that there were several residents around at the time and he was just yelling in general not at one person. No other action would be taken from the 24-hour summary. -The investigation failed to include any documentation of staff interviews, interviews with the other resident or residents in the area, how and where Resident #21 was redirected to, or what adverse effects were monitored for and for how long. B. 1/7/24 incident The investigation for Resident #21's verbal abuse incident on 1/7/24 was requested on 2/26/24 at 9:23 a.m. The NHA provided a copy of the 1/7/24 progress note from Resident #21's EMR which documented the verbal incident and a copy of the Resident's care plan -A handwritten note was on the copies of the progress note and care plan. The note read Care planned, no investigation. -The facility failed to initiate, complete and maintain documentation that an alleged violation was thoroughly investigated. IV. Staff interviews The social services director (SSD) was interviewed on 2/27/24 at 1:00 p.m. The SSD said she had seen documented behaviors for Resident #21 saying he would kill someone but only once. The SSD said if a resident stated repeatedly they would kill someone the behavior was specifically described as such in the resident's care plan. The NHA was interviewed on 2/27/24 at 1:50 p.m. The NHA said Resident #21 had a care plan that documented his behavior stating he would kill people and his behavior was discussed in the clinical meeting every morning. The NHA said she determined Resident #21 had this behavior where he stated he would kill people after interviewing the facility staff who stated Resident #21 frequently said he would kill people. The NHA said she did not keep track of the notes or document the staff conversations following the 1/7/24 incident with Resident #21.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for 15 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 15 residents reviewed for immunizations out of 18 sample residents. Specifically, the facility failed to: -Offer Resident #1 the pneumococcal vaccine upon admission; -Failed to determine which pneumococcal vaccine was given to Resident #3, Resident #4 and Resident #15 and offer additional doses as needed; -Ensure Resident #5 and Resident #7 ' s electronic medical record (EMR) was up to date; -Administer and document Resident #6, Resident #9, Resident #10, Resident #12 and Resident #13 received the pneumococcal vaccine after consenting; and, -Offer additional doses of the the pneumococcal vaccine to Resident #8. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2022, retrieved on 9/11/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). (see notes) -For those over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. -Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), [NAME] disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. -Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, [NAME] disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Facility policy The Pneumococcal Vaccine policy, dated March 2023, was provided by the nursing home administrator (NHA) on 8/29/23 at 4:05 p.m. It revealed in pertinent part, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident ' s admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. The Influenza Vaccine policy, dated March 2023, was provided by the NHA on 8/29/23 at 4:05 p.m. It revealed in pertinent part, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. III. Resident #1 A. Resident status Resident #1, age 85, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO) the diagnoses included Parkinson ' s disease (deterioration of the brain that causes tremors), dementia and anxiety disorder. The 7/20/23 minimum data set (MDS) assessment revealed Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He required extensive assistance of one person for bed mobility, transfers, walking in his room and in the corridor, locomotion on the unit, dressing, eating, toileting and personal hygiene. The MDS assessment documented the resident was offered the pneumococcal vaccination and declined. -However, a review of Resident #1 ' s EMR revealed the resident had not been offered the pneumococcal vaccine. B. Record review A review of Resident #1 ' s EMR revealed Resident #1 had received the influenza vaccine on 11/15/22. Resident #1 ' s EMR did not document if Resident #1 had been offered the pneumococcal vaccination. IV. Resident #3 A. Resident status Resident #3, age 79, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included dementia, post-traumatic stress disorder (PTSD) and hypertension (high blood pressure). The 8/9/23 MDS assessment revealed Resident #3 had severe cognitive impairment with a BIMS score of zero out of 15. He required extensive assistance of two for bed mobility, dressing and personal hygiene. He required total dependence of two for transfers and toileting. He required extensive assistance of one for locomotion on and off the unit. He required supervision of one person for eating. The MDS assessment documented the resident was offered the pneumococcal vaccine, but declined it. -However, according to the Resident #3 ' s EMR the resident received the pneumococcal vaccine was administered at a different facility. B. Record review A review of Resident #3 ' s EMR revealed the resident declined to have the pneumococcal vaccine on 2/22/18, because he had received the vaccine at a different facility. -However, the consent did not specify which dose of the pneumococcal vaccine Resident #3 had received or offered an additional dose since. V. Resident #4 A. Resident status Resident #4, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 CPO the diagnoses included dementia, depression and anxiety. The 7/26/23 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 14 out of 15. He required extensive assistance of one person for bed mobility, dressing, toileting and personal hygiene. He required supervision of one person for transfers and supervision with set-up assistance for locomotion on and off the unit. The MDS assessment documented the resident ' s pneumococcal vaccination was up to date. B. Record review A review of Resident #4 ' s EMR revealed the resident received the pneumovax dose one on 8/12/13. The resident ' s EMR also said that he refused the pneumovax dose one and did not have a date that it was refused. VI. Resident #5 A. Resident status Resident #5, over the age of 90, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included dementia with behavioral disturbance. The 8/8/23 MDS assessment revealed she had moderate cognitive impairment with a BIMS score of 11 out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. She required supervision with locomotion on and off the unit. She required limited assistance of one person for eating. The MDS assessment documented Resident #5 was offered the pneumococcal and declined. B. Record review A review of Resident #5 ' s EMR revealed the resident had not been offered the pneumococcal vaccine according to the tracking system. The prevnar 23 vaccine consent documented the resident declined the vaccine. -However, the consent did not indicate why the resident refused the vaccine or documentation that education was provided to the resident or resident representative. VII. Resident #6 A. Resident status Resident #6, age 81, was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 CPO the diagnoses included Alzheimer ' s disease, vascular dementia and gastro-esophagueal reflux disease (GERD). The 7/27/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He required extensive assistance of two people for bed mobility, transfers and toileting. He required limited assistance of one person for walking in his room and in the corridor. He required extensive assistance of one person for locomotion on and off the unit, dressing, eating and personal hygiene. The MDS documented Resident #6 ' s pneumococcal vaccination was not up to date. B. Record review A review of Resident #6 ' s EMR revealed Resident #6 had not received a pneumococcal vaccine. The Prevnar 23 consent form in Resident #6 ' s EMR revealed Resident #6 consented to having the pneumococcal vaccine on 6/8/21. VIII. Resident #7 A. Resident status Resident #7, age 71, was admitted on [DATE]. According to the July 2023 CPO the diagnoses included dementia and depression. According to the 8/3/23 MDS assessment the resident had severe cognitive impairment with a BIMS score of three out of 15. He was independent with all activities of daily living (ADLs). The MDS assessment documented the resident ' s pneumococcal vaccination was not up to date. B. Record review A review of Resident #7 ' s EMR did not indicate if the resident had received a pneumococcal vaccine. The pneumococcal consent in Resident #7 ' s EMR documented Resident #7 refused the pneumococcal vaccine in 2021, but did not indicate why or if education had been provided to the resident regarding the pneumococcal vaccine. IX. Resident #8 A. Resident status Resident #8, age 74, was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 CPO the diagnoses included dementia and obesity. According to the 8/8/23 MDS assessment the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. She required extensive assistance of one person for bed mobility, transfers, toileting and personal hygiene. She required limited assistance of one person for locomotion on the unit and dressing. She required supervision with set-up assistance for eating. The MDS assessment documented Resident #8 was up to date on her pneumococcal vaccination. -However, according to Resident #8 ' s EMR the resident received the pneumovax dose one on 11/1/2013 and was not offered an additional dose to date. B. Record review A review of the resident ' s EMR revealed the resident received the pneumovax dose one on 11/1/23. There was no additional documentation that Resident #8 was offered an additional dose. X. Resident #9 A. Resident status Resident #9, age 84, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included Alzheimer ' s disease, dementia and prediabetes. The 6/20/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required extensive assistance of one person for bed mobility, toileting and personal hygiene. She required limited assistance of one person for transfer and dressing. She was independent with set-up assistance for walking in her room and in the corridor and for locomotion on the unit. She required supervision with set-up assistance for locomotion off the unit and eating. The MDS assessment documented the resident was not up to date on her pneumococcal vaccine, but did not indicate why. B. Record review A review of Resident #9 ' s EMR revealed Resident #9 consented to receive the Prevnar 13 vaccination on 10/1/21. According to Resident #9 ' s EMR she had not received the pneumococcal vaccine. [NAME]. Resident #10 A. Resident status Resident #10, age 69, was admitted on [DATE] and readmitted on [DATE]. According to the 6/22/23 CPO the diagnoses included non traumatic brain dysfunction, and hypertension. According to the 6/22/23 MDS assessment the resident had severe cognitive impairments with a BIMS score of five out of 15. He required supervision of one person for bed mobility. He required supervision with set-up assistance for transfers, dressing, eating, toileting and personal hygiene. The MDS assessment documented that Resident #10 was offered the pneumococcal vaccine and declined. -However, a review of Resident #10 ' s EMR revealed Resident #10 signed a consent to receive the pneumococcal vaccine on 6/16/23. B. Record review A review of Resident #10 ' s EMR revealed Resident #10 had not received the pneumococcal vaccine after he requested to have it on 6/16/23. XII. Resident #11 A. Resident status Resident #11, age 78, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included heart failure and alcohol abuse. According to the 8/10/23 MDS assessment the resident was cognitively intact with a BIMS score of 14 out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. The MDS assessment documented Resident #11 was not up to date on his pneumococcal vaccination. B. Record review A review of Resident #11 ' s EMR documented Resident #11 said he had received the pneumococcal vaccination at a previous facility. The immunization record documented in Resident #11 ' s EMR revealed Resident #11 had not received the pneumococcal vaccine. -However, the facility did not confirm when the resident had received the vaccine. XIII. Resident #12 A. Resident status Resident #12, age 87, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included Alzheimer ' s disease and dementia. The 5/30/23 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. He required extensive assistance of one person for bed mobility, transfers, personal hygiene, toileting and dressing. He required supervision with set-up assistance for eating. The MDS assessment documented Resident #12 was not up to date on his pneumococcal vaccination. B. Record review A review of the immunization record in Resident #12 ' s EMR revealed the resident had not received the pneumococcal vaccination. A consent form was signed on 8/23/22 in Resident #12 ' s EMR that documented he wanted to receive the vaccination. XIV. Resident #13 A. Resident status Resident #13, age 79, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included schizoaffective disorder (mental illness that can affect behaviors). The 8/17/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required supervision for all ADLs. The MDS assessment documented Resident #13 was offered and declined the pneumococcal vaccination. B. Record review A review of Resident #13 ' s EMR revealed Resident #13 refused the vaccine on 4/5/16. Resident #14 was not provided education or offered the vaccine again. XV. Resident #14 A. Resident status Resident #14, age 78, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included osteoarthritis, and thyroid disorder. The 6/6/23 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision for all ADLs. The MDS assessment did not document if the resident was up to date on the pneumococcal vaccination. B. Record review A review of Resident #14 ' s immunization record in her EMR revealed the resident had not received a pneumococcal vaccination. The prevnar 23 consent form documented Resident #14 desired to receive the vaccination. XVI. Resident #15 A. Resident status Resident #15, age 93, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included dementia. The 5/16/23 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. She required limited assistance of one person for walking in her room and in the corridor. She required supervision of one person for eating. The MDS assessment documented Resident #15 was up to date on her pneumococcal vaccination. -However, Resident #15 received the prevnar 13 vaccination on 4/2/15 and was not offered the prevnar 23. B. Record review A review of the immunization record in Resident #15 ' s EMR documented Resident #15 received the prevnar 13 vaccination on 4/2/15 and was not offered the second dose. XVII. Resident #16 A. Resident status Resident #16, age 86, was admitted on [DATE]. According to the August 2023 CPO the diagnoses included dementia. The 7/20/23 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. She required limited assistance of one person for eating. The MDS assessment documented Resident #16 was not up to date on her pneumococcal vaccination. B. Record review A review of the immunization record in Resident #16 ' s EMR revealed Resident #16 had not received the pneumococcal vaccine. A consent form documented the pneumococcal vaccination was refused on 4/14/23. The consent form did not indicate why the vaccine was refused or provide education regarding the vaccine. XVIII. Resident census and conditions The Resident Census and Conditions report dated 8/30/23 documented 14 residents received the pneumococcal vaccine out of a total census of 64 residents. XIX. Staff interviews The registered nurse (RN) from the second floor was interviewed on 8/31/21 at approximately 11:00 a.m. The RN said the admitting nurse provided education to the residents about the importance of receiving the pneumonia vaccination and the flu vaccination. He said if the resident wanted the vaccinations, then an order would be obtained, and then the nurse would administer. The RN said the pneumonia vaccination was a vial for the facility, not individual. The infection preventionist (IP) was interviewed on 8/31/23 at 12:44 p.m. The IP said he had started his position on 8/29/23. The IP said the facility utilized the immunization tab in the EMR to track vaccines. The IP said the immunization tab should be up to date with all received and refused vaccinations. The IP said when a resident was admitted to the facility, the facility confirmed what immunizations the resident had received. The IP said the resident was offered the vaccines if they were due. The IP said if a resident refused the vaccination the consent should indicate why and education should be provided to the resident or representative. The IP said he could not confirm if Resident #1 had been offered the pneumococcal vaccine, since it was not documented in his EMR and there was not a consent form indicating Resident #1 had declined the vaccine. The IP confirmed Resident #3 had declined to have the pneumococcal vaccine upon admission in 2018. The IP said the resident had received the pneumococcal vaccine prior to admission. The IP said he was unsure what dose of the pneumococcal vaccine the resident had received prior to admission. The IP said the facility should have figured out what dose the resident had received and offered an additional dose to ensure the resident was up to date on his pneumococcal vaccinations. The IP said Resident #5 ' s EMR was not up to date, because it did not include that the resident had received the prevnar 13 vaccine prior to admission. The IP said he was able to locate a document that was in the immunization binder in his office that revealed Resident #5 had received two doses of the pneumococcal vaccine prior to admission. The IP said the resident ' s EMR should have been updated with the current vaccine information. The IP said the pneumococcal consent form should have indicated that the resident had already received the prevnar 13 dose. The IP said Resident #6 requested to have the pneumococcal vaccine on 6/8/21. The IP said there was no documentation indicating Resident #6 received the pneumococcal vaccine. The IP said Resident #7 ' s EMR did not document that Resident #7 had refused the pneumococcal vaccine. The IP said Resident #7 ' s consent should have documented why he refused and education should have been provided to the resident. The IP said residents should be offered vaccinations yearly if they refused upon admission. The IP said he was not sure if Resident #8 had been offered an additional dose of the pneumococcal vaccine. The IP said the second dose should be offered at least 12 months after the first dose. The IP said Resident #9 consented to receive the pneumococcal vaccine, but there was no documentation revealing Resident #9 had received the pneumococcal vaccine. The IP said the facility should have completed a vaccination review for Resident #11 upon admission to determine which vaccinations he had received and when. The IP said Resident #12 had not received the pneumococcal vaccination. The IP said Resident #13 refused the vaccine several years ago. The IP said residents should be offered the vaccine yearly after a refusal. The IP said Resident #15 needed to be offered the second dose of the pneumococcal vaccination. The IP said the immunization tab was not a good tool to track when residents were due for vaccinations. The IP said he would implement a new tool to better monitor vaccination status of the residents and when they were due for additional doses. The assistant director of nursing (ADON) was interviewed on 8/31/23 at 4:45 p.m. The ADON said she was unsure which dose the EMR was referring to when it documented pneumovax dose one. The ADON said the documentation needed to be more clear on which pneumococcal vaccine was given, so the correct second dose could be administered. The ADON was interviewed again on 8/31/23 at 5:18 p.m. The ADON said vaccines should be verified upon admission. The ADON said if a resident needed a vaccination upon admission it was offered to them. The ADON said it was the facility ' s responsibility to call the pharmacy and get a dose of the pneumococcal vaccination delivered to the facility for that resident. The ADON said the residents were not getting the pneumococcal vaccines, because nursing staff was only obtaining the consent for the vaccine. The ADON said the nursing staff was not calling the physician for an order to administer the vaccine. The medical director (MD) was interviewed on 8/31/23 at 5:20 p.m. The MD said the facility used the Colorado immunization system to check what immunizations a resident had received. The MD said it was recommended for the residents to receive the prevnar 13 and then the prevnar 20 at least 12 months after. The MD said the facility should have offered the vaccinations yearly if a resident had refused. The MD said she would help the facility conduct an audit of all immunizations. The MD said it would be acceptable for residents to receive additional doses of the pneumococcal vaccination. The ADON was interviewed again on 8/31/23 at 6:28 p.m. The ADON said the facility would conduct an audit and ensure residents were provided the vaccines they needed.

Based on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all 64 residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program. Findings include: I. Professional references The Centers for Disease Control and Prevention (CDC) (updated 3/29/21) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, retrieved on 9/7/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Assign One or More Individuals with Training in Infection Control to Provide On-Site Management of the IPC Program. This should be a full-time role for at least one person in facilities that have more than 100 residents. II. Facility policy and procedure The Infection Prevention and Control Program policy, dated March 2023, was provided by the nursing home administrator (NHA) on 8/29/23 at 4:05 p.m. It revealed in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. III. Record review A request was made for the infection preventionist (IP's) infection control certificate on 8/30/23. The IP said he had yet to enroll in the course to obtain the infection control certificate (see interview below). IV. Staff interviews The IP was interviewed on 8/31/23 at 12:44 p.m. The IP said he had started a new position as the IP and the staff development coordinator on 8/29/23. The IP said he had the paperwork to enroll into an infection prevention course to obtain a certificate, but had not signed up for it yet. The IP said he understood he needed to complete the course as soon as possible. The IP said the previous infection preventionist had resigned six to eight weeks ago. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 8/31/23 at 2:55 p.m. The DON and the ADON said there was not another staff member at the facility that had an infection control certificate.

