Every finding on record at Heights Care & Rehabilitation LLC

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to ensure appropriate use of gloves when handling ready-to-eat foods. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/7/26. It revealed in pertinent part, Food employees may not contact exposed ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (3-301-11) Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink that is equipped to provide water at a temperature of at least 29.4oC (85oF) through a mixing valve or combination faucet.(2-301-12)II. ObservationsDuring a continuous observation of the dinner meal service on 4/1/26, beginning at 4:25 p.m. and ending at 5:55 p.m. the following was observed:At 4:30 p.m. dietary aide (DA) #2 placed three plates on the serving line. She picked up three hot dog buns with her bare hands and placed one bun each on a plate. At 4:38 p.m. DA #2 picked up a hot dog bun bare hands and placed it on a plate and assembled a meatball sandwich.At 4:40 p.m. DA #2 picked up a meal ticket. Without performing hand hygiene DA #2 picked up a hot dog bun with her bare hands and placed it on a plate. She assembled a meatball sandwich and passed the plate to cook (CK) #1.At 4:41 p.m. DA #2 touched another meal ticket. Without performing hand hygiene, she picked up a hot dog bun and prepared a meatball sandwich.At 4:42 p.m. DA #2 touched the counter top and picked a plate and put it on the counter top. Without washing her hands, she picked up a hot dog bun and placed it on the plate. She assembled a meatball sandwich and passed the plate to CK #1.At 4:45 p.m. DA #2 touched a wet towel on the table to her left with her right hand. CK #1 adjusted her shirt and apron around her waist with her bare hands.At 4:45 p.m. CK #1 picked up a meal ticket order]. She picked up a hot dog bun bare hands and placed it on the plate.At 4:46 p.m. DA #2 touched another meal ticket. Without performing hand hygiene, she picked up a hot dog bun and prepared a meatball sandwich.At 4:47 p.m. DA #2 picked up a meal ticket with bare hands. Without performing hand hygiene DA #2 picked up a hot dog bun with her bare hands and placed it on a plate. She assembled a meatball sandwich and passed the plate to CK #1. At 4:52 p.m. DA #2 touched another meal ticket. Without performing hand hygiene, she picked up a hot dog bun and prepared a meatball sandwich.At 4:54 p.m. DA #2 touched another meal ticket. Without performing hand hygiene, she picked up a hot dog bun and prepared a meatball sandwich. DA #2 swiped a plate with food bare hands with the chef.At 4:55 p.m. DA #2 brought trays bare hands from the dishwasher room. She grabbed meal tickets and placed them on the trays, picked up plates and placed them on the trays bare hands. She picked up hot dog buns bare hands and placed them on the plates.At 4:57 p.m. DA #2 picked up a hot dog bun bare hands and placed it on a plate and assembled a meatball sandwich.At 4:59 p.m. CK #1 touched her wrist watch with bare hands. Without washing her hands she picked a bowl, grabbed an utensil and scooped a spoonful of macaroni onto the bowl.At 4:59 p.m. without wearing gloves, DA #2 picked up a bun with her right hand, and assembled a meatball sandwich. CK #1 did not wash her hands after adjusting her shirt and apron and touching the plate. DA #2 picked up meal tickets on the table with both hands. She then picked up a plate with her right hand and placed a hot dog bun on the plate with her bare left hand. CK #1 finished assembling the plate and placed the plate on a tray in the window to be served to a resident.At 5:00 p.m. DA #2 touched her clothes. Without washing her hands, she resumed serving meals. At 5:16 pm DA #1 started assembling the meal plates and placed them in the meal cart bare hands.At 5:18 p.m. the staff continued to assemble meal plates bare hands and placed them in the meal cart.At 5:21 p.m. DA #2 washed her hands and picked a hot dog bun without wearing gloves and assembled a meatball sandwich.At 5:23 p.m. CK #1 washed her hands and scooped pasta salad onto a plate with a utensil.At 5:25 p.m. DA #1 started to assemble two meal plates. She used her bare hand to place a hot dog bun on two plates. The meal plates were assembled and placed in the meal cart for service.At 5:25 p.m. DA #2 touched her clothes with her hands. Without washing her hands she picked a meal ticket, read it and put it back on the tray. She picked a hot dog bun bare hand and placed on the plate, grabbed an utensil and scooped meatball onto the plate, passed the plate to CK #1 .At 5:27 p.m. DA #1 started to assemble three meal plates. She used her bare hand to place a hot dog bun on two plates. The meal plates were assembled and placed in the meal cart for service.At 5:45 p.m. DA #2 wore gloves and went to get more trays from the dishwashing room. She removed gloves and resumed serving meals bare hands.III. Staff interviewsDA #3 was interviewed on 4/2/26 at 3:20 p.m. DA #3 said she washed her hands, went to the serving line, served food, and washed her hands again before serving the next meal. DA #3 said she took a handwashing break between serving the next meal. DA #3 said she could not touch bread or buns with bare hands and avoided direct contact with ready-to-eat food. She