Based on record review and interviews, the facility failed to establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program. Specifically, the facility failed to have a process in place to track antibiotic usage in the facility. Findings include: I. Professional standard The Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on [DATE], included the following recommendations: Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections. II. Facility policy and procedure The Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy, dated [DATE], was provided by the assistant director of nursing (ADON) on [DATE] at 6:15 p.m. It revealed in pertinent part, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. III. Antibiotic tracking system The ADON provided a copy of the Antibiotic Stewardship Program pharmacy services agreement on [DATE] at 4:30 p.m. It revealed in pertinent part, a one year antibiotic stewardship program was initiated on [DATE] (see NHA interview below). IV. Staff interviews The ADON was interviewed on [DATE] at 4:30 p.m. The ADON said that she had looked through the records to see if she could find the tracking of the infections in the building. However, she was unable to locate any sort of tracking of the infections in the building. The NHA was interviewed on [DATE] at 5:05 p.m. The NHA said the facility had contracted with an outside pharmacy company to complete the antibiotic stewardship program. The NHA said there had recently been a change in leadership at the facility. The NHA said she reached out to the outside pharmacy company to renew the contract and the pharmacy explained to her that the contract expired three or four years ago. The NHA said a new contract was drafted, but the corporation wanted to sign a contract with a different pharmacy company. The NHA said they did not currently have a process in place to track antibiotic usage within the facility.

Based on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease in three of three units. Specifically, the facility failed to: -Ensure hand hygiene was offered to residents before meals on the first and second floors; -Ensure hand hygiene was performed after providing incontinence care; and -Ensure laundry was sorted and cleaned properly; Findings include: I. Failure to provide hand hygiene opportunities for residents A. Facility policy and procedure The Handwashing/Hand Hygiene policy, dated September 2019, was provided by the assistance director of nursing (ADON) on 8/31/23 at 6:15 p.m. It revealed in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. B. Observations During a continuous observation in the first floor dining room on 8/30/23 beginning at 11:20 a.m. and ended at 12:14 p.m. the following showed: -At 11:25 a.m. there were 13 residents in the dining room. The residents were not encouraged to perform hand hygiene upon entering the dining room before the meal. During continuous observations in the second floor dining room on 8/30/23 beginning at approximately 11:15 a.m., the following showed. -The front entrance to the dining room had a free standing hand sanitizer dispenser. However, residents entered the dining room did not use. The certified nurse aides in the dining room failed to offer residents hand hygiene prior to their meal being served. C. Interviews The infection preventionist (IP) was interviewed on 8/31/23 at 12:44 p.m. The IP said residents should be offered hand hygiene upon entering the dining room. II. Failure to ensure hand hygiene was performed after incontinent care A. Observations On 8/31/23 at 10:08 a.m., certified nurse aide (CNA) #1 was observed to assist Resident #17 to his room to assist him in the bathroom. The CNA donned gloves and removed the soiled incontinence brief. Without removing the used gloves or performing any hand hygiene the CNA went to a cupboard in the resident's room opened the door and retrieved a clean brief. When the resident was finished the CNA using the same used gloves placed her arm under the resident arm and assisted him to stand. She opened the wipes container and pulled out a clean wipe from the pack and cleansed the resident's buttocks and peri area. With the same soiled gloves the CNA reached into a basket with hygiene products and removed a tube of barrier cream and squeezed some onto the used glove and wiped it onto the resident's buttocks. The CNA removed the used gloves at that point but did not perform any hand hygiene. The CNA reached her hands into a box of clean gloves to retrieve new gloves and put them on. The CNA then helped the resident apply the brief and pull up his pants. The CNA then assisted the resident into his wheelchair. The CNA removed the used gloves but did not perform hand hygiene. On 8/31/23 at 11:02 a.m., registered nurse (RN) #1 was observed performing a wound care treatments. RN #1 was in the dining room area gathering wound care supplies for the medication cart. RN #1 applied gloves and gathered a packaged gauze pad and packaged betadine solution. The nurse was dictated to by another task where she came into contact with the top of the nurses cart and another table in the dining room. Once done using the same gloves and no additional hand hygiene the nurse gather the supplies from the top of the medication cart went to Resident #18 with the same gloves and no additional hand hygiene the nurse opened the gauze and betadine pack. With the gauze soaked pad the nurse lifted the resident's shirt and applied the solution to the wound on the resident's back. B. Interviews The infection preventionist (IP) was interviewed on 8/31/23 at 12:44 p.m. The IP said prior to entering a resident room, staff were required to perform hand hygiene. Once gloves were donned, then gloves needed to be changed in between each task, and perform hand hygiene after the gloves were doffed. The IP said staff had received training on proper hand hygiene. III. Laundry room A. Professional reference The Centers for Disease Control (CDC) Linen and laundry management, https://www.cdc.gov/hai/prevent/resource-limited/laundry.html retrieved on 9/12/23 read in pertinent parts, Always launder soiled linens from patient care areas in a designated area, which should: -be a dedicated space for performing laundering of soiled linen -not contain any food, beverage or personal items -have floors and walls made of durable materials that can withstand the exposures of the area (e.g., large quantities of water and steam) -have a separation between the soiled linen and clean linen storage areas, and ideally should be at negative pressure relative to other areas B. Observation The laundry room was located in the basement. The laundry room had two washing machines, and two dryers along the wall. To the right of the washing machine, directly next to the machine was a space approximately three feet wide. The space had a wheeled laundry cart. This small area was the location where the linens were sorted to begin the laundry process. The linen and personal clothes were then folded across from the washing machines. The laundry assistant (LA) #1 provided an overview of the process of how laundry which included linens, and personal laundry was handled. B. Record review The facility was unable to provide the temperature of the washing machines for each cycle. The facility provided the washing machine manual, however, it was not specific to what the temperatures of each cycle were. C. Interview Laundry assistant (LA) #1 was interviewed on 8/30/21 at 1:41 p.m. LA #1 said the laundry arrived from the three floors to the basement. She said the laundry was in a laundry cart. She said she wore a gown and gloves to sort the laundry. She sorted the laundry between linens, and personal laundry as each set was washed on a different wash cycle. She sorted dirty laundry in the same room as the washing machine, dryer and where she folded clean clothes. LA #1 said when residents were on isolation for an infection the laundry was put into sugar bags by the nursing staff. LA #1 said the nursing staff often combined resident personal clothes and linens into the sugar bags. LA #1 said she would reach into the sugar bags to sort the laundry and then would place it into the washing machine. LA #1 said she was not sure what the temperature of the water was for each cycle. The IP said the dirty laundry should not be sorted in the same room as the clean laundry. The IP said the laundry assistants should use a sanitizing chemical to clean the laundry machines between use. The IP said the laundry assistant should never reach into a sugar bag and sort laundry.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for four of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #4 and CNA #5. Findings include: I. Record review A request for CNA #2 (hired 3/9/2020) , CNA #3 (hired 6/17/03) and CNA #4 (hired 1/29/22), and CNA #5 (hired 9/10/23) annual performance review and in-service education based on the outcome of the reviews on 8/31/23. The staff development coordinator provided a copy of CNA #2's last performance review that had been completed on 8/22/22. CNA #3, CNA #4, CNA #5 and CNA #6 did not have a performance review. CNA #2, CNA #4 and CNA #5 had not completed the annual in-service education based on the outcome of their reviews. II. Staff interviews The staff development coordinator (SDC) was interviewed on 8/31/23 at 6:48 p.m. The SDC said he had started a new position as the IP and the SDC on 8/29/23. The SDC said CNA's should have an annual performance review. The SDC said the CNA's should be provided at least 12 hours of training based on their annual performance review.

Based on observations, record review and interviews, the facility failed to ensure three of three units were free from accident hazards. Specifically, the facility failed to: -Ensure three of three serving kitchens were equipped with ventilation hoods when cooking items that contained grease -Ensure coffee was served at an appropriate temperature on the first floor unit; and, -Ensure linens, chemicals and dry storage was stored appropriately. Findings include: I. Failed to have ventilation hoods when cooking items that contained grease A. Facility policy and procedure The Fire Prevention policy, dated 2021, was provided by the admissions coordinator (AC) on 8/31/23 at 6:55 p.m. It revealed in pertinent part, The facility should be constructed, equipped and maintained to promote fire safety and protect the health and safety of patients/residents, employees and the public. Hoods, fans, vents, grills, and other equipment should be kept free of grease and dust accumulation. B. Observations The facility had three floors. Each of the floors had a kitchenette, which contained a sink, refrigerator, steam table, microwave and a plug in griddle. During a continuous observation in the first floor dining room on 8/30/23 beginning at 11:20 a.m. and ended at 12:14 p.m. the following: -Dietary aide (DA) #2 opened the refrigerator and placed a hamburger onto the griddle in the serving kitchen. There was not a vent above the griddle. Above the griddle on the ceiling there was a dark round circle of grease. -DA #2 cooked an additional two more hamburgers on the griddle in the serving kitchen. During a continuous observation on the second floor dining room on 8/30/23 beginning at 11:15 a.m. DA #3 had a griddle which plugged into the wall. The griddle had no vent above the griddle. She placed three uncooked hamburger patties on the griddle. She cooked the hamburger patties. During the cooking, smoke arose from the griddle. C. Staff interviews DA #3 was interviewed on 8/30/23 at approximately 12:00 p.m. DA #3 said she used the griddle in their serving kitchen to cook hamburgers daily. DA #2 was interviewed on 8/30/23 at 12:08 p.m. DA #2 said the microwave that was above the griddle had a vent. DA #2 said he did not turn the vent on during the meal service. The FBD was interviewed on 8/30/23 at 3:21 p.m. The FBD said there was a griddle in the second, third and fourth unit serving kitchens. The FBD said the griddles were used to cook eggs, grilled cheeses and hamburgers to order at meals. The FBD said there was not a ventilation system in the serving kitchens. The FBD said she would remove the griddles immediately and have all foods prepared in the main kitchen. The NHA was interviewed on 8/30/23 at 3:21 p.m. The NHA said griddles could not be used in the serving kitchens, because there was not proper ventilation. II. Failed to serve coffee at an appropriate temperature A. Professional reference According to the U.S. Consumer Product Safety Commission (CPSC) regarding Tap Water Scalds. Document #5098, retrieved from https://www.cpsc.gov on 9/13/23. Most adults will suffer third degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees; a five minute exposure could result in third degree burns. B. Observations During a continuous observation in the second floor dining room on 8/30/23 beginning at 11:20 a.m. and ended at 12:14 p.m. the following: -An unidentified dining staff member poured a cup of coffee directly from the coffee machine. The coffee was steaming and the dining staff member gave it directly to a resident. -The unidentified dining staff member poured another cup of coffee and gave it directly to a resident. The coffee was steaming. -At 12:08 p.m. upon prompting DA #2 took the temperature of the coffee. It was 174.4 degrees fahrenheit ( F). The coffee was steaming. The unidentified dining staff member said she typically did not take the temperature of the coffee or hot water prior to serving it to residents. The unidentified dining staff member said they did not have a log to monitor the temperatures of hot liquids. -At 12:14 p.m. the cup of coffee that DA #2 took a temperature that was still on the counter and was steaming. C. Record review A request was made for the hot beverage monitoring logs on 8/30/23. The FBD said the facility did not have a system in place to monitor the temperature of hot beverages that were served to residents. D. Staff interviews An unidentified dietary aide (DA) was interviewed on 8/30/23 at 12:08 p.m. The unidentified DA said she did not take the temperature of hot liquids prior to serving them to the residents. The unidentified DA said she got hot coffee out of the machine and gave it directly to residents. The FBD was interviewed on 8/30/23 at 3:21 p.m. The FBD said the residents had complained that the coffee was too cold. The FBD said a company came out and raised the temperature of the coffee machines to make the coffee hotter. The FBD said the facility did not monitor the temperature of the coffee after the outside company raised the internal temperature. The FBD said she would contact the company to come adjust the temperature of the coffee machine on the second floor and would implement a hot beverage monitoring system. III. Failed to store linens, chemicals and dry goods properly A. Professional reference According to National Fire Protection Association, https://www.nfpa.org/assets/files/AboutTheCodes/13/Errata_13_19_2.pdf, Shelving, and any storage thereon, directly below the sprinklers shall not extend above a plane located 18 in. (450 mm) below the ceiling sprinkler deflectors. B. Observations On 8/30/23 at 1:30 p.m. pillows and linens were stored against the ceiling and pipes in the basement. Chemicals were stored within six inches of pipes and the ceiling. -At 1:52 p.m. dried goods were stored within six inches of the ceiling and fire sprinklers, in the food dry storage room. C. Staff interviews The NHA was interviewed on 8/30/23 at 3:21 p.m. The NHA said linens, chemicals and dry goods could not be stored within 10 inches of the ceiling. The NHA said she would have staff remove the items immediately. The director of maintenance (DOM) was interviewed on 8/31/23 at 11:21 a.m. The DOM said items cannot be stored within 18 inches of the ceiling.

Based on observations and interviews the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment for five out of 14 resident rooms. Specifically, the facility did not facilitate the necessary housekeeping and maintenance services to maintain the resident rooms to include room [ROOM NUMBER], #104, #201, #220 and #223 in a sanitary and comfortable manner. Findings include: I. Facility policies The Cleaning and Disinfecting Resident's Rooms policy, revised August 2013, was provided by the nursing home administrator (NHA) on 3/28/23 at 4:11 p.m. The policy revealed housekeeping surfaces (floors and tabletops) would be cleaned on a regular basis, when spills occur and when the surfaces were visibly soiled. Environmental surfaces would be disinfected (or cleaned) on a regular basis (daily, threes per week) and when the surfaces were visibly spoiled. All floors should be mopped/cleaned/vacuumed daily in accordance with the established procedures. Bathrooms, including showers, whirlpools, century baths, commodes, would be cleaned daily in accordance with the established procedures. II. Room observations Resident room [ROOM NUMBER] was observed on 3/28/23 at 11:47 a.m. There was missing cove base in the bathroom. The bathroom floor corners were soiled and grimy and there was debris (trash, litter) in the corners. There was a hole in one of the bathroom walls. The bathroom floor was yellowed (discolored, aged) and the bathroom entrance threshold was soiled, stained and grimy. The room's cove base was grimy and stained and the floor adjacent to the cover base was grimy. The room corners were grimy and contained debris. Resident room [ROOM NUMBER] was observed at 11:59 a.m. The room's cove base was grimy and the floor adjacent to the cover base was grimy. The room corners were grimy and contained debris. Resident room [ROOM NUMBER] was observed at 12:30 p.m. The bathroom cove base was grimy and the floor adjacent to the cove base was grimy. The bathroom corners were grimy and contained debris. The room's cove base was grimy and the floor adjacent to the cover base was grimy. The room corners were grimy and contained debris. There was a hole in the room wall by the entrance to the bathroom. Resident room [ROOM NUMBER] was observed at 12:41 p.m. The bathroom floor had yellowed stains and the bathroom entrance threshold was grimy. The bathroom cove base was grimy and the floor adjacent to the cove base was grimy. The bathroom corners were grimy and contained debris. There was grimy caulk around the toilet base. The room's cove base was grimy and the floor adjacent to the cover base was grimy. The room corners were grimy and contained debris. Resident room [ROOM NUMBER] was observed at 1:25 p.m. The bathroom floor had yellowed stains. The bathroom cove base was grimy and the floor adjacent to the cove base was grimy. The bathroom corners were grimy and contained debris. The room's cove base was grimy and the floor adjacent to the cover base was grimy. The room corners were grimy and contained debris. III. Staff interviews An environmental tour of the above mentioned rooms was conducted on 3/28/23 at 1:52 pm. with the NHA. The NHA acknowledged the above observations in the resident's rooms and bathrooms. The floor technician (FT) was interviewed on 3/29/23 at 2:00 p.m. He said resident rooms and bathrooms were cleaned daily. He said this included sweeping and mopping the floors. He said the housekeeping staff should clean the cove base and the debris on the floors each day. He said there was no routine deep cleaning schedule for resident rooms. The housekeeping supervisor (HSKS) said the resident rooms and bathroom were cleaned daily. She said each housekeeping cart contained a form that let the housekeeper know what to clean. She said the floors were swept and mopped daily in the resident rooms and bathrooms. She said the cove base and debris should be cleaned daily in the resident rooms and bathrooms. She said she had been the supervisor for a few days and had not had the time to check the efficiency of the housekeepers. The environmental services director (ESD) was interviewed on 3/29/23 at 4:21 p.m. He said resident rooms and bathrooms were cleaned daily. He said sweeping and mopping of floors was part of the daily cleaning regimen. He said he felt the housekeeping staff were doing a good job cleaning and disinfecting resident rooms and bathrooms. -However, based on observations (see above) there were several resident rooms and bathrooms that were not cleaned.

Based on observations, staff interviews, and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#60 and #62) of two residents reviewed for catheter care, out of 31 sample residents. Resident #60 admitted to the facility on [DATE] without having a catheter in place. The resident did not have a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . While in the care of the facility, the resident fell and fractured a hip and required surgical intervention. The resident returned to the facility on [DATE] with the indwelling catheter. The facility failed to ensure Resident #60 had orders for the use of an indwelling catheter to assist the resident with bladder function. The facility failed to conduct a comprehensive assessment to determine if the indwelling catheter was clinically indicated. The facility failed to have order for routine catheter care to maintain a healthy bladder and prevent catheter associated urinary tract infections to the extent possible. Once the catheter was in place, the facility failed to continually assess the resident's catheter for possible removal to aid the resident in maintaining and/or restoring bladder continence to the resident's best optimal ability. Additionally, the facility failed to ensure proper maintenance and care of the resident's indwelling catheter and the resident's bladder health declined, the resident became increasingly confused and was in a weakened condition, leading the facility to send the resident to the hospital where the resident was assessed and diagnosed with a significant urinary tract infection with [CONDITION(S)] requiring antibiotic treatment and intravenous fluids. The resident required intravenous (IV) antibiotic therapy and hospital care to treat a catheter associated urinary tract infection (CAUTI). In addition, the facility failed to: -Ensure Resident #62 was provided appropriate catheter care assistance using acceptable standards of nursing care, to ensure the resident's catheter was draining to gravity and not backing up into the resident's bladder; -Ensure orders for catheter care and maintenance; and, -Ensure Resident #62's leg bag was emptied timely and not bulging full of urine. Findings include: I. Professional reference According to Potter, P.A., Perry, A.G. , et.al. Fundamentals of Nursing, ninth ed., 2017, pp. 1121: Routine catheter care: Patients with indwelling catheters require regular perineal hygiene, especially after a bowel movement, to reduce the risk for catheter-associated urinary tract infections ([CONDITION(S)]) and catheter associated [CONDITION(S)] (CAUTI). -In many institutions, patients receive catheter care every 8 hours as the minimal standard of care. -Empty the drainage bags when half full. An overfull drainage bag can create tension and pulling on the catheter, resulting in trauma to the urethra (the duct by which urine is moved out of the body from the bladder) and/or urinary meatus (the opening in the body from which the urine leaves the body), and increase risk for CAUTI. -Expect continuous drainage of urine into the drainage bag. In the presence of no urine drainage, first check to make sure that there are no kinks or obvious occlusion of the drainage tubing or catheter. Preventing catheter-associated infection (CAUTI): A critical part of routine catheter care is reducing the risk for CAUTI. -A key intervention to prevent infection is maintaining a closed urinary drainage system. Another key intervention is prevention of urine backflow from the tubing and bag into the bladder. The nurse should monitor the system to prevent pooling of urine within the tubing and to keep the drainage bag below the level of the bladder. II. Facility policy and procedure The Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing policy and procedure, revised September 2017, was provided by the nursing home administrator (NHA) on 11/3/22 at 8:30 p.m. It read in pertinent part: It is the responsibility of the interdisciplinary team to maintain vigilant practices to prevent CAUTI and to recognize and report early indications that a [CONDITION(S)] may be developing. Facility-wide surveillance of infections is collected as part of the infection control program. The following CAUTI prevention strategies have been adopted and are to be followed: -Insert catheters only for indications deemed appropriate for urinary catheter insertion, and as ordered. -Leave catheters in place only as long as needed. Conduct ongoing assessment and monitoring of residents with indwelling catheters to establish continued need. Document every 24 hours or per facility protocol. -Do not insert or maintain a urinary catheter unless you have been properly trained and demonstrated competency in this area. -Always practice vigilant hand hygiene and standard precautions when handling catheter systems. -After aseptic insertion, maintain a sterile closed drainage system. -Maintain unobstructed urine flow. -Perform daily meatal hygiene with soap and water for residents with an indwelling catheter. Document: The continued need for the resident's indwelling catheter; and any signs or symptoms of urinary tract infection. III. Resident #60 A. Resident status Resident #60, age 75, was admitted on [DATE] and discharged on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/9/22 admission minimum data set (MDS) assessment revealed the resident had intact cognition and scored a 15 out of 15 on the brief interview for mental status (BIMS). The resident showed no signs of delusions or [CONDITION(S)] and had no aggressive behaviors. The resident did not reject care or assistance. The resident upon admission was able to complete some activities of daily living with only set up assistance from staff. The resident needed extensive assistance from staff for bed mobility, transferring, toileting, dressing, and with personal hygiene. Once assisted to a standing position the resident was able to walk unassisted with a walker device. The resident was occasionally incontinent of bladder and bowel. The resident did not have a catheter and was not placed on a toileting program. C. Record review review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of admission the resident needed minimal assistance setting up the task from staff to walk and perform activities of daily living including using the bathroom. While the resident had occasional episodes of bladder incontinence there was no documentation that the resident was having difficulty emptying the bladder. There was no documentation that the resident was having problems emptying the bladder. The resident had a fall on 9/1/22 and fractured a hip. Following the fall the facility provided the resident an indwelling catheter. The record failed to document a clinical indication or an assessment of need for the catheter. Review of the resident's October 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -No orders for placement of the indwelling catheter and no clinical indication (reason) of why the catheter was placed; -No orders for routine catheter care, maintenance or monitoring of the resident catheter; and -No care interventions to promote a healthy bladder, to maintain bladder continence or restore bladder continence and/or function as possible. Facility progress notes failed to show the date and time the resident was provided with the indwelling catheter, as per the admission MDS the resident admitted on [DATE] without an indwelling catheter (see above). The first progress notes to document the resident's catheter were on 9/12/22 and 9/14/22. -A progress note: Spiritual care note, dated 9/12/22 at 9:59 a.m., read in part: Resident #60 complained that his Foley is painful sometimes. (Resident) says he prefers to use his wheelchair to move around and be able to use the bathroom. -Progress note dated 9/14/22 at 2:54 a.m. read in part: Towards the night time on 9/13/22, this nurse observed that urine in resident Foley catheter bags appears to be dark with spotted patterns of blood clots in the bag and drainage tube. Foley catheter bag emptied and subsequent urine return continues to come out with dark blood stained urine with strings of blood clots .This nurse notified the on-call (physician provider office). The on-call provider gave orders to send the resident to the hospital for further evaluation. -Progress note dated 9/14/22 at 3:27 p.m. read in part: Resident returned to facility at 9:05 a.m. from the hospital emergency room , hospital discharge papers indicate all labs performed at the hospital were within normal (limits). Foley catheter was also changed with 16 fr (French)/ 10 cc (cubic centimeter) balloon. Denies any spasms, Foley is draining dark amber urine. -A progress note dated 9/26/22 at 11:41 a.m. read in part: Resident complained of burning and pain and having the urge to urinate. The Foley catheter was intact and draining well. Complaining of lower abdominal pain with palpation. Foley catheter changed, with 16fr and 10cc; immediate output was 200cc, of cloudy, thick and concentrated urine. -A skilled evaluation note dated 9/27/22 at 1:40 a.m. read in part: [CONDITION(S)]: Cloudy in appearance. Complaint of urinary urgency. Complaint of urinary burning. Urine sample collected due to milky urine, (physician office) notified awaiting physician instructions. -A progress note dated 10/5/22 at 5:58 p.m. read in part: Resident is lying on the floor in his room. Resident Foley catheter was out with the balloon intact. Foley catheter 18 fr changed today. Catheter in place due to urinary retention. Prior to the 10/5/22 note, the resident was provided a 16 fr Foley catheter (see notes above). Additionally, there was no documentation about the results of the resident's urinalysis done on 9/27/22 or resolution of the resident's documented symptoms (see notes above). -A progress note dated 10/19/22 at 9:48 a.m. read: Early this morning, right after, the resident was noted to be sleepy, tired and poorly aroused. Resident appeared to be lethargic, and gasping for air. Upon further assessment the resident revealed low blood pressure. Physician notified and urged to send the resident out to the hospital for further evaluation. (See hospital notes above.) Hospital emergency room treatment records dated 10/19/22 revealed the resident was admitted from the facility for a change in mental condition, increased shortness of breath, increased fatigue and [CONDITION(S)] (low blood pressure). The resident's Foley catheter appeared cloudy. The hospital performed a urinalysis and found the resident's urine showed pyuria (the presence of pus in the urine, typically from bacterial infection) and hematuria (presence of blood). Diagnosis, assessment /plan: -Acute complicated [MEDICATION(S)] - urine with pyuria and hematuria. Likely secondary to chronic indwelling Foley catheter. -[CONDITION(S)] ([CONDITION(S)]) (enlarged prostate gland) with chronic Foley catheter - Uncertain if chronic Foley is due to chronic urinary retention. Consider a void trial while here. The resident was admitted to the hospital on 10/20/22 for further treatment. Hospital admission notes dated 10/20/22 documented, Intensive care unit (ICU) consulted after (patient) had to be intubated in the emergency room . (diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Severe [CONDITION(S)] with septic shock. SIRS (a serious condition in which there is inflammation throughout the whole body) criteria: Hypoxemia (lack of oxygen in the blood), leukocytosis (high white blood cell count; indicating the body is fighting and infection), [CONDITION(S)] (elevated heart rate), tachypnea (rapid breathing) Source: Urinary tract infection. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Urinary tract infection: On [MEDICATION(S)] and Vancomycin; adjust these antibiotics based on (urine) cultures -Acute on chronic renal failure: IV (intravenous) fluids given for [CONDITION(S)]. Renally dose (adjust medications based on renal function) all meds, hold nephrotoxins (substances damaging to the kidneys), and monitor ins and outs (urine intake and output); and, -[CONDITION(S)] with chronic Foley catheter: monitor urine cultures. D. Staff interview The director of nursing (DON) was interviewed on 11/3/22 at 5:34 p.m. The DON said the facility ensures nurses and certified nurse aides are competent with catheter care before they provide service for a resident with a catheter. In order to ensure the resident's catheter is maintained properly, nursing staff tracks the date the catheter was changed and monitors catheter function daily. A resident's catheter should be changed once a month and as needed. Between changes, nursing staff were expected to monitor the catheter for leaks. If there are no orders for the resident to continue with the catheter the nurse on duty will contact the resident's physician for an order to maintain and change the resident's catheter once a month. Upon receipt of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A full set of treatment orders for catheter care will auto-populate once the nurse entered the catheter order. The DON should confirm the resident's catheter orders are entered into the resident's TAR. The DON said Resident #60 received physician services from an outside physician provider and with that particular provider, it can be challenging to get physician treatment notes and orders timely. The physician did provide verbal direction that it was better for the resident to keep the catheter in place so the resident would not have to be changed a lot while the resident was in the healing process after recent hip surgery. The DON said Resident #60 had ongoing issues with the indwelling catheter. The physician ordered lab tests on the resident's urine and results were delayed because they were sent to the wrong facility. Because of catheter complications, the resident was sent to the hospital twice for medical assessment and treatment. The resident's condition was progressively declining, being less likely to participate in activities of daily living and other social activities. III. Resident #62 A. Resident status Resident #62 , under the age of 65, was admitted on [DATE]. According to the computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 9/9/22 minimum data set assessment (MDS) the resident had severely impaired cognition as evidenced by a score of five out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance from one staff member for transfers, bed mobility, toilet use, hygiene, and was totally dependent on staff for bathing. The Resident was always incontinent of bowel, and had an indwelling catheter in place. B. Resident observations and interview On 10/31/22 at 10:18 a.m., Resident #62 was observed. Resident #62 was observed sitting on the side of her bed. The resident's Foley catheter drainage tube was exiting upwards over the top of the resident's waistband of her pants then extended downward towards the floor. The tubing was then looped upward from the drainage bag which was then attached to her walker assistive device at a height above her bladder. -This placement of the catheter bag and tubing promotes urine to drain properly. When the drainage tube is placed below the level of the resident's bladder it will flow out of the bladder with gravity and prevent the urine from flowing backwards into the bladder. When urine flows back into the bladder once it has left the body the individual risks infections and other bladder complications. On 10/31/22 at 12:20 p.m., Resident #62 was observed exiting the lunchroom with the Foley catheter drainage tubing running up the resident leg above the bladder and exiting the top of the resident's pants over the waistband, causing the urine flow to flow out of the resident's bladder against gravity risking that the expelled urine may flow back into the resident's bladder. The catheter drainage tubing was long and was dragging on the floor. The urine in the tube was clearly visible and was observed to be cloudy, milky in color with stringy [MEDICATION(S)] present. A CNA approached and said this is not right and asked the resident if she would walk to the bathroom so the catheter tubing could be readjusted correctly. On 11/1/22 at 10:30 a.m. Resident #62 Foley catheter leg bag was observed. The leg bag was over full and bulging out with cloudy yellow urine. Resident #62 was interviewed on 11/2/22 at 11:30 a.m. Resident #62 was unable to describe how the nurses took care of her catheter or understand the reason the nurses changed the overnight bag to the leg bag in the daytime while awake. C. Record Review The resident's October 2022 CPO was reviewed. Orders pertinent to the catheter revealed: -Indwelling Foley catheter, change each month on the 24 of the month, with 16 French, 30 cubic centimeters (CC) bulb inflation. The CPO did not document the reason for the catheter placement,orders for routine catheter care, maintenance to ensure proper function, placement of tubing or use of a leg bag during waking hours. D. Staff interviews Registered nurse #3 was interviewed on11/3/22 at 1:15 p.m. RN #3 reviewed the resident's CPO and confirmed the resident did not have orders for Foley catheter care, monitoring and assessment. RN #2 and RN #4 were interviewed on 11/3/22 at 2:10 p.m. RN #4 said when a patient was admitted with a Foley catheter the admitting nurse conducts an assessment to determine why the catheter was in place, including whether or not the catheter is new or had been in place for a significant amount of time. The nurse should also consider why the catheter is in place, is a trial removal to be performed. If a catheter is in place at admission, the admitting nurse will use a collaborative practice order to initiate nursing care for the catheter. The DON was interviewed on.11/3/22 at 5:34 p.m. The DON stated that the facility had a check off process regarding who can perform catheter care and when. The DON said that nurses should be checking for drainage tube leaks, and monitor positioning of the drainage tube daily. The DON said Resident #62 drainage tubing. should have been draining to gravity and not draining upward over the resident's pants waistband. The DON said that catheter orders are considered treatment orders and the order set should be activated by a nurse when a resident was admitted or ordered to have a Foley catheter placed. IV. Facility follow-up On 11/3/22 at 8:00 p.m, the facility obtained orders for catheter care, assessment, and use of leg bag and entered the order into the resident's treatment administration records.

Based on record review and interviews, the facility failed to keep residents safe from accident hazards related to falls and elopement for four (#61, #60, #45, and #218) of six residents reviewed for falls and one (#61) of one resident reviewed for elopement/missing person out of 31 sample residents. Specifically, the facility failed to prevent residents at risk for falls from having repeated falls, falls with injury, and major injury. Resident #60 was admitted to the facility on [DATE]. At the time of admission, the resident was able to walk throughout the facility with staff supervision and weight bearing and balance support. Once the resident was assisted to a standing position with balancing support the resident was able to walk up to 50 feet with a walker assistive device and staff supervision, touch assistance and verbal cuing. The resident did not use a wheelchair for mobility. Resident #60 was assessed to be at low risk for falls upon admission, however the resident started to experience a decline and began to experience repeated falls after admission to the facility. The resident's first fall was on 8/6/22, due to losing balance during a self-transfer out of a chair. The resident had four additional falls while a resident of the facility. Following the first fall, the facility failed to reassess the resident risk for falls, implement an appropriate person centered care plan focus for balance and standing deficits, and implement fall prevention measures with effective interventions against repeated falls. The resident had a second fall on 9/1/22 and fractured the right thighbone, then had three additional falls. The facility's failure to address the resident's balance and gait concerns, consider other medical reasons for the resident's balance deficits, and implement person centered interventions to address a method for staff to ensure the resident received care assistance when needed, for care tasks where the facility assessed the resident needed assistance. These failures led to repeated falls and a fall with a major injury. Resident #45 experienced multiple falls while a resident of the facility. Resident #45 was assessed to have had poor balance, unsteady gait and poor safety awareness. The fall prevention care plan was vague and lacked any specific person centered interventions. After the resident's fall on 8/10/22, the nurse on duty conducted a post fall investigation. It revealed that the interdisciplinary team (IDT) would discuss effectiveness of interventions and possible clinical indications (reasons) for the resident's continued fall and need for additional interventions to prevent future falls and injury from falls. However, the resident's medical record did not document any further assessment or discussion of implementing fall prevention interventions at that time. The facility did not revise the resident's care plan to add a fall prevention focus until 9/21/22; by that time the resident had three additional falls, one with a major injury. The facility's failures led to the resident having continued falls and one fall resulting in a subdural hematoma (bleeding between the brain and skull). Additionally, the facility failed to: -Ensure safe transfers with a mechanical lift and provide the correct size equipment (lift sling) to perform a safe transfer for Resident #60; -Implement person centered detailed fall prevention care plans with individualized interventions for Residents #61, #45 and #218; -Complete a comprehensive post fall assessments following resident falls, for Resident #218; -Ensure that all staff working were made aware that a new resident had been admitted to the secured unit, and ensure that staff working on the secured unit were informed of the newly admitted resident's care needs for Resident #61, -Prevent Resident #61, a newly admitted resident, from eloping out of the secure unit; and -Develop and implement a person centered elopement prevention care plan with individualized interventions for Resident #6. Findings include: I. Resident Falls A. Facility policy and procedure The Fall Clinical Protocol, revised March 2018, was provided by the nursing home administrator (NHA) on 11/3/22 at 8:30 p.m. The protocol read in pertinent part, The physician will help identify individuals with a history of falls and risk factors for falling. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The staff and practitioner will review each resident's risk factors and document them in the medical record. -After the first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using the assistance of his or her arms, walk several paces, and return to sitting. If the individual has difficulty or is unsteady in performing this test additional evaluation should occur. -The physician will identify medical conditions affecting fall risk and risk for significant complications of falls and the risks for significant complications for falls. The staff, with the physician's guidance, will follow up on any falls with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. -If the individual continues to fall, staff and physicians will re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions. B. Resident #60 1. Resident status Resident #60, age 75, was admitted on [DATE] and discharged on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included [CONDITION(S)] ([CONDITION(S)]), diabetes, and heart failure. The 8/9/22 admission minimum data set (MDS) assessment revealed the resident had intact cognition and scored 15 out of 15 on the brief interview for mental status (BIMS). The resident showed no signs of delusions or [CONDITION(S)] and had no aggressive behaviors. The resident did not reject care or assistance. According to the MDS assessment the resident, upon admission, was able to complete some activities of daily living with only set up assistance from staff. The resident needed extensive assistance from staff for bed mobility, transferring, toileting, dressing, and with personal hygiene. Once assisted to a standing position the resident was able to walk unassisted with a walker device. The resident was occasionally incontinent of bladder and bowel. The resident did not have a catheter and was not placed on a toileting program. 2. Record review Review of the resident medical record revealed Resident #60 had five falls while a resident of the facility from 8/1/22 through 10/19/22 when the resident was discharged from the facility due to a decline in health condition. The resident's repeated falls started on 8/6/22, five days after admission (see below for details). On 8/6/22 at 11:55 p.m., Resident #60 had an unwitnessed fall in the dining room; the resident lost balance and fell while getting up from a chair. The resident did not appear to be injured other than some discoloration to the skin to the abdomen below the belly button. There were no recommended interventions. Facility progress notes dated 8/6/22 at 11:54 p.m., revealed the resident told the nurse who assessed the resident post fall a chair where I sat is broken while I was getting up and that's why I fell . There was no documentation to verify if the chair the resident sat in was or was not broken. Facility progress notes dated 8/7/22 at 3:41 a.m., read in part: Resident required Hoyer (mechanical lift) to get up off floor, he is on neurological checks from a fall yesterday morning. He refuses to call staff for assistance, will not wear shoes, after he is Hoyered (lifted) into bed he gets up again immediately. Resident does seem to have good strength as he can lift his lower body up off the bed when supine and can get in a sitting position as well when supine, but he offers no effort during these falling episodes. On 9/1/22 at 7:50 p.m., Resident #60 had an unwitnessed fall in the resident's room while transferring to bed. The resident was assessed to be in severe pain at a level of 10 out of 10 (excruciating pain) and was not able to move the right leg. Deformity of the right knee was noted. Contributing factors included water on the floor and having bare feet. The resident was sent to the hospital emergency room for assessment. Facility progress notes dated 9/1/22 at 7:50 p.m., read in part: Post fall evaluation: Resident stated to nurse that he felt his right knee pop when he landed on floor. Resident stated pain was a 10 and was not able to move right leg. Floor mat was on the floor: No footwear at time of fall: Bare feet. Resident was not using a walker as instructed. Resident was wearing oxygen as prescribed at the time of fall. Bathroom call light on when resident was found: No. Physical Findings: Change in diagnosis status: No. Actioned clinical suggestions: (none listed). Resident #60's comprehensive care plan documented initiation of a fall prevention focus on 9/2/22, after two falls in the facility where one of the falls resulted in a major injury sustaining a fracture to the right thighbone. After the resident had experienced two falls while a resident of the facility (see below). The care focus revealed the resident had actual falls related to repeated unsafe decision making for self-transfers. Interventions included: -Resident choose not to ask for assistance with ambulation, transfers. The resident is able to make needs known, staff will do frequent checks on the resident for assistance offering. -Resident was non-compliant with asking for assistance with ambulation, transfers. Resident was able to make needs known, staff will do frequent checks on the resident for assistance offering. Additionally, the nursing assessment of the resident's physical function and other physiological factors revealed the resident had a decline in function and ability to complete activities of daily living (ADLs) independently. The resident was assessed to need assistance with self-care including transfers and mobility. The resident assessment revealed the resident did not reject or refuse care. Care planned interventions revealed the resident needed two staff to assist the resident with transfers and standing to walk, toileting and bed mobility. The care plan had no person-centered interventions to address the resident's reluctance to call for staff assistance. Hospital treatment notes dated 9/7/22 revealed Resident #60 was admitted on [DATE] and remained in-patient for five days. X-ray assessment of the resident's injuries confirmed a right femur (thighbone) fracture with adjacent soft tissue injury. X-ray right knee results showed pronounced right knee [CONDITION(S)] changes without displaced fracture, although the hospital could not exclude mild impacted fracture of the medial tibial plateau (the flat area of the larger of the two bones of the leg just below the knee). While in care of the hospital, the resident received surgical intervention to treat a right femur shaft (thighbone between the hip and knee) fracture after a fall. The after visit note revealed the resident could walk on the fractured leg post-surgery as tolerated. The facility Safe Resident Handling and Mobility Objective Transfer assessment dated [DATE] revealed Resident #60 could not bear any weight and was not able to follow instructions due to confusion. -The assessment did not address any related risk factors or recommendations to address the assessment findings. On 9/10/22 at 12:22 p.m., nursing notes revealed Resident #60 had an unwitnessed fall possibly while transferring to bed. The resident said he slid off the bed. The resident was not injured in the fall. Contributing factors listed included poor safety awareness. The facility placed a floor mat at bedside and educated the resident to use the call light for staff assistance to prevent future falls. Facility progress notes dated 9/11/22 at 3:53 p.m., read: Resident constantly using call light through the night, saying I want to walk to the bathroom, I lost my television (TV) control, I am not able to see TV in this position. Resident was repositioned many times; offered a bed pan that he declined. Resident dropped the bedside table on the floor; his bed sheets were moved on the floor many times. Resident denied any pain and kept saying I want to walk to the bathroom. Explained to the resident that it is not safe for him to walk and there was only one nurse and one CNA on the floor and we are not able to support him with walking. Resident keeps saying nobody cares. Bed is in a low position, floor mattress in place. Facility progress notes dated 9/18/22 at 6:59 p.m., read: Resident never received any non-slip strips or any other product to provide floor traction. He fell in his room and fractured his femur. -The interventions still did not address the resident's reluctance to use the call light. The comprehensive care plan revised on 9/24/22 documented new fall prevention interventions which included: -Educated the family about the barriers to care and coordination with partnering services for assistance; placing the resident bed in the low position; -Place a fall mat next to the resident's bed; provide outpatient services for PT/OT (physical and occupational therapy); -Resident had repeated falls since admission to the facility, August 2022. Staff goes into the room each time the resident uses the call light for assistance and frequently each shift while the resident is awake. The resident had a history of asking staff to go get water refilled or some other request then after staff leaves the room and resident will attempt to ambulate and transfer alone because of previous functioning. Resident is having a hard time with asking for help with transfers of any kind and will state that he did not think he needed help with that. -Social Services to evaluate the resident for current BIMS for ability to make decisions. -Therapy notes from (provider name) for PT/OT aftercare updates if any. -Provide frequent toileting check and change. -Ensure oxygen tubing, cords and clutter in the room is kept neat. -Coordination of care between services will be communicated and coordinated with the facility for continued care with the resident, including barriers to resident acceptance for needing increased help with transfers, toileting/peri care. -Although there were new interventions, some lacked individualized personalized approaches. The care plan documented the resident was reluctant to call for staff assistance; however, the care plan did not offer any specific approaches staff should take to ensure all needs were met prior to staff leaving the resident's room. -Additionally, a review of progress notes from 9/12/22 through 10/19/22 (date of discharge), revealed the resident was experiencing increased episodes of restlessness, increased attempts to get out of bed, increased complaints of pain, and increased agitation which were not address as potential factors in the resident's increased falls. On 10/2/22 at Resident #60 had an unwitnessed fall from bed after trying to reach something on the floor. The post fall evaluation documented Contributing factors note: resident is anxious and exhibiting poor safety awareness. The resident complained of pain to the right hip and knee at a level of 3 out of 10. -There were no clinical suggestions. Facility skilled evaluation notes dated 10/2/22 at 3:17 p.m., read in pertinent part: Safety concerns: Yes. Safety concerns - note: when using the Hoyer lift exercising caution when transferring. -There was no more detailed explanation about the nature of the safety reference to use caution when using the Hoyer lift in the note written above. There was an allegation that staff performed an improper transfer with the mechanical lift and the lift tipped during the transfer onto the staff performing the transfer, and staff had to lower the resident to the floor. The director of nursing (DON) acknowledged this did occur and attributed it to staff using the incorrect size Hoyer sling (see interview below). On 10/4/22 at 6:50 a.m., Resident #60 was found lying on the floor at the bedside. The resident had no injuries. The resident said he was trying to reposition himself in the bed and did not want to have to rely on others. Implementation of a floor mattress was listed as the recommended intervention, but the fall mat should have already been in place since 9/24/22 (see care plan revision above). -The resident's medical record did not document a review of the effectiveness of fall prevention interventions for effectiveness. On 10/5/22 at 5:58 p.m. at 3:00 p.m., Resident #60 was found lying on the floor at the bedside. -The resident's medical record revealed there were no new interventions implemented and no assessment of the existing fall prevention interventions. On 10/19/22 at 3:38 p.m., Resident #60 was found on the floor at bedside during nursing rounds. The resident told nursing staff he rolled out of bed. -There was a progress note documenting the event but no post fall assessment in the resident's medical record. 3. Staff interview The director of nursing (DON) was interviewed on 11/3/22 at 5:23 p.m. The DON said IDT reviewed any resident after a fall and investigated the predisposing factors of the fall in order to develop appropriate fall prevention interventions. This process can take approximately two to three days to complete, sometimes longer if the resident was experiencing repeated falls. Once the assessment was complete, the care plan will be updated and interventions will be implemented. The DON said Resident #60 was experiencing repeated falls and declining health with increasing episodes of being confused. The facility was having trouble communicating with the physician provider, getting physician orders timely and getting lab results. Meanwhile the resident was slowly declining in his ability to perform ADLs and less active with social activities. The DON acknowledged that the resident was in a Hoyer transfer accident and ended up on the floor with no injury. The DON said staff used the incorrect Hoyer sling to transfer the resident out of bed to the wheelchair. The sling was too small for the resident and the resident was improperly placed into the sling. Once the resident was lifted up off the bed and the staff moved the Hoyer towards the resident wheelchair the resident slid out of the sling and the lift tipped. Staff performing the lift had to lower the resident to the floor. The resident was not injured in the process. After investigation, the facility obtained the correct size Hoyer sling for the resident to use in all future Hoyer transfers. C. Resident #15 1. Resident status Resident #45, under age 75, was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses include [CONDITION(S)] ([CONDITION(S)]), history of falling, generalized anxiety disorder, cerebral infarction (stroke), unsteadiness on feet, muscle weakness, and difficulty walking. The 9/9/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental health status score of 11 out of 15. According to the MDS assessment the resident required extensive assistance from two people with bed mobility, transfers, toileting and one person assistance with walking in the room, corridor, on and off the unit, personal hygiene, and dressing. The resident was unsteady while moving from seated to standing position, surface to surface transfers, walking, turning around, and moving on and off the toilet. The resident has a manual wheelchair that requires substantial to maximum assistance, the helper does more than half of the assistance. 2. Resident interview and observation Resident #45 was interviewed on 11/1/22 at 10:41 a.m. The resident said that he had fallen once about four months ago, right after he started using the walker. The resident said he was trying to get up and the floor was slick, then his legs gave out and he slipped and fell off the bed. The resident said that he used the walker when he was walking in the hallways, used a manual wheelchair when he was going to the shower room, and did not use any assistive devices while walking in his room. The resident said the only fall prevention intervention the facility provided was to move him closer to the nurses station in order to monitor his movements. The resident was observed on 11/1/22 at 10:41 a.m. The resident was in bed; the bed was in the lowest position. The resident did not have non-skid slip strips or fall mat on the floor at the bedside, while he was in bed. 3. Record review The comprehensive care plan, implemented on 7/11/22, documented the resident had an actual fall in the facility, poor balance, poor communication, poor comprehension, and unsteady gait. The goal was to resume usual activities without further incident. Interventions included to continue the interventions on the at-risk plan, determine and address the causative factors of the fall, monitor and report changes in mental status, use a urine leg bag while awake, and resident room moved closer to the nurses station for more frequent checks every shift. -The care plan did not explain what the actual interventions were, or provide details of the fall at-risk prevention plan for Resident #45. The comprehensive care plan documented generic interventions, to continue to follow the intervention on the at-risk plan, and determine and address the cause of falls, but failed to document individualized person centered approaches and interventions. On 8/10/22 at 6:45 a.m., Resident #45 had an unwitnessed fall in his room and sustained a skin tear to the right elbow. No treatment of the skin tear was documented. The resident was found sitting on the floor next to the bed facing the television with the walker behind him. -No new interventions were put into place. The post fall investigation reports documented that the IDT and resident physician would discuss the effectiveness of interventions, with possible clinical indications (reasons) for the resident's continued falls, or need for additional interventions to prevent future falls and injury from falls. On 8/12/22 at 5:00 a.m., Resident #45 had an unwitnessed fall in his room.The nurse responded to a loud noise from the resident room and found the resident lying face down on the floor with blood coming from the resident's forehead, the resident's walker was nearby. The resident sustained a laceration on his forehead that required four stitches. Interventions included encouraging the resident to use the call light for help -The facility failed to document the size or appearance of the laceration. The resident went to the hospital emergency room for further assessment (see hospital note below). Upon the resident's return to the facility, there was no documentation or monitoring of the wound for signs of infection or healing The hospital note dated 8/12/22 revealed the resident was admitted to the emergency room for assessment after a fall with injury and head trauma after tripping over oxygen tubing and hitting his head on the floor. Based on hospital evaluation the resident was found to have suffered a right frontal subdural hematoma (occurs when a blood vessel in the space between the skull and the brain the subdural space is damaged following a trauma to the head), resulting from the resident's fall in the facility. The resident received four stitches to the forehead. Computerized tomography notes dated 8/12/22, revealed the resident sustained a right frontal lobe injury 3-4 millimeter hyperdense collection (a small area of pool blood or fluid within the skull, but outside the brain), consistent with a small acute subdural hematoma. On 8/17/22 at 1:50 p.m., Resident #45 had an unwitnessed fall. The resident was found on the floor on his knees and lying partly across the bed. The resident did not sustain an injury. Interventions included removing the wheelchair from the room to discourage the resident from attempting to transfer himself without help. This intervention included removing the resident wheelchair from his room to discourage the resident from self transferring to the wheelchair unassisted. -This intervention was not implemented consistently, as the resident's wheelchair was observed at bedside during an observation on 11/1/22 at 10:41 while the resident was lying in bed resting. On 8/31/22 at 9:30 a.m., Resident #45 had an unwitnessed fall in his room; the resident was not injured. The resident was found sitting on the floor with his back to the dresser. The resident told the nurse that he fell out of his wheelchair. Interventions included moving the resident to a new room closer to the nurses station. The resident's room was moved. -No other new interventions were put into place. The 9/18/22 fall risk assessment documented the resident had a history of three or more falls in the past three months with three or more predisposing diagnoses for falls, indicating the resident was at risk for falls. The resident's gait and balance were unsteady, and the resident required assistive devices for mobility including a wheelchair or walker. The fall care plan revised on 9/21/22, documented the resident had several falls without injury. The care focus revealed Resident #45 had poor balance, poor communication and poor comprehension skills. Interventions included moving the resident to a room closer to the nursing station for more frequent monitoring, and to assess and determine the causative factors of the fall. -No other new interventions were put into place. 