said gloves should be worn and changed as needed after use. DA #3 said they did not wear gloves when serving food because they washed their hands consistently. She said DA #2 and CK #1 were not supposed to handle hot dog buns with bare hands.The kitchen manager was interviewed on 4/2/26 at 3:38 p.m. The kitchen manager said kitchen staff should wash their hands consistently between tasks. He said they should use tongs or wear gloves for a single task while handling ready-to-eat food. The dietary cook said DA #2 and CK #1 should not touch hot dog buns with bare hands. The kitchen manager said the dietary staff should have worn gloves when handling the hot dog buns.The nursing home administrator (NHA) was interviewed on 4/6/26 at 2:34 p.m. The NHA said the kitchen staff were educated on proper hand hygiene during meal preparation and service on 4/1/26.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the residents care plan.Specifically, the facility failed to ensure soft and bite size chicken was produced and serviced according to the International Dysphagia Diet Standardisation Initiative (IDDSI) standards. Findings include:I. Professional referenceAccording to the IDDSI reference (July 2019), retrieved on 4/14/26, https://www.iddsi.org/images/Publications-Resources/DetailedDefnTestMethods/English/V2DetailedDefnEnglish31july2019.pdf Can be eaten with a fork, spoon or chopsticks. Can be mashed/broken down with pressure from fork, spoon or chopsticks. A knife is not required to cut this food, but may be used to help load a fork or spoon. Soft, tender and moist throughout but with no separate thin liquid. Chewing is required before swallowing. Bite-sized pieces as appropriate for size and oral processing skills. Adults no larger than 1.5 centimeters (cm). Fork pressure test: pressure from a fork held on its side can be used to cut or break apart or flake this texture into smaller pieces. When a sample the size of a thumb nail (1.5 by 1.5 cm) is pressed with the tines of a fork to a pressure where the thumb nail blanches to white, the sample squashes, breaks apart, changes shape, and does not return to its original shape when the fork is removed.II. Facility policy and procedureThe Therapeutic Diet Orders policy and procedure, revised 4/2/26, was provided by the nursing home administrator (NHA) on 4/2/24 at 3:47 p.m. The policy read in pertinent part, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.III. Record reviewThe texture modified diet menu was provided by the NHA on 4/1/26 at 9:47 a.m. The menu documented the residents prescribed a soft and bite sized diet were to receive the following items for dinner on 4/1/26:-Bite-size meatballs with thick sauce with a minced or pureed bun;-Bite-sized pasta salad with vinaigrette; and,-Bite-sized chilled peaches.-However, the facility failed to serve the menu as posted. IV. Observations During a continuous observation of the meal service on 4/1/26, beginning at 4:25 p.m. and ending at 5:55 p.m. The following was observed: At 4:29 p.m. the soft and bite sized menu items were in the hot steam table. The mechanically altered menu items held in the hot food holding table were reviewed with cook (CK) #1. CK #1 said foods in the hot food holding table were for the soft and bite sized meals. The chicken for the soft and bite sized meals was approximately 1/4 inch to 1/2 inch in size.-However, soft and bite sized foods should be less than 1.5 cm by 1.5 cm (see professional reference above). At 4:35 p.m. CK #1 assembled a soft and bite-sized texture plate. CK #1 scooped the diced chicken, green beans and rice. He covered it all with au-jus. The plate was delivered to a resident seated in the dining room.At 4:48 p.m the kitchen manager was notified the chicken was diced incorrectly. The kitchen manager was asked to do a fork test and he said he was not sure how to do the fork test. After demonstrating the fork test with the dietary cook, the chicken did not break apart or flake. At that time the kitchen manager corrected the issue and made the chicken pieces smaller.V. Staff interviewsCK #1 was interviewed on 4/1/26 at 4:36 p.m. during meal service. CK #1 said the chicken was for the soft and bite sized Level 6 texture and minced and moist Level 5 texture. She said the chicken was prepared at the facility by the kitchen manager, who cooked and diced the chicken.The kitchen manager was interviewed on 4/1/26 at 4:49 p.m. The kitchen manager said the chicken on the hot line was the chicken for the soft and bite sized Level 6. He said he did not do the fork test prior to service. He said he cut the size of the chicken according to the size of the thumb nail in the picture posted on the wall in the kitchen and the au-jus was to put on top of the chicken for moisture. The kitchen manager said he had done a fork test to ensure the correct texture of the food in the past but did not do it at that time. He said he was not sure how to do the fork test.The regional clinical resource was interviewed on 4/1/26 at 5:45 p.m. The regional clinical resource said she had printed the IDDSI education materials for the staff to do additional education and assigned the electronic IDDSI learning to them in the system. She said the training would take about an hour and a half to complete and they would start working on it possibly the following day.The kitchen manager was interviewed again on 4/2/26 at 3:38 p.m. The kitchen manager said he received training on textures one month later, shortly after the facility changed the ownership. He said he relied on his previous facility texture training for reference. The kitchen manager said there was a choking risk associated with an incorrect texture.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high frequency touched areas (call lights, door handles, light switches and bed controls);-Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents' rooms;-Ensure housekeeping staff performed appropriate hand hygiene between glove changes; and,-Ensure Resident #6's catheter tubing was not touching the floor.Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 4/7/26 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 4/7/26 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedures The Routine Cleaning and Disinfecting Resident Rooms policy and procedure, revised 4/2/26, was provided by the nursing home administrator (NHA) on 4/2/26 at 4:21 p.m. It read in pertinent part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Cleaning considerations include, but are not limited to, the following: dry cleaning procedures will be conducted before wet procedures, clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty, clean from top to bottom (bring dirt from high levels down to floor levels), clean from back to front areas. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: toilet flush handles, bed rails, tray tables, call buttons, television remote, telephones, toilet seats, monitor control panels, touch screens and cables, resident chairs, IV poles, blood pressure cuffs, sinks and faucets, light switches and door knobs. Disinfectant solutions will be prepared fresh daily and changed frequently in order to ensure effectiveness. Follow manufacturer recommendations for dilution and frequency of changing of disinfectant solution. Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection. Change solution after cleaning a room under transmission-based precautions. Clean and disinfect any equipment that enters the room before use in another location. Verify products used to clean and disinfect surfaces in rooms under transmission-based precautions are effective against the pathogen of concern. The Handwashing/Hand Hygiene policy and procedure, revised 2026, was provided by the NHA on 4/6/26 at 8:43 a.m. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Applying and removing gloves: perform hand hygiene before applying non-sterile gloves. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. Then perform hand hygiene. C. Observations During a continuous observation on 4/2/26, beginning at 10:47 a.m. and ending at 11:05 a.m. Housekeeper (HK) #1 was observed exiting room [ROOM NUMBER] and using alcohol-based hand rub (ABHR). She pushed the housekeeping cart to room [ROOM NUMBER], a double-occupancy room, and donned gloves. She knocked on the door and asked permission to clean the room. HK #1 removed a spray bottle of disinfectant and a clean blue rag. The disinfectant spray bottle had a label on it that indicated the disinfectant had a dwell time of three to five minutes. At 10:48 a.m. HK #1 sprayed the residents' sink and faucet with the disinfectant. She removed the toilet brush from the cart and placed it in the bathroom. She removed her gloves and donned clean gloves without performing hand hygiene. At 10:50 a.m. (two minutes after spraying the disinfectant), HK #1 wiped out the sink and faucet with the blue rag. She splashed water onto the mirror and wiped it clean. She placed the disinfectant spray bottle and rag back into the cart and removed her gloves. HK #1 donned clean gloves, without performing hand hygiene, and removed the disinfectant spray bottle and a rag from the cart. She sprayed the rag with the disinfectant and wiped the top of the over bed table for bed B. She sprayed the rag again and wiped down the legs and base of the overbed table. She placed the disinfectant spray bottle and rag back into the cart and removed her gloves. Without performing hand hygiene, HK #1 donned clean gloves and removed the disinfectant spray bottle and a rag from the cart. She sprayed the rag with the disinfectant and wiped the top of the over bed table for bed A. She folded the rag in half, sprayed it with disinfectant and wiped down the legs and base of the overbed table. She placed the disinfectant spray bottle and rag back into the cart and removed her gloves. Without performing hand hygiene, HK #1 donned clean gloves and removed the disinfectant spray bottle and a clean rag from the cart. She sprayed the rag with the disinfectant and wiped off the top and front of bed A's nightstand. She placed the disinfectant spray bottle and rag back into the cart and removed her gloves. -HK #1 failed to allow the disinfectant to remain on surfaces for the appropriate disinfectant dwell time while cleaning the residents' room. -HK #1 failed to disinfect high touch areas, such as the door knobs, light switches, call light and bed controller. -HK #1 failed to perform hand hygiene during her multiple glove changes. HK #1 donned clean gloves without performing hand hygiene and removed a clean rag from the cart. She entered the bathroom of room [ROOM NUMBER] and used the toilet brush to scrub the toilet seat, underneath the toilet seat, the rim of the toilet and then the toilet bowl. She used the dry blue rag (without any disinfectant spray) to wipe the toilet rim, underneath the toilet seat, the toilet seat, the toilet tank, the top of the toilet tank and the base of the toilet. She placed the rag and the toilet brush back into the cart and removed her gloves and then donned clean gloves without performing hand hygiene. -HK #1 failed to use disinfectant to clean any parts of the toilet. -HK #1 failed to disinfect the light switch and door knobs in the bathroom. -HK #1 failed to clean from top to bottom or clean to dirty when cleaning the toilet. -HK #1 failed to perform hand hygiene between glove changes and after cleaning the bathroom. HK #1 donned clean gloves and proceeded to sweep the room and empty the trash. She placed the broom and trash onto the cart and removed her gloves. She donned clean gloves, without performing hand hygiene and removed a mop pad from the mop bucket and mopped bed B's side of the room. She removed her gloves and donned clean gloves without performing hand hygiene. She removed the soiled mop pad from the mop handle and placed it in a bag. HK #1 removed her gloves and donned clean gloves without performing hand hygiene. She removed a clean mop pad from the mop bucket and mopped bed A's side of the room. She removed the soiled mop pad and placed it on the cart. She removed her gloves and donned clean ones, again without performing hand hygiene. HK #1 removed a clean mop pad from the mop bucket and started to mop the bathroom. She removed her gloves, used ABHR and removed a roll of toilet paper from the cart. She returned to the bathroom and finished mopping. She removed her gloves and donned clean gloves without performing hand hygiene. She removed a fourth mop pad from the mop bucket and mopped behind the door and the entry to the room. She removed her gloves and washed her hands, she shut the door, donned clean gloves and removed the soiled mop pad. She placed the soiled mop pad onto the cart and removed her gloves. She placed a wet floor sign at the entrance of the room and pushed the cart to the next room. -HK #1 failed to consistently perform hand hygiene between glove changes while cleaning the bathroom of room [ROOM NUMBER]. D. Staff interviews HK #1 was interviewed on 4/2/26 at 3:08 p.m. HK #1 said she had cleaned residents' rooms the same way for 28 years. She said if she left a room or removed a mop pad, she would change her gloves. She said she should perform hand hygiene between glove changes to prevent bacterial microbes. She said the disinfectant needed to remain wet on surfaces for three to five minutes to kill microbes. She said the toilet brush could be used on the seat and the toilet bowl and that was how she always cleaned the toilet. She said the toilet should be cleaned from top to bottom to prevent taking dirt to cleaner areas to prevent contamination. She said she always sprayed the rag instead of the surfaces because some residents did not like the disinfectant to be sprayed. She said high touch areas should be cleaned daily, but she was unable to identify what the high touch surfaces were. She said she did receive training on cleaning residents' rooms and it was important to disinfect and clean the rooms properly to prevent the spread of infections. The housekeeping supervisor (HKS) was interviewed on 4/6/26 at 1:35 p.m. The HKS said residents' rooms were cleaned daily. She said the disinfect spray should be left wet on the surface for three to five minutes and was used for surfaces and a different disinfectant was used for the bathroom, which also had a dwell time of three to five minutes. The HKS said the toilet brush should only be used inside the toilet bowl and nowhere else. She said the toilet should be disinfected and cleaned from top to bottom. She said high touch areas included the over bed table, the television remote, the call light, the bed controller, the door knobs and lights switches and they should be disinfected daily. She said the disinfectant should be sprayed directly on a surface and not sprayed just on the rag. She said she would immediately provide education to the housekeeping staff on hand hygiene, the correct use of the disinfectants and the proper room cleaning procedure. The infection preventionist (IP) was interviewed on 4/6/26 at 2:421 p.m. The IP said hand hygiene should be performed in between glove changes, when entering a resident's room, when exiting a resident's room and when hands were visibly soiled. She said when disinfecting a surface, the surface should remain visibly wet for the correct dwell time before being wiped. She said high touch areas should be cleaned daily. She said the toilet brush should only be used in the toilet bowl. She said she would immediately provide education to the housekeepers for the areas of concern. E. Facility follow-up The facility provided all housekeepers education on 4/6/26 that included hand hygiene and best practices when cleaning/disinfecting resident rooms. -However, the education was not provided to the housekeeping staff until the concern was brought to the facility's attention during the survey. II. Failed to ensure Resident #6's catheter tubing was not touching the floor A. Facility policy and procedure The Catheter Care policy, undated, was received from the nursing home administrator (NHA) on 4/7/26 at 4:24 p.m. The policy read in pertinent part, Ensure the drainage bag is located below the level of the bladder to discourage backflow of urine. B. Observations On 3/30/26 at 10:19 a.m. Resident #6's tubing for his urinary catheter was observed hanging and dragging on the floor while the resident was self-propelling himself in his wheelchair. 04/1/26 at 12:39 p.m. the tubing for Resident #6's urinary catheter was observed to be hanging and dragging on the floor while the resident was self-propelling himself to the dining room in his wheelchair. An unidentified staff member was following behind Resident #6. -However, the unidentified staff member made no attempts to ensure the urinary catheter tubing was adjusted to prevent it from dragging on the floor. C. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 4/2/26 at 2:37 p.m. CNA #3 said he was assigned to monitor Resident #6 one-on-one and he was required to accompany the resident anywhere he chose to go in the facility and assist him with care as needed. CNA #3 said a resident's urinary catheter bag should not touch the ground because the ground was dirty. Licensed practical nurse (LPN) #3 was interviewed on 4/2/26 at 2:57 p.m. LPN #3 said the CNAs were responsible for making sure that the Resident #6's urinary catheter bag was transferred when the resident transferred from his bed to his wheelchair and that the catheter tubing was free from dragging on the floor. LPN #3 said the importance of making sure the urinary catheter tubing was not dragging on the floor was to prevent urinary tract infections (UTI). LPN #3 said she had not observed Resident #6's urinary catheter tubing dragging on the floor, but she said Resident #6 did throw the urinary drainage bag on the floor. She said the resident's urinary catheter tubing could have been dragging on the floor, but she said she would pick it up if she observed it.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#1) of three residents reviewed for grievances out of 53 sample residents.Specifically, the facility failed to report, document and follow-up on grievances reported by Resident #1 concerning her care preferences.Findings include:I. Facility policy and procedureThe Grievances policy, revised April 2017, was provided by the nursing home administrator (NHA) on 4/7/26 at 4:24 p.m. It read in pertinent part, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, or any other concerns regarding his or her stay at the facility. Grievance also may be filed regarding care that has not been furnished.II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included amyotrophic lateral sclerosis (a nervous system disease that affects nerve cells in the brain and spinal cord), anxiety disorder, depression, tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck), and acute respiratory failure with hypoxia (a condition where tissues and organs do not receive adequate oxygen).The 2/10/26 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 was dependent with toileting, personal hygiene and eating.B. Resident interviewResident #1 was interviewed on 3/30/26 at 10:29 a.m. Resident #1 said she informed a certified nurse aide (CNA) #1 approximately one week ago that she was frustrated that several CNAs assigned to provide her with care could not understand her during care. The resident said she told CNA #1 that she was frustrated and it made her angry when they could not understand what she asked for during her care. The resident said several CNAs would just nod their heads and keep going with her care. Resident #1 said she informed CNA #1 one week before the survey that she was tired of not being understood, but nothing had changed.Resident #1 was interviewed a second time on 4/1/26 at 1:50 p.m. Resident #1 said no staff members had had a discussion with her about her concern since she informed CNA #1 of the concern. Resident #1 said she told CNA #1 that her preference was to be assigned a CNA who could understand English, but she continued to have CNAs who could not understand her during care.C. Record reviewA review of the facility's Grievance Log, from 1/21/26 through 4/1/26, revealed that no entries had been made regarding Resident #1's concerns about her care provider preferences. During this time frame, the facility failed to document any formal or informal grievances regarding the resident's care-related preferences not being met.III. Staff interviewsCNA #1 was interviewed on 4/1/26 at 2:46 p.m. CNA #1 said she was in charge of scheduling. CNA #1 said Resident #1 had informed her one week prior to the survey about her specific preference for her care providers. CNA #1 said the resident had requested to be assigned a CNA who could communicate proficiently in English to support her care and enhance interaction during clinical tasks. CNA #1 said Resident #1 had mentioned she often became frustrated because several CNAs had difficulty understanding her due to their limited English proficiency. CNA #1 acknowledged that she