4. Staff Interview The director of nursing (DON) was interviewed on 11/3/22 at 5:34 p.m. The DON said the floor nurse assessed Resident #45's risk for falls and the interdisciplinary team (IDT) discussed the need and implemented interventions for fall prevention. Interventions for Resident #45 included moving him closer to the nurses station in order to better monitor his mobility. The DON said Resident #45 should have been on a toileting schedule with hourly rounds to ensure the resident was offered assistance with care needs. D. Resident #218 1. Resident status Resident #218, age 81, was admitted on [DATE]. According to the November 2022 computerized physician orders, diagnoses included Alzheimer's disease, hypertension, fracture of clavicle and [CONDITION(S)]. The 10/25/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview of mental status score of zero out of 15. It indicated the resident required extensive, two person assistance with activities of daily living. It indicated the resident had at least two falls since admission with no injuries. 2. Resident representative interview Resident #218's representative was interviewed on 11/1/22 at 10:03 a.m. She said the resident had multiple falls since admission. She said she was called at least four times but was unsure how many falls the resident actually had. She said she found the resident on the floor when she went to visit him shortly after he was admitted . She said she could hear him calling for help as she approached his room. She said the resident had dried feces on him and it was upsetting to her to find him like that. She said she did not believe his call light was working and the nurse told her they did not use call lights on the secure unit. She said staff told her they would try to move the resident to a different floor since he was not ambulatory and did not need to be on the secure unit. She said when the staff moved him they would make sure he was close to the nurses' station because his current room was far away from the nurses' station. 3. Observation On 10/31/22 at 11:50 a.m. Resident #218 was observed in the dining room in his wheelchair. Resident was eating lunch and a hospice nurse was sitting next to him. Resident #218 began to slide out of his wheelchair and attempted to grab the table for support. Licensed practical nurse (LPN) #2 went over to the resident and with the assistance of the hospice nurse, repositioned the resident upright in his wheelchair. 4. Record review The fall care plan, initiated 11/1/22, indicated Resident #218 had falls with no injuries. Interventions included assistance with toileting prior to going to bed, bed in lowest position, fall mat in place near bed, and flat call light. -The resident did not have a flat call light based on observation and interview with staff. Progress notes from 10/19/22-11/2/22 revealed the following: -On 10/19/22 a post fall evaluation was completed and indicated the resident had a fall in his room on 10/19/22. It indicated the resident said he did not fall but was on the floor because he was crawling to the bathroom and was found by his wife. The evaluation indicated the resident had small scrapes to his knees. -On 10/19/22 a fall progress note was completed that provided additional fall details. It indicated the resident's wife found the resident on the floor of his room. The resident was assisted to bed ten minutes prior but the resident wanted to use the bathroom and was on the floor to crawl to the bathroom. -On 10/21/22 a fall progress note was completed that indicated the resident had a fall on 10/20/22. A CNA reported they found the resident on the floor of his room near the fall mat. An intervention of frequent checks was added post fall. -On 10/27/22 a fall progress note was completed that indicated the resident had a fall on 10/26/22 in his room. It indicated staff heard the resident calling for help and he was found on the floor near his bathroom. It indicated a new intervention of frequent checks and possible room move to be closer to the nurses station. -On 10/29/22 a post fall evaluation was completed that indicated the resident had a fall in his room on 10/29/22. It indicated the resident was found on his fall mat and did not indicate any injuries. -On 11/2/22 a post fall evaluation was completed that indicated the resident had a fall in his room on 11/2/22. It indicated the resident said he did not fall and instead rolled out of bed. The note indicated the resident was found on the floor mat and his call light was on. -There were no post fall evaluations for the falls on 10/21/22 and 10/27/22. 5. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/2/22 at 1:36 p.m. She said Resident #218 had a few falls since he was admitted to the facility. She said interventions included having the resident sit in the television room near staff, a fall mat on the floor beside his bed, and a new wheelchair through hospice. She said the resident was able to use his call light. CNA #2 was interviewed on 11/2/22 at 1:45 p.m. She said when a call light was activated the nurse's phone was paged. She said a light outside of the resident's door would not illuminate. She said Resident #218 was able to use his call light and he had a pointed call light, not a flat button. Registered nurse (RN) #1 was interviewed on 11/3/22 at 9:48 a.m. She said Resident #218 had a few falls that occurred in his room at night or early morning. She said interventions included a floor mat that was placed beside his bed, the bed in a low position, and hourly rounding. She said his room was far away from the nurses station and it could be safer if he was closer. She said he was able to use his call light but needed reminders. The director of nursing (DON) was interviewed on 11/3/22 at 5:34 p.m.[TRUNCATED]

Based on record review and interview, the facility failed to ensure residents who resided in the secure unit, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being to include four (#1, #2, #10 and #11) of four residents reviewed with a [DIAGNOSES REDACTED]. The facility was aware Resident #2 with a [DIAGNOSES REDACTED]. Resident #2 had a gradual dose reduction (GDR) of his [MEDICATION NAME] (antipsychotic) from 2.5 milligrams (mg) by mouth twice daily to 2.5 mg by mouth daily at bedtime on 9/12/19. Resident #2 had an increase in behaviors as early as 10/29/19. He had several altercations thereafter on 11/3/19, 11/14/19, 11/17/19 and then on 11/20/19 he had an altercation with Resident #1 which resulted in a fall with injury (see record review below). The facility failures to implement appropriate interventions timely for Resident #2, who had an increase of unprovoked behaviors and physical aggression towards multiple residents, contributed to the physical harm of Resident #1 with a [DIAGNOSES REDACTED]. Furthermore, the facility was aware Resident #11 with [DIAGNOSES REDACTED]. Resident #11 had six resident-to-resident altercations from 8/9/19 to 8/27/2020 that involved hitting, kicking and chest butting and the facility did not review the overall plan of care to ensure that interventions in place were effective. Additionally, the facility was aware Resident #1 with [DIAGNOSES REDACTED].#10 with [DIAGNOSES REDACTED]. Repeated incidents of resident-to-resident aggression, staff's limited responses to resident aggression and behaviors, and incomplete staff training placed all of the residents on the secure unit with symptoms of dementia at risk for physical, mental, and psychosocial harm. Findings include: I. Professional reference The Alzheimer's Association (last updated 3/30/2020) Coronavirus (COVID-19): Tips for Dementia Caregivers in Long-Term or Community-Based Settings, retrieved on 9/15/2020 from: https://www.alz.org/professionals/professional-providers/coronavirus-covid-19-tips-for-dementia-caregivers?_ga=2XXX 437XXX XXX - XXX &_gac=1XXX 9244XXX .eaiaiqobchmiqfd6qvlr6wivqdbach2thgoceaayasaaegl_8pd_bwe. It read in pertinent part, Nonverbal dementia-related behaviors may be an option or response for a person living with dementia to communicate a feeling, unmet need or intention. These behaviors are triggered by the interaction between the individual and his or her social and physical environment. A response may include striking out, screaming, or becoming very agitated or emotional. The dementia care provider's role is to observe and attempt to understand what the person living with dementia is trying to communicate. Root causes of dementia-related behaviors may include: -Pain; -Hunger; -Fear, depression, frustration; -Loneliness, helplessness, boredom; -Hallucinations and/or overstimulation; -Changes in environment or routine; -Difficulty understanding or misinterpreting the environment; -Difficulty expressing thoughts or feelings; and, -Unfamiliarity with personal protective equipment or clothing, such as gowns or masks. Strategies to observe and respond to dementia-related behaviors include: -Rule out pain, thirst, hunger or the need to use the bathroom as a source of agitation; -Speak in a calm low-pitched voice; -Try to reduce excess stimulation; Ask others what works for them; -Validate the individual's emotions. Focus on the feelings, not necessarily the content of what the person is saying. Sometimes the emotions are more important than what is said; -Understand that the individual may be expressing thoughts and feelings from their own reality, which may differ from generally acknowledged reality. Offer reassurance and understanding, without challenging their words, can be effective; -Through behavioral observation and attempted interventions, try to determine what helps meet the person's needs and include the information in the individualized plan of care; Be aware of past traumas (veterans, abuse survivors, survivors of large-scale disasters); and, Never physically force the person to do something. Proactive strategies for addressing dementia-related behaviors It can be difficult to anticipate and respond to dementia-related behaviors in a changing environment - especially in emergency situations. However, applying some of the following strategies may help: -Provide a consistent routine; -Use person-centered care approaches for all individuals living with dementia during activities of daily living - every interaction or task is an opportunity for engagement; -Promote sharing of person-centered information across the care team; -Encourage all staff to treat individuals living with dementia with dignity and respect; and, -Put the person before the task. II. Secure unit residents and layout The secure unit where the altercation occurred on 11/20/19 was located on the third floor, where 21 residents resided. The lounge area and dining area were adjacent to each other. The lounge area was on the East side of the third floor and the dining area was on the West side of the third floor; however there were two pillars in between the areas which could obstruct view to either area. III. Resident #2 A. Resident status Resident #2, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 9/23/2019 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. He did not exhibit any behavioral symptoms. Specifically, there were no physical behaviors directed towards others. He required supervision with transfers, walking in the room, walking through the corridor and walking on and off the unit. He required extensive one-person assistance with toileting and dressing. B. Behavior care plan The behavior care plan, initiated on 11/14/19 and revised on 5/22/2020 revealed the resident had a history of [REDACTED]. He was triggered by invasion of personal space, loud vocalization, someone sitting in his dining spot, and other residents who touch items in his environment. Interventions included to approach the resident in a calm manner, monitor for signs and triggers for aggression such as invasion of personal space, threatening remarks, irritability around certain people; and, keep in line of sight if he was showing signs of aggression remove the resident from others and area to keep them safe. The acute behavioral care plan, initiated 11/14/19, updated 11/15/19 and 11/18/19 revealed Resident #2 was involved in a physical altercation with other residents, which he was the aggressor on 10/29, 11/3, 11/13 (I was involved in a physical altercation I shoved another resident two times in the arm), 11/14 and 11/17/2019. Interventions included the following: -Approach in a calm manner. Provide the resident with choice/options -Provide time to de-escalate, offer to take for a walk off the secured neighborhood or offer conversation. -Monitor for signs, triggers for aggression such as invasion of personal space, threatening remarks and irritability around certain people. -Keep the resident in line of sight if he is showing signs of aggression. Remove others from the area to keep safe. The [MEDICAL CONDITION] care plan, initiated on 1/2/19 and revised on 11/20/19 revealed the resident took antipsychotic medication for dementia with behaviors. Interventions included to monitor effectiveness of medication, observe the resident's gait for steadiness, balance, muscle coordination, ability to position and turn; and monitor resident's mood and behavior and notify the physician for significant changes. C. Resident #2's safety plan The 11/13/19 safety plan revealed Resident #2 ambulated independently interacting with staff and other residents on the unit. The current interventions to prevent physical altercations between Resident #2 and other residents were unsuccessful. Staff were to be hyper aware of antecedents and triggers. Staff had been educated after each incident to ensure they were present in common areas, communicated with co-workers if they needed to leave the area so there was replacement monitoring. Staff were to redirect other residents who invaded Resident #2's space, provide the resident with independence with personal cares and supervise to decrease the likelihood of agitation, use tools and resources to get to know the resident for meaningful engagement. Staff were to position themselves throughout the day to be in line of sight of Resident #2 when he was in common areas around other residents. -However, this was not done after the education was provided to the staff to ensure they understood the expectation of keeping Resident #2 in line of sight while in the common areas around other residents (see interviews below). D. Physician orders [REDACTED].>The September 2019 CPO revealed an order dated 9/12/19 to discontinue [MEDICATION NAME] 2.5 mg by mouth twice daily and start [MEDICATION NAME] 2.5 mg by mouth daily at bedtime for dementia with behaviors. The 10/30/19 NP note documented Resident #2 was being assessed for complaints of lower abdominal suprapubic pain which he stated traveled across his back. On exam Resident #2 had suprapubic tenderness and complaints of dysuria. The plan was to check stat (immediate) CBC (complete blood count), CMP (complete metabolic panel) and urinalysis, along with abdominal x-ray. The resident was afebrile and stable since a decrease in his medication [MEDICATION NAME] (antipsychotic) to 2.5 mg by mouth daily. The 11/4/19 NP note documented the reason for the visit was because Resident #2 had an altercation with another resident. Per the staff, reported a resident was being intrusive and Resident #2 took a clipboard and hit him with it. Nursing reported Resident #2 continued to complain of lower abdominal pain, however they were unable to obtain a urinalysis due to patient refusal and behaviors. Resident #2 continued on a low dose of [MEDICATION NAME] and had no previous behaviors before that incident. Further documented in the NP note, it was discussed with nursing if Resident #2 continued to have resident-to-resident altercations the [MEDICATION NAME] may need to be increased. The plan was to redirect the resident as needed and continue non-pharmacological interventions ( such as activities, a walk outside or facetime call with his sister). Will continue to monitor and attempt to obtain a urinalysis if Resident #2 developed a fever as the previous work-up was unremarkable. -However, Resident #2 had documented behaviors on 10/29/19 (see behavioral above). The NP addressed that if the resident continued to have resident-to-resident altercations the [MEDICATION NAME] was going to be increased, which was not a person-centered approach to dementia care. The 11/20/19 physician note documented Resident #2 was being assessed for another resident altercation in which he pushed a resident to the ground and that resident suffered a [MEDICAL CONDITION]. The physician discussed with facility staff Resident #2 becoming increasingly unpredictable and aggressive towards other residents. Resident #2 was occasionally resistive to care by staff and made threats of violence toward staff; because of his cognitive deficits he was difficult to redirect. The resident was sent to the hospital for a mental evaluation of his behaviors and determination of safety to return to the facility within 24 hours. E. Social service note The 11/15/19 social service note documented Resident #2 was reviewed in the [MEDICAL CONDITION] committee and an increase was recommended. -However, an increase was not implemented until 11/20/19 after the altercation with Resident #1. F. Resident-to-resident altercations with Resident #2 preceding 11/20/19 Resident #2 had been involved in resident-to-resident altercations on 10/29/19, 11/3/19, 11/14/19, 11/17/19 that often occurred in the dining room, in which he was triggered by an invasion of personal space, loud vocalization, someone sitting in his dining spot, and other residents who touch items in his environment (see behavior care plan above). The interventions implemented by the indisplionary team (IDT) were 15 minute checks for 72 hours and line of sight vision that was implemented on 11/13/19. Cross-reference F600 for failure to ensure residents remained free from abuse. G. Resident to resident altercation 11/20/19 1. Resident #1 status Resident #1, age 78, was admitted on [DATE] and readmitted on [DATE]. According to the July 2020 CPO, [DIAGNOSES REDACTED]. The 10/22/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. He did reject care four to six days and exhibited behaviors towards staff or others of hitting, kicking, scratching one to three days. He required extensive two-person assistance with bed mobility, dressing, transfers and toileting. He required limited one-person assistance with walking in the corridor and in the room. He was always incontinent of bowel and bladder. His ability to hear was highly impaired, he wore a hearing device and his vision was severely impaired. 2. Record review a. Care plan The communication care plan, initiated 10/22/19 and revised on 2/12/2020 revealed Resident #1 had a communication issue related to hearing and vision deficits (he was legally blind and very hard of hearing). Interventions included to speak loudly into his right ear, anticipate and meet his needs and be conscious of his position when in groups, activities, dining room to promote proper communication with others. The [MEDICAL CONDITION] care plan, initiated 2/3/2020 and 2/5/2020 for use of medications [MEDICATION NAME] and [MEDICATION NAME] (antipsychotics) revealed Resident #1 had dementia with behaviors and [MEDICAL CONDITIONS], he could be aggressive as evidenced by kicking and attempting to hit staff during personal cares and he had a history of [REDACTED]. He was also impulsive, had poor safety awareness and required frequent redirection, step by step instruction to encourage participation in day to day care. Interventions included to approach the resident from the front due to vision deficit and speak clear into his right ear to explain what you want or need from the resident, assist the resident with ambulation as needed, monitor and document signs and symptoms of agitation, monitor and document triggers to assist with establishing approach that will not escalate the agitation, anticipate and meet the resident's needs, attempt to keep the environment calm and quiet, and monitor for any signs and symptoms of [MEDICAL CONDITION]: flashbacks, nightmares, difficulty sleeping, feeling jumpy and being easily irritated or angered. The fall care plan, initiated 10/21/19 and revised on 7/12/2020 revealed Resident #1 was high risk for falls related to impaired balance, poor coordination, poor safety awareness, unsteady gait, use of [MEDICAL CONDITION] medication and visual deficit. Interventions included to walk with him when he got up from his seat, check him frequently to ensure safety, encourage him to use handrails in halls properly and inform him of each new area he was taken to such as (dining room day room) so that he knew where he was and what was near him. However, the facility did not assess and implement appropriate interventions prevent Resident #1 from wandering into a common area dining room where Resident #2 was sitting, who did not like others in his personal space which caused an altercation. b. Facility documentation The 11/20/19 facility documentation of the altercation was provided by the NHA on 8/26/2020 at 12:55 p.m. It documented in pertinent part, Resident #2 was sitting at the table in the dining room at 11:37 a.m. and Resident #1 was sitting in a chair in the lounge area. Resident #1 got up from the chair and walked over to the dining area towards the kitchen window. Resident #2 turned around in his seat and looked toward Resident #1. Resident #2 then got up from his chair at 11:38 a.m. and grabbed Resident #1 by his left arm. Resident #1 tried to pull his arm away from Resident #2 and they both struggled with each other for a moment. Resident #1 turned around facing away from Resident #2. Resident #2 then pushed Resident #1 from behind and he fell to the floor. The 11/20/19 at 1:26 p.m. x-ray of the left femur revealed Resident #1 had a [MEDICAL CONDITION] femoral neck with superior displacement of the distal fragment. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/26/2020 at 2:20 p.m. She said she worked the secure unit on day shift full time. She said there were a couple of residents who they had to monitor for increased behaviors, one being Resident #2. She said he had to remain in line of sight. She said Resident #2 used have increased behaviors but he had been okay/calm lately. Licensed practical nurse (LPN) #1 was interviewed on 8/26/2020 at 2:25 p.m. She said she worked the secure unit for several months on the day shift. She said if the unit was noisy Resident #2 would get agitated. She said prior to admitting to the facility the resident had severe behaviors and prior facility could not care for him because he was hitting other residents. Activity assistant (AA) #1 was interviewed on 8/27/2020 at 12:29 a.m. He said he worked at the facility for two years. He said he worked in the secure unit full time from 9:00 a.m. until 3:30 p.m. for the past couple of months and his previous work hours were 8:00 a.m. until 4:00 p.m. He said he was working the day Resident #2 had an altercation with Resident #1 on 11/20/19. He said on 11/20/19 he did not witness the altercation between Resident #1 and #2. He said he remembered that he was engaged with a resident in a coloring activity. He said he and the resident were seated at a table in the lounge area. He said he was seated facing east with his back towards the dining room and outside patio. He acknowledged the pillars would have obscured his view of Residents #1 and #2 during their altercation as they were located in the southwest corner of the dining room and he was seated on the lounge area close to one of the two pillars that blocked his sight of the residents when the altercation happened. He said he did not hear any of their conversation, but he heard a thud and he saw Resident #1 on the floor and he went to get the nurse to come and help. He said he received education and training regarding Resident #2's safety plan; however, he said he did not receive education or instruction on staff to position themselves throughout the day to be in line of sight of Resident #2 when he was in the common areas around other residents until after the altercation occurred between Residents #1 and #2 on 11/20/19. He said since he had received numerous staff trainings on dementia and behaviors and the need to keep a close eye on individual residents with behaviors. He said since then staff position themselves, one at the nurse's station and one in the dining area to keep the whole unit in view. LPN #2 was interviewed on 9/1/2020 3:10 p.m. He said he worked at the facility for many years on the secure unit. He said he was caring for Resident #1 and Resident #2 the afternoon on 11/20/19. He said that day Resident #1 was pushed by another resident. He said he was assisting another resident and did not see what had happened. He said a staff member notified him Resident #1 was on the floor and he called an registered nurse (RN) to come and assess Resident #1 as he could not stand or walk. He said they received orders to get an x-ray which showed he had a fracture and he was sent to the hospital. The activity director (AD) was interviewed on 9/1/2020 at 5:45 p.m. She said during the facility's morning clinical call with the interdisciplinary team (IDT) which included all managerial department heads, they talked about resident behaviors or safety concerns. She said then she notified the activity department staff during afternoon huddles. She said she informed the activity department staff of any changes with residents, if residents were engaged or not engaged in the activities. She said if her staff shared anything with her in the huddle then she would share it with the IDT the following morning. She said they completed education on sensory activities, monitoring and positioning of themselves to watch residents in the secure unit. She said she provided training to her staff when to document in progress notes if residents had new or increased behaviors. The NHA, director of nursing (DON) and social services director (SSD) were interviewed on 9/2/2020 at 11:00 a.m. The SSD said if a resident received a gradual dose reduction (GDR) of an antipsychotic the nursing staff and social services would monitor the resident for 14 days for any signs or symptoms of any increased behaviors. She said staff documented if the resident had increased behaviors, needed 15 minute checks and what helped settle the resident down to help with the behaviors. The SSD said staff would document if the resident had increased behaviors, needed 15 minute checks that lasted for 72 hours, what helped settle the resident down and what would help with their behaviors such as a snack or a walk. The NHA said residents were reviewed in morning meetings as an interdisciplinary team (IDT) for any pertinent changes (behavioral or clinical) and managers would disperse any pertinent information to their departments such as the need for increased monitoring of certain residents. She said the IDT met every Friday to complete a quarterly comprehensive review of residents ' care plans for updates. She said Resident #2's sister and power of attorney (POA) felt his behaviors were due to his dementia. She said his POA did not provide much if any input regarding his plan of care. The DON said she felt Resident #2 was being monitored appropriately for his increased behaviors. They acknowledged Resident #2 had an increase in behaviors, refusals of care and certain treatments such as the urinalysis ordered 10/30/19. She said if a resident refused a treatment or they were unable to collect a specimen, staff should have documented the information in the resident's clinical record and notified the physician. She said Resident #2 would not have benefitted from an increase in his antipsychotic medications. They acknowledged Resident #2's safety plan was not followed as it was not communicated in its entirety to all staff which resulted in him pushing another resident to the floor causing injury. The NHA said the reason AA #1 did not know to keep Resident #2 in line of sight prior to his altercation with Resident #1 on 11/20/19 was because the AD sent the education regarding Resident #2's safety plan via email and she did not ensure AA #1 understood keeping the resident in line of sight. She said immediately after the incident she went to all the floors to complete on the spot training with the staff to ensure they understood what was expected of them when monitoring a resident for increased behaviors. IV. Altercations involving Resident #11 A. Resident #11 1. Resident status Resident #11, age 89, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 8/28/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He required supervision with all activities of daily living. It indicated he had behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, and grabbing one to three days during the assessment period. 2. Record review The behavioral care plan, initiated 8/16/19 and revised on 7/20/2020 revealed Resident #11 was involved in resident-to-resident altercations on 10/30/19, 1/22/2020, 4/25/2020, 6/8/2020, 8/27/2020, and for the last three altercations was the aggressor. Interventions included the following: -Approach in a calm manner; -Monitor for signs and symptoms of agitation, pacing, asking to leave, verbal expressions of anger and fidgeting; -Monitor reaction toward other residents and redirect or remove from area if showing signs of agitation; -I have a stop sign across my doorway to deter other residents from entering my room. I am able to enter and exit my room by demonstrating removing sign and placing it back up across the doorway; -Monitor for triggers that may escalate a physically abusive reaction, such as invasion of personal space, others going into my room or taking something from me; and -Speech therapy to conduct staff education on cognitive decline to implement interventions. The September 2020 Medication Administration Record [REDACTED]. B. Resident #10 1. Resident status Resident #10, age 83, was admitted on [DATE] and discharged on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 6/12/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He required extensive assistance of two people with all activities of daily living. It indicated the resident had physical behavioral symptoms not directed toward others for four to six days, rejection of care one to three days and wandering daily during the assessment period. 2. Record review The elopement care plan, initiated 5/26/17 and cancelled on 8/31/2020 as the resident was no longer in the facility, revealed Resident #10 was an elopement risk as evidenced by his history of to leave the facility unattended and his [DIAGNOSES REDACTED]. Interventions included he resided on the secure unit for safety, anticipate his needs and he required 24/7 supervised care in the memory unit. The physical altercation care plan, initiated 6/8/2020 and cancelled on 8/31/2020 (due to discharge) revealed Resident #10 was involved in a resident-to-resident altercation. Interventions included Resident #10 would benefit from positive redirection and encouragement to not invade others personal space. Interventions included to monitor the resident's whereabouts and keep resident from going into other resident's room by using positive redirection and to remove him gently from area and engage him in an appropriate activity. However, the facility did not assess and implement appropriate interventions prevent Resident #10 from wandering into Resident #11's room which caused an altercation between the two (see below). C. Resident #11's altercations on 6/7/2020 and 8/27/2020 Resident #11 was involved with altercations on 6/7/2020 and 8/27/2020 on the secured unit where he resided. Another resident wandered into his room and he kicked the resident on 6/7/2020 and revealed the resident had an altercation on 8/27/2020 by an elevator that was not witnessed by staff. Cross-reference F600 for failure to ensure residents remained free from abuse. Although Resident #11's care plans were reviewed after the resident-to-resident altercation 6/7/2020 and 8/27/2020, there was no documentation if the interventions were effective and/or if a new intervention or approach was needed. D. Staff interviews AA #1 was interviewed on 9/16/2020 at 12:30 p.m. He said Resident #11 had altercations with other residents if they were in his way and Resident #11 was easily provoked because he believed he owned the place; so they tried to give him one-to-one attention. CNA #1 was interviewed on 9/16/2020 at 12:38 p.m. She said Resident #11 was involved with many resident-to-resident altercations and was a known aggressor. She said the staff watched him closely because he was easily agitated when people invaded his space. V. Administrative interview The DON and NHA were interviewed on 9/16/2020 at 3:08 p.m. The NHA and DON acknowledged they had a systemic problem with caring for the residents in the secure unit and had started an action plan to include dementia care training videos to be provided to the staff. The NHA said the staff lacked training/education with caring for the residents with dementia and she planned to ensure they did understand. She said they had been interviewing internally and externally for staff who were certified in dementia care. The facility purchased a new dementia care training, they were reviewing each resident's plan of care, their activity programming, and implementing an evening program specifically for those residents who had behavioral issues. She said they would start training with staff on 9/28/2020 and 10/2/2020.

Based on record review and staff interview, the facility failed to ensure five residents (#1, #2, #3, #6, and #10) reviewed for abuse were free from resident-to-resident altercations out of eleven sample residents. The facility failed to ensure Resident #1 was free from physical abuse by Resident #2, a resident with several known altercations as the aggressor on 10/29/19, 11/3/19, 11/14/19 and 11/17/19 prior to the incident that occurred on 11/20/19 where Resident #1 was pushed to the floor by Resident #2. The facility failed to provide line of sight supervision of Resident #2 implemented in a safety plan on 11/13/19. Furthermore, due to the facility failures Resident #1 was pushed to the floor by Resident #2, and sustained a left [MEDICAL CONDITION] with subsequent decline in medical condition. Furthermore, the facility failed to ensure Resident #10 was free from physical abuse by Resident #11 and Resident #2 was free from physical abuse by Resident #11 with a history of physical resident to resident altercations. Additionally, the facility failed to ensure Resident #3 was free from physical abuse by Resident #4 and Resident #6 was free from physical abuse by Resident #5. Findings include: I. Facility policy The Abuse Prevention Program policy, revised October 2018, was provided by the nursing home administrator (NHA) on 9/1/2020 via email at 10:41 a.m. It read, in pertinent part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the staff will protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior . III. Resident #2 A. Resident status Resident #2, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 9/23/2019 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. He did not exhibit any behavioral symptoms. Specifically there were no physical behaviors directed towards others. He required supervision with transfers, walking in the room, walking through the corridor and walking on and off the unit. He required extensive one-person assistance with toileting and dressing. He was frequently incontinent of urine and always incontinent of bowel. B. Resident-to-resident altercations prior to 11/20/19 1. 10/29/19 The 10/29/19 at 10:53 p.m. behavior note documented at 5:10 p.m. Resident #2 was in the dining room. Resident #2 started yelling at another resident and said Why are you here. Resident #2 pushed the table and was trying to hit the other resident. Staff intervened as Resident #2 was angry. Resident #2 pushed the other resident and hit him on his hand with no injury. The residents were kept apart and monitored for the behavior. -The plan was to monitor Resident #2 by completing frequent checks and the resident was assessed by the nurse practitioner on 10/30/19 for abdominal pain. 2. 11/3/19 The 11/3/19 at 7:17 p.m. behavior note documented at 5:20 p.m. staff saw Resident #2 hit another resident on the right arm in the dining room. Both residents were eating dinner at the same table in the dining room. -Resident #2 was placed on 15 minute checks. 3. 11/14/19 The 11/14/19 at 8:29 p.m. behavior note documented Resident #2 was on monitoring for physical aggression initiated toward another resident. -However, there was no documentation of what occurred in Resident #2's medical record except for in the behavior care plan revised on 11/13/19 (see below). The 11/15/19 at 4:50 a.m. behavior note documented Resident #2 was being monitored for a resident to resident altercation. -The plan was to continue to monitor the resident for physical aggression and a safety plan was put into place; however, it was not followed and Resident #2 had a physical altercation with Resident #1 on 11/20/19 causing him injury (see record review below). 4. 11/17/19 The 11/17/19 at 7:18 p.m. behavior note documented at 4:30 p.m. staff saw Resident #2 was walking by the nursing station and another resident was walking towards the nursing station. Without provocation, Resident #2 used his left shoulder and hit the other resident on the left shoulder area causing that resident to fall to the floor. -Resident #2 was placed on 15 minute checks. 5. Behavior care plan The behavior care plan, initiated on 11/14/19 and revised on 5/22/2020 revealed the resident had a history of [REDACTED]. He was triggered by invasion of personal space, loud vocalization, someone sitting in his dining spot, and other residents who touch items in his environment. Interventions included to approach the resident in a calm manner, monitor for signs and triggers for aggression such as invasion of personal space, threatening remarks, irritability around certain people; and, keep in line of sight if he was showing signs of aggression remove the resident from others and area to keep them safe. The acute behavioral care plan, initiated 11/14/19, updated 11/15/19 and 11/18/19 revealed Resident #2 was involved in a physical altercation with other residents, which he was the aggressor on 10/29, 11/3, 11/13 (I was involved in a physical altercation I shoved another resident two times in the arm), 11/14 and 11/17/2019. Interventions included the following: -Approach in a calm manner. Provide the resident with choice/options -Provide time to de-escalate, offer to take for a walk off the secured neighborhood or offer conversation. -Monitor for signs, triggers for aggression such as invasion of personal space, threatening remarks and irritability around certain people. -Keep the resident in line of sight if he is showing signs of aggression. Remove others from the area to keep safe. C. Resident-to-resident altercation involving Resident #1 and Resident #2 on 11/20/19 1. Secure unit layout The secure unit where the altercation occurred on 11/20/19 was located on the third floor. The lounge area and dining area were adjacent to each other. The lounge area was on the east side of the third floor and the dining area was on the west side of the third floor; however there were two pillars in between the areas, which could obstruct view to either area. 2. Resident #1 status Resident #1, age 78, was admitted on [DATE] and readmitted on [DATE]. According to the July 2020 CPO, [DIAGNOSES REDACTED]. The 10/22/19 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of one out of 15. He did reject care four to six days and exhibited behaviors towards staff or others of hitting, kicking, scratching one to three days. He required extensive two-person assistance with bed mobility, dressing, transfers and toileting. He required limited one-person assistance with walking in the corridor and in the room. He was always incontinent of bowel and bladder. His ability to hear was highly impaired, he wore a hearing device and his vision was severely impaired. The 12/20/19 MDS assessment for Resident #1 revealed he did not reject care. He declined in his ability to perform activities of daily living (ADLs) compared to the 10/22/19 MDS assessment. He required extensive two-person assistance with bed mobility, dressing, transfers, toileting and extensive one-person assistance with locomotion on the unit and walking through the corridor. Walking in the room did not occur. 3. Altercation between Resident #1 and Resident #2 on 11/20/19 The 11/20/19 facility documentation of the altercation was provided by the NHA on 8/26/2020 at 12:55 p.m. It documented in pertinent part, Resident #2 was sitting at the table in the dining room at 11:37 a.m. and Resident #1 was sitting in a chair in the lounge area. Resident #1 got up from the chair and walked over to the dining area towards the kitchen window. Resident #2 turned around in his seat and looked toward Resident #1. Resident #2 then got up from his chair at 11:38 a.m. and grabbed Resident #1 by his left arm. Resident #1 tried to pull his arm away from Resident #2 and they both struggled with each other for a moment. Resident #1 turned around facing away from Resident #2. Resident #2 then pushed Resident #1 from behind and he fell to the floor. Video footage reviewed from 11:25 a.m. to 11:41 a.m. On 11/20/19 at 11:36 a.m. Resident #2 was sitting at the table in the dining room at 11:37 a.m. and Resident #1 was seen sitting in a chair in the lounge area. Resident #1 got up from the chair and walked over to the dining area towards the kitchen window. At 11:37 a.m., Resident #2 noticed Resident #1 walk in the dining room area. At 11:38 a.m., Resident #2 turned around in his chair and got up from his chair, and grabbed Resident #1 by his right arm. Resident #1 tried to pull his arm away from Resident #2 and they both grabbed onto each other's arms. Resident #2 seemed to be guiding Resident #1 out of the dining room area while talking to him (unable to make out the words spoken). Resident #2 continued to hold onto Resident #1's left arm and Resident #1 appeared to begin walking out of the dining room area. Resident #2 let go of Resident #1's arm and at this time appeared to push Resident #1 on the middle of his back. Resident #1 stopped and turned back around toward the dining area and walked back into the dining area. Resident #2 then pushed Resident #1 with both hands on his right upper arm/back area causing Resident #1 to fall to the floor. At 11:39 a.m., a staff member intervened and separated residents. The time frame for the altercation was from 11:38 a.m. to 11:39 a.m. The 11/20/19 at 1:26 p.m. x-ray of the left femur revealed Resident #1 had a [MEDICAL CONDITION] femoral neck with superior displacement of the distal fragment. 4. Safety plan The 11/13/19 safety plan revealed Resident #2 ambulated independently interacting with staff and other residents on the unit. The current interventions to prevent physical altercations between Resident #2 and other residents were unsuccessful. Staff were to be hyper aware of antecedents and triggers. Staff had been educated after each incident to ensure they were present in common areas, communicated with co-workers if they needed to leave the area so there was replacement monitoring. Staff were to redirect other residents who invaded Resident #2's space, provide the resident with independence with personal cares and supervise to decrease the likelihood of agitation, use tools and resources to get to know the resident for meaningful engagement. Staff were to position themselves throughout the day to be in line of sight of Resident #2 when he was in common areas around other residents. -However, this was not done after the education was provided to the staff to ensure they understood the expectation of keeping Resident #2 in line of sight while in the common areas around other residents (see interviews below). Cross-reference F744 for treatment and services for dementia care. 5. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/26/2020 at 2:20 p.m. She said she worked the secure unit on day shift full time. She said there were a couple of residents who they had to monitor for increased behaviors one being Resident #2. She said he had to remain in line of sight. She said Resident #2 used have increased behaviors but he had been okay/calm lately. Licensed practical nurse (LPN) #1 was interviewed on 8/26/2020 at 2:25 p.m. She said she worked the secure unit for seven months on the day shift. She said if the unit was noisy Resident #2 would get agitated. She said prior to admitting to the facility the resident had severe behaviors and prior facility could not care for him because he was hitting other residents. Activity assistant (AA) #1 was interviewed on 8/27/2020 at 12:29 a.m. He said he worked at the facility for two years. He said he worked in the secure unit full time from 9:00 a.m. until 3:30 p.m. for the past couple of months and his previous work hours were 8:00 a.m. until 4:00 p.m. He said he was working the day Resident #2 had an altercation with Resident #1 on 11/20/19. He said on 11/20/19 he did not witness the altercation between Resident #1 and #2. He said he remembered that he was engaged with a resident in a coloring activity. He said he and the resident were seated at a table in the lounge area. He said he was seated facing east with his back towards the dining room and outside patio. He acknowledged the pillars would have obscured his view of Residents #1 and #2 during their altercation as they were located in the southwest corner of the dining room and he was seated on the lounge area close to one of the two pillars that blocked his sight of the residents when the altercation happened. He said he did not hear any of their conversation, but he heard a thud and he saw Resident #1 on the floor and he went to get the nurse to come and help. He said he received education and training regarding Resident #2's safety plan; however, he said he did not receive education or instruction on staff to position themselves throughout the day to be in line of sight of Resident #2 when he was in the common areas around other residents until after the altercation occurred between Residents #1 and #2 on 11/20/19. He said since he had received numerous staff trainings on dementia and behaviors and the need to keep a close eye on individual residents with behaviors. He said since then staff position themselves, one at the nurse's station and one in the dining area to keep the whole unit in view. LPN #2 was interviewed on 9/1/2020 3:10 p.m. He said he worked at the facility for many years on the secure unit. He said he was caring for Resident #1 and Resident #2 the afternoon on 11/20/19. He said that day Resident #1 was pushed by another resident. He said he was assisting another resident and did not see what had happened. He said a staff member notified him Resident #1 was on the floor and he called an registered nurse (RN) to come and assess Resident #1 as he could not stand or walk. He said they received orders to get an x-ray which showed he had a fracture and they sent him to the hospital. The activity director (AD) was interviewed on 9/1/2020 at 5:45 p.m. She said during the facility's morning clinical call with the interdisciplinary team (IDT) (all managerial department heads) they talked about resident behaviors or safety concerns and she notified the activity department staff during afternoon huddles. She said she informed them of any changes with residents, if residents were engaged or not engaged in the activities. She said if her staff shared anything with her in the huddle then she would share it with the IDT the following morning. The NHA, director of nursing (DON) and social services director (SSD) were interviewed on 9/2/2020 at 11:00 a.m. They acknowledged Resident #2 was involved with several altercations prior to an incident which caused injury to Resident #1. The SSD said staff would document if the resident had increased behaviors, needed 15 minute checks (which would typically last for 72 hours), what helped settle the resident down and what would help with the behaviors such as a snack or a walk. The NHA said residents were reviewed in morning meetings as an interdisciplinary team (IDT) for any pertinent changes (behavioral or clinical) and managers would disperse any pertinent information to their departments such as the need for increased monitoring. The DON said she felt Resident #2 was being monitored appropriately for his increased behaviors. They acknowledged Resident #2's safety plan was not followed as it was not communicated in its entirety to all staff which resulted in him pushing another resident to the floor causing injury. The NHA said the reason AA #1 did not know to keep Resident #2 in line of sight prior to his altercation with Resident #1 on 11/20/19 was because the AD sent the education regarding Resident #2's safety plan via email and she did not ensure AA #1 understood keeping the resident in line of sight. She said immediately after the incident she went to all the floors to complete on the spot training with the staff to ensure they understood what was expected of them when monitoring a resident for increased behaviors. III. Resident-to-resident altercation involving Resident #10 and Resident #11 A. Resident #10's status Resident #10, age 83, was admitted on [DATE] and discharged on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 6/12/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He required extensive assistance of two people with all activities of daily living. It indicated the resident had physical behavioral symptoms not directed toward others for four to six days, rejection of care one to three days and wandering daily during the assessment period. B. Resident #11's status Resident #11, age 89, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 8/28/2020 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He required supervision with all activities of daily living. It indicated he had behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, and grabbing one to three days during the assessment period. C. Resident altercation 6/7/2020 The 6/7/2020 at 3:35 p.m. skin/wound note for Resident #10 revealed the CNA reported to the nurse that Resident #10 was found in Resident #11's room. Resident #10 complained of pain to his right shin and said he was kicked by Resident #11. Resident #11 told the CNA he kicked Resident #10 and would have hit him with the table if she was not present. Resident #10's right shin was assessed and the area was red. The physician, family and law enforcement was notified. Review of the facility documentation dated 6/7/2020 was provided by the NHA on 9/16/2020 at 3:08 p.m. It documented resident to resident altercation happened on memory care neighborhood (secured unit). It appeared that Resident #10 wandered into Resident #11's room at which time Resident #11 kicked Resident #10 in the shin, no injuries were observed. -However, Resident #10's right shin was assessed as being red (see 6/7/2020 skin/wound note above). In conclusion, the facility was unable to substantiate or unsubstantiate specific details regarding physical altercation due to the incident occurring in a resident room, staff had not witnessed it, and poor cognitive status of both residents. However, they did substantiate there was form of contact made to Resident #10's right shin area post nurse assessment. The intervention was to continue to monitor Residents #10 and #11's behaviors and staff were to have specific charting stations in areas that allowed staff to have full view of assigned areas. IV. Resident-to-resident altercation involving Resident #2 and Resident #11 A. Resident altercation 8/27/2020 Review of the facility documentation dated 8/27/2020 was provided by the NHA on 9/16/2020 at 3:08 p.m. It documented both residents on the memory care neighborhood (secure unit) were found on the floor next to each other and there was a possible physical altercation. Both residents were assessed by the registered nurse (RN)and separated. The facility's review of video footage revealed an altercation had occurred between both residents. Staff were interviewed as they did not observe the incident. It was documented the staff left their assigned areas and did not notify any other staff member when the incident occurred. The staff were provided education not to leave the area without notification to another staff member. -However, the staff were to be in line of sight of Resident #2 implemented 11/13/19 and staff were to have specific charting stations in areas that allowed staff to have full view of assigned areas that was implemented 6/7/2020. B. Record review 1. Resident #2's progress notes The 8/27/2020 post fall evaluation at 4:05 p.m., documented Resident #2 had an unwitnessed fall in the hallway. The 8/27/2020 falls detailed report at 9:40 p.m., documented heard a loud thud from the dining area at 4:05 p.m. staff observed Residents #2 and #11 on the floor by the elevator. The assistant director of nursing came to assess the resident, notifications were made to the physician and family, 15 minute checks and frequent monitoring was implemented. 2. Resident #11's progress notes The 8/27/2020 falls detailed report at 10:09 p.m., documented heard a loud thud from the dining area at 4:05 p.m. staff observed Residents #2 and #11 on the floor by the elevator. Resident #11 was assessed by the ADON, found to have a bruise to his right lower leg, the nurse practitioner (NP) also assessed the resident, ordered an x-ray of his leg (negative for fracture) and the family was notified. In conclusion, verbal education was provided to staff to stay in their assigned areas to monitor the residents and prevent resident to resident altercations and if they left the area they were to notify another staff member. C. Staff interviews The DON and NHA were interviewed on 9/16/2020 at 3:08 p.m. The NHA said the staff lacked training/education with caring for the dementia resident and she planned to ensure they did understand. She said they had been interviewing internally and externally for staff who were certified in dementia care. The facility purchased a new dementia care training, they were reviewing each resident's plan of care, their activity programming, and implementing an evening program specifically for those residents who had behavioral issues. She said they would start training with staff on 9/28/2020 and 10/2/2020. V. Resident-to-resident altercation involving Resident #3 and Resident #4 A. Resident #3's status Resident #3, older than 85, was admitted on [DATE]. According to the August 2020 CPO, [DIAGNOSES REDACTED]. The 5/30/2020 MDS assessment revealed the resident was cognitively impaired with a BIMS five out of 10. She required extensive one-person assistance with toileting and dressing and required supervision with bed mobility, transfers and walking in her room. B. Resident #4's status Resident #4, age less than 60, was admitted on [DATE]. According to the August 2020 CPO, [DIAGNOSES REDACTED]. The 6/23/2020 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required supervision and set up with most ADLs. C. Resident altercation 8/19/2020 The 8/19/2020 at 9:00 a.m. behavior note for Resident #4 documented at 4:45 a.m. a staff member was called to the second floor regarding an incident that occurred between Resident #3 and Resident #4. Resident #4 said Resident #3 was in the bathroom for an hour and she needed to use the restroom, I'm the one that pushed her. She said she moved her out of the way, It wasn't even really a push. Review of the facility documentation dated 8/19/2020 was provided by the NHA on 8/26/2020 at 5:22 p.m. It documented in pertinent part, the house supervisor was called to the second floor by the nurse on duty found Resident #3 on the floor in her room. Resident #3 said Resident #4 pushed her. Resident #3 was assessed and found to have a hematoma to the back of her head. Resident #4 was interviewed and she stated I'm the one that pushed her, Resident #3 was taking too long in the bathroom so I moved her out of the way. In conclusion, the facility substantiated Resident #4 put her hands on Resident #3; however, the facility did not substantiate she was pushed. The intervention was to provide Resident #4 with education to call staff for help if she needed assistance if another resident was toileting. Resident #4 was moved to a different neighborhood and offered counseling options to return to the community. IV. Resident-to-resident altercation involving Resident #6 and Resident #5 A. Resident #6's status Resident #6, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the August 2020 CPO, [DIAGNOSES REDACTED]. The 6/26/2020 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required supervision with most ADLs. He had minimal difficulty hearing and required hearing devices. B. Resident #5's status Resident #5, age less than 50, was admitted on [DATE] and readmitted on [DATE]. According to the August 2020 CPO, [DIAGNOSES REDACTED]. The 7/22/2020 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with all ADLs. C. Altercation 8/11/2020 Review of the facility documentation dated 8/11/2020 was provided by the NHA on 8/26/2020 at 5:22 p.m. It documented in pertinent part, Resident #5 asked Resident #6 to stop messing with the television (the residents were roommates). Resident #5 stood up walked over to Resident #6 and slapped him in the face and threw an apple at him. Resident #6 left the room and went to tell the nurse. Law enforcement was notified and an investigation was started. In conclusion, it documented the verbal and physical altercation between Resident #5 and Resident #6 was substantiated. Resident #5 and Resident #6 engaged in a verbal altercation in which Resident #6 was hit in the right eye with a closed fist by Resident #5. Resident #6 did not realize the remote he was using to change his television (TV) was also changing Resident #5's TV. Resident #5 was moved to another room and offered counseling options to return to the community. Resident #6 was encouraged to wear his hearing aids as he did not hear his roommate ask him to stop changing his TV.

Based on observations, resident interviews, record review, and staff interviews, the facility failed to ensure one (#31) of one out of 35 total sampled residents ' maintained acceptable parameters of nutritional status. Specifically, the facility failed to: - Provide timely and resident appropriate interventions to prevent the rapid and severe weight loss of resident #31; - Maintain resident #31 ' s body mass index (BMI) from falling below the normal range; - Maintain acceptable protein levels; - Maintain an effective communication system between departments; - Monitor and update the care plans; - Provide care based on care plan interventions; - Provide and document snack and nutritional supplement intake; and - Provide and evaluate the effectiveness of the therapeutic diet order. The findings included: I. Professional references According to the Center for Disease Control and Prevention (CDC), Division of Nutrition, Physical Activity, and Obesity http://www.cdc.gov/nccdphp/dnpao/index.html, About Adult BMI, 5/15/15, http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html (8/15). .BMI Below 18.5 .Weight Status Underweight .BMI 18.5-24.9 .Weight Status Normal or Healthy Weight .Formula: weight (kg) / (height (m))2 . According to the American Family Physician, Unintentional Weight Loss in Older Adults, http://www.aafp.org/afp/2014/0501/p718.html (8/15). .Unintentional weight loss (i.e., more than a 5 (five) % (percent) reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of [MEDICAL CONDITION] in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . II. Facility Policy and Procedure (P&P) According to the Weight Assessment and Intervention P&P revised in 9/08, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . Weight Assessment 3. .Any weight change of 5 (five) % (percent) or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietitian . 4. .The Dietician will review the unit Weight Record to follow individual weight trends over time. Trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met . 5. .The threshold for significant unplanned and undesired weight loss will be based on the following criteria . a. .1 (one) month-5 (five) % (percent) weight loss is significant; greater than 5 (five) % (percent) is severe . b. .3 (three) months- 7.5 (seven and one half) % (percent) weight loss is significant; greater than 7.5 (seven and one half) % (percent) is severe . c. .6 (six) months- 10 (ten) % (percent) weight loss is significant; greater than 10 (ten) % (percent) is severe . Analysis 1. .Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made . 2. .The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss . a. .Cognitive or functional decline . b. .Chewing or swallowing abnormalities . c. .Pain . d. .Medication-related adverse consequences . e. .Environmental factors (such as noise or distractions related to dining) . f. .Increased need for calories and/or protein . g. .Poor digestion or absorption . h. .Fluid and nutrient loss . i. Inadequate availability of food or fluids . Care Planning 1. .Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident ' s legal surrogate . 2. .Individualized care plans shall address, to the extent possible . a. .The identified causes of weight loss . b. .Goals and benchmarks for improvement . c. .Time frames and parameters for monitoring and reassessment . Interventions 1. .Interventions for undesirable weight loss shall be based on careful consideration . a. .Resident choice and preferences . b. .Nutrition and hydration needs of the resident . c. .Functional factors that may inhibit independent eating . d. .Environmental factors that may inhibit appétit or desire to participate in meals . e. .Chewing and swallowing abnormalities and the need for diet modification . f. .Medications that may interfere with appetite, chewing, swallowing, or digestion . g. .The use of supplementation and/or feeding tubes .h. .End of life decisions and advance directives . III. Resident #31 Resident #31, who was under [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the significant change Minimum Data Set (MDS) document dated 8/31/15 she had short and long term memory problems. Her decision making was documented as having been moderately impaired with poor decision making skills. She required extensive assistance for bed mobility, transfers, walking in room and corridor, dressing, eating, toilet use, and personal hygiene. She required a walker and wheelchair for mobility. Her height was 60 inches and her weight was 85 pounds (lbs). She was not on a physician prescription weight loss regimen and received a therapeutic diet. The care plan (CP) that was titled nutritionally at-risk related to dementia, GERD, diabetes, low intake, and low BMI had a goal for the resident of maintaining her weight through the next review period. The approaches included the following pertinent information: - 6/12/15, draw labs as needed, - 8/31/15, encourage resident to attend the dining room for meals, - 6/12/15, monitor and record food intake, - 6/12/15, monitor and weight, - 6/12/15, offer alternative food as needed, - 6/12/15, offer snack as requested at activities, - 6/12/15, provide assistance as needed, - 6/12/15, provide diet as ordered: CC (consistent carbohydrate) diet, regular texture, and fortified, - 6/12/15, provide medications as ordered, and - 6/12/15, provide supplements as ordered related to weight loss. The last update to her care plan was on 8/31/15 (see above). The registered dietician (RD) identified the resident had severe weight loss on 7/28/15. As of 10/6/15 she had lost 17.5% of her body weight. As of the last day of the survey, on 10/20/15 there was not any new nutrition interventions put into place. On 10/6/15 she was 60 inches tall, 79.2 lbs, with a BMI of 15.5 which indicated she was underweight. A. Resident observations and interviews On 10/14/15 at 8:35 a.m. she was observed sleeping in bed, without breakfast in her room. On 10/14/15 at 10:55 a.m. she was observed lying flat on her back and in bed. Her water was out of reach and there was not any food observed in her bedroom. The room was dark and she began to yell out help over and over again. The certified nurse aide (CNA) #8 revealed that this was a common behavior. She explained to the resident that she would be back in a minute to take her to lunch and then reported that she did not always eat breakfast and would lie in bed until she got her up for lunch. She revealed she was not always offered a breakfast meal or an alternative later in the day and walked out of the room. The resident continued to yell out for help until 11:05 a.m. when the CNA returned and assisted her out of bed. On 10/14/15 at 11:45 a.m. she was observed in the dining room and sitting in the assisted section. When cued she would consume small bites of her food. She did not have adaptive equipment and struggled to use a fork. When distracted by other residents she would stop eating. She was observed to consume about 40% of the meal on her plate. On 10/15/15 at 2:15 p.m. she was observed in bed and lying flat on her back and awake. There was no music on and there was not a television in the bedroom. The room was dark and her water pitcher and the non-dairy protein drink wasobserved out of reach. On 10/15/15 at 4:50 p.m. she was observed lying flat on her back in bed. There were not any sounds in the room and the lights were off. She was visibly thin and drawn in the face. At 5:02 p.m. she was observed sitting in her wheelchair and in the dining room. She was not consuming her meal and looked upset. She revealed that she was not feeling well and had chest pain. At 5:13 p.m. licensed practical nurse (LPN) #1 brought her apple juice with a straw inside of it. At 5:15 p.m. the MDS Coordinator was observed to assist her with eating. She was able to consume about half of her meal. On 10/19/15 at 9:38 a.m. and 10:01 a.m. she was observed lying in bed on her side towards the wall. There was no food or beverages within reach. At 11:54 a.m. she was observed lying in bed and she revealed that her chest was still hurting. She reported with CNA #5 and CNA #7 in the room that she could not eat because of her chest pain. CNA #5 revealed that they try to encourage her to attend meals in the dining room, but she began to have behaviors and would want to go back to bed. CNA #7 reported that she was going to obtain a peanut butter and jelly sandwich with a clear protein drink for her to eat in her room. At 12:59 p.m. CNA #5 reported she was able to encourage her to attend lunch. She reported that she had consumed an entire non-dairy protein drink, a few bites of meat loaf, and a few bites of a peanut butter and jelly sandwich. On 10/20/15 at 8:07 a.m. she was observed in her bedroom, lying in bed. CNA #1 was standing over her and assisting her with eating French toast. He had stopped assisting her and left the room to obtain a chair to sit down in. He revealed that he was unsure if she was receiving a nutritional supplement or snacks throughout the day. He revealed if she had asked for something they would give it to her without restrictions. He reported that she ate well and preferred to consume sweets and sugar. On 10/20/15 at 11:55 a.m. she was observed in her bedroom lying in bed. She revealed that she was not feeling well and reported that her stomach was hurting. She said that she had not been offered medication and pointed to her [MEDICAL CONDITION] bag. The registered nurse (RN) #1 was informed of her stomach pain. She assessed the resident and readjusted her [MEDICAL CONDITION] bag. The resident reported that she felt much better and asked the RN for food because she was hungry. B. Record review The Physician order [REDACTED]. - Order date: 6/3/15, CC diet with regular textures; and - Order date: 8/15/15, non-dairy protein drink (four ounces (oz) three times a day as needed (PRN) and when awake or with meals for weight loss). There was not a PO or a mention of fortified foods. The nutritional supplement order for non-dairy protein drink was a PRN order and was not required three times a day for weight loss. The resident was ordered a diet that restricted carbohydrates (sugar intake) and required smaller portions of desserts, diet, skim, or sugar free meal products and substitutes. The Medication Administration Record [REDACTED] - Order date: 6/3/15, CC diet with regular textures. The fortified foods and snacks/additional food items were not documented or mentioned on the MAR; and - Order date: 8/13/15, non-dairy protein drink (four oz three times a day as needed when awake or with meals for weight loss). The non-dairy protein drink was not documented as given TID or PRN in 8/15, 9/15, and 10/15. The Telephone Order (TO) dated 8/7/15 revealed the non-dairy protein drink was TID (three times per day) or PRN (as needed) when awake with medications or meals. The MAR indicated [REDACTED]. She received the nurtritional supplement 6/3/15-6/11/15. On 6/11/15 the RD recommended, according to the TO dated 6/11/15, to discontinue the sugar free nutritional supplement. According to the Nutritional Assessment document dated 6/3/15, she refused the product because she believed that there was milk inside of it and she was lactose intolerant. A secondary nutritional supplement was not recommended to replace the sugar free nutritional supplement. Her poor intake had already been identified as a potential contributing factor for potential weight loss. 1. Weight loss The Weight document dated 6/3/15-10/14/15 revealed: - 7/14/15, 96 lbs, - 7/21/15, 96.8 lbs, - 7/28/15, 90.4 lbs, - 8/5/15, 84.6 lbs, - 8/11/15, 86.4 lbs, - 8/25/15, 84.8 lbs, - 9/2/15, 88.2 lbs, - 9/8/15, 88.6 lbs, and - 10/6/15, 79.2 lbs. Between 9/2/15 and 10/6/15 she had lost nine pounds, which was 10.2 percent (%) of her body weight in approximately one month. This was a severe weight loss because it was over five percent in one month. Between 7/14/15 and 10/6/15 she had lost 16.8 lbs, which was 17.5% of her body weight in approximately three months. This was a severe weight loss because it was over seven and one half percent weight loss in three months. According to the dietary progress notes severe weight loss was identified on the following dates: - On 7/28/15 the RD revealed that she had lost five and eight tenths percent of her body weight in two weeks; - On 8/7/15 the RD revealed that she had lost 12.6% of her body weight in one month; - On 8/31/15 the dietetic technician registered (DTR) revealed that she had lost 11.67% of her body weight in one month; and - On 9/25/15 the RD revealed that she had lost five percent of her body weight in the past 30 days due to isolation and shingles. 2. Laboratory Values The most recent Laboratory documents revealed the following pertinent information: - On 6/9/15, the [MEDICATION NAME] was 20.3 mg/dL. This value was borderline low; the normal range was 20.0-40.0 mg/dL; - On 6/9/15, the Total Protein was six and one tenths g/dL. This value was low; the normal range was six and two tenths-eight and two tenths g/dL; - On 6/9/15, the [MEDICATION NAME] was three and two tenths g/dL. This value was low; the normal range was three and four tenths-five g/dL; - On 6/26/15, the BUN was four mg/dL. This value was low; the normal range was five-28 mg/dL; and - On 6/26/15, the BUN/Creatinine Ratio ration was 8. This value was low; the normal range was 10-28 mg/dL. 3. Nutrition Assessments and Interventions The nutritional full assessment document dated 6/3/15 revealed the following pertinent information: - The initial assessment revealed that the resident was receiving a regular texture, therapeutic CC diet; - The admission weight was documented as 93 lbs and her height was 60 inches; - Her ideal body weight was 100 lbs and her usual body weight was not documented; - Her intake risk was documented as moderate, which revealed that her intake was 26-75% of her estimated needs; - Her calorie needs were documented as 1080 calories and the protein needs were documented as 42 grams; - She was documented as being able to feed herself and she did not have any chewing or swallowing difficulties; - She was lactose intolerant and did not refuse major food groups or complain about the taste of food; - Her food preferences were Italian food, pizza, green tea, ice cream, peaches, pineapple, and oatmeal; - The medical conditions that were relevant were documented as dementia, anxiety, GERD, [MEDICAL CONDITIONS], and type II diabetes; and - The summary revealed that her intake was 14% and had increased to 21%, and she preferred to sleep in and skip breakfast. She liked chocolate pudding for a snack and had refused nutritional supplement because she believed that it contained milk so the order had been discontinued. The staff had reported that she eats, just not the things we would like her to eat. She preferred donuts and juice. There were not any recommendations at this time and it was recorded that her weight should have continued to improve. Her BMI was documented as 18.8 at the end of the note, which indicated that she was within the normal range. The nutrition quarterly assessment document dated 8/26/15 revealed the following pertinent information: - The quarterly assessment revealed that her weight had gone from 96 lbs to 85 lbs in one month; - She was not on a prescribed weight loss regimen and the loss was not desirable; - Her diet was documented as regular texture, therapeutic CC diet with fortified foods; - She was to receive four oz of the non dairy protein drink three times a day/as needed and to receive peanut butter and jelly as a snack; - She did not require adaptive equipment, did not leave the table before meals were finished, and was able to finish meals during the allocated meal time; - Her labs were not in the acceptable or normal range. Her glucose was high and her BUN was low; and - The summary revealed that her intake was 24% and the nurses' note reported that the resident consumed little, received room trays, and declined going to the dining room. She had a significant weight loss of 11.67% in one month. The current interventions were four oz of non-dairy protein drink three times a day/as needed, trial of calorie and protein food enhancer, and peanut butter and jelly sandwich as an evening snack. Her BMI was 16.6, which indicated that she was underweight. There was not any supporting documentation that the calorie and protein food enhancer was trialed, liked or disliked. There was not a TO or PO for the calorie and protein food enhancer and there was not any supporting documentation on the MAR indicated [REDACTED] The dietary progress notes revealed the following pertinent information: - On 7/28/15 the RD reported that the nurses did not think that she would accept any dietary supplements. She recommended that the dietary manager would trial food items with her. There was not any supporting documentation that food items were trialed or the outcome of the trial. - On 8/7/15 the RD revealed that because of the resident's agitation and sleeping it would have been difficult for her to consume a supplement. The non-dairy protein drink was recommended and an order completed. - On 8/31/15 the DTR revealed that the current interventions were a non-dairy protein drink TID or PRN, Peanut butter and jelly sandwich, and a trial of a calorie and protein food enhancer; and - On 9/25/15 the RD mentioned that there was an order for [REDACTED]. There was not any supporting documentation that dietary had trialed half sandwiches or any documented outcomes. She reported that she would continue to monitor the resident as adding another intervention at this time may not be taken well. The explanation why the resident might not take a supplement well was not documented. The consultant dietitian resident recommendations and comments dated 9/25/15 revealed that the dietary recommendations were to provide a non-dairy protein drink which was already ordered three times a day/as needed in the apple flavor and to trial a meat sandwich or grilled cheese. There was not any supporting documentation that the meat sandwich or grilled cheese was trialed or what the outcome of the trial was. The meal intake document received from the dietary manager (DM) on 10/20/15 at 11:06 a.m. revealed that the resident had an intake average of 19.05% in one week, 18.5% in four weeks, and 20.54% in 12 weeks. This document did not reveal the percentage of snacks and nutritional supplements consumed, or preferred/additional food items request by the resident. He revealed that it was the responsibility of the nurse to document nutritional supplement and snack intakes. Food preferences sample form dated 6/3/15 revealed that the resident preferred the dining room for meals and spaghetti sauce, meatballs, grapes, apple juice and ice cream for food preferences. The Meal Extension Menu revealed that there was a finger food diet available. 4. Activities and Therapy The activity calendar revealed a steady decline in resident participation in scheduled group activities. Review of the 8/15, 9/15, and 10/15 calendars revealed the following pertinent information: - In 8/15 she participated in 12 activities either actively or passively; - In 9/15 she participated in six activities either actively or passively; and - In 10/15 she participated in two activities passively. The physical therapy progress and discharge summary dated and signed 9/14/15, did not reveal that she was evaluated for eating assistance or adaptive equipment use. There was not an occupational therapy (OT) or speech therapy (ST) evaluation. She did not receive range of motion services (ROM). IV. Staff interviews On 10/19/15 at 3:26 p.m. the DM revealed that care plans were not updated during formal meetings with a multidisciplinary team. He reported that they were updated when the information needed to be changed or updated. He revealed that a weight loss of more than three pounds a week would be a concern and he would meet with his staff to implement weight loss interventions. He reported his team would review eating habits, food likes/dislikes, intakes, desirable verses undesirable weight loss, low BMI, past history, and medications to determine the root cause of the weight loss and come up with customized interventions. The DTR revealed that she would review the resident ' s labs and weights before recommending weight loss interventions. She revealed that she was responsible for updating the care plans and completing the MDS. She reported that interventions should have been represented on the care plans and updated upon a significant change, quarterly, or annually. She revealed that she was not aware that the resident had experienced stomach and chest pain or had a [DIAGNOSES REDACTED]. On 10/20/15 at 11:45 a.m. CNA #1 revealed that he frequently worked with the resident. He revealed that he was familiar with her plan of care and would assist her with eating breakfast in bed in the mornings almost every day. He reported that she fed herself in the dining room and would consume a higher amount of food on her own with cueing and when she had finger foods available. He reported that she liked feeling independent and eating on her own was something she had enjoyed. He revealed that she cannot use a fork or a spoon very well. He revealed that she liked to consume sweet foods such as grapes with sugar and apple juice. He said that she did not follow the CC diet and did not receive fortified foods. He reported that he was unsure if she had experienced severe weight loss and was to receive supplements. He reported that the physical therapists obtained the resident ' s weight and he was unsure what her current weight was or if the facility monitored weights weekly. He revealed that all residents in the facility were encouraged to consume snacks and had the ability to order whatever they would like from the kitchen. On 10/20/15 at 2:11 p.m. CNA #8 revealed that she frequently worked with the resident. She revealed that she was familiar with her plan of care but had not seen a nutrition care plan on this resident. She revealed that she was communicated the resident ' s needs from the resident directly and the nurses. She reported that the resident frequently consumed peanut butter and jelly sandwiches, fruit loops, and grapes with sugar. She reported when working with the resident it was important to be prompt, encouraging, and constantly remind her to eat. She prefered finger foods that she was able to consume on her own. She reported that she would not let you help her eat and when you try to assist her she would become aggressive. She reported that the resident did not use adaptive equipment for eating or drinking assistance. She said that she was unsure if she received a nutrition supplement. She revealed that she may receive a strawberry or chocolate shake because those were her favorites. She reported that she would drink more fluids then consume food, unless it was unhealthy, sweet foods. She said that she was not a big breakfast eater, but did enjoy eggs. She suggested trying hard boiled eggs and other finger foods with her. She revealed that the resident would sometimes complain of chest pain and she would lie her down in bed and give her apple juice. At 2:17 p.m. CNA #8 reported that she had taken the resident back to her room earlier in the day because she was complaining about stomach pain. She revealed that she had taken the resident ' s vitals and placed her back into bed. She said she reported this information to LPN #2. See resident observations/interviews above. On 10/20/15 at 12:05 p.m. LPN #2 revealed that she frequently worked with the resident. She revealed that she was familiar with her plan of care but did not read them. She revealed that the MDS coordinator would update her when there were changes to the care plans. She revealed that the resident preferred to consume peanut butter and jelly sandwiches, donuts, and apple juice. She revealed that she had not seen her receive a meat sandwich. She reported that she preferred to feed herself and liked eating finger foods. She did receive a non-dairy protein drink TID or PRN. She revealed that the order was written in that format so the nurses did not have to document refusals. She revealed that she preferred to consume the non-dairy protein drink because they were sweet. She revealed that monthly and weekly weights were taken, but she did not know her current weight. She reported that nursing would verbally communicate concerns with resident ' s weight to the nurses. She revealed that she was unsure about any new nutrition interventions since 8/15. On 10/20/15 at 1:00 p.m. the RD was interviewed on the phone with the DM present. She revealed that she had been working for the facility for over one year and was aware that the resident had severe weight loss since admission. She revealed that she worked inside of the facility two days out of the month and depended heavily on the dietary and nursing department to provide her up to date and accurate resident information for her assessments. She reported that that the resident had been offered feeding assistance and had declined the assistance in the past. Some risk factors associated with severe weight loss were defined as poor intake and resistance to care. She said that the first intervention in 6/15 had been declined by the resident because she believed there was milk inside of it. She was placed on a non-dairy protein drink in 8/15 that was apple flavor TID or PRN when awake or with meals per the nurses request to have the order written that way. She reported that peanut butter and jelly and a calorie and protein food enhancer had been trialed, but was not ordered. She revealed that the CC diet was a non-restrictive version of a diabetic diet. She reported that the only difference was that the desserts were half the portion of the regular meals. She revealed that she had been placed on that diet upon admission due to her diabetes diagnosis. She confirmed that the clear protein drink was high in sugar and the DM reported the opposite and that it was not high in sugar. Both the RD and the DM revealed they were unaware that the resident had a complaint of pain in the chest area that was care planned and a complaint of reflux that may have caused food consumption discomfort or pain. The RD revealed that food to avoid when with the [DIAGNOSES REDACTED]. She reported that she had not been seen by ST or OT, and was unsure about PT. At 1:30 p.m. the RD was no longer on the phone. The DM revealed that he and the DTR was responsible for the resident ' s likes and dislikes. He reported that the facility had a finger foods diet on the meal extension menu, but it was not currently in use. He revealed that she liked to consume peanut butter and jelly, grapes, and junk foods. On 10/20/15 at 2:22 p.m. the consultant pharmacist revealed some non-pharmaceutical interventions for the prevention [MEDICAL CONDITION] be to avoid spicy foods and to not lay down right after a meal. On 10/20/15 at 2:34 p.m. the director of nursing (DON) revealed that clinically the signs and symptoms [MEDICAL CONDITION] be indigestion, gastric pain, reflux, discomfort, pain, or bloating. She revealed that a resident would [MEDICAL CONDITION] have been effected by what they had eaten and would have required more of a bland diet with no spicy and acidic foods or medication intervention. She reported that if a resident did not feel well, that they would most likely not eat well. She said that some new interventions would have been to give her foods that were easy for her to eat and pick up. She reported that she could be offered different types of food or finger foods that promote resident independence instead of the CC diet. She shared a story that had occurred during an activity on 10/6/15. She revealed that the resident was watching a scary movie and the staff was assisting her with consuming her meal. She reported that she was so distracted and involved with the movie that she had consumed her whole snack. On 10/20/15 at 3:45 p.m. the MDS coordinator revealed that the significant change had been triggered on the MDS on 8/31/15 due to the resident ' s pain, weight loss, and decrease of activities of daily living. She revealed that the resident would benefit from one on ones, multiple food choices, small and frequent meals due to the dementia, and finger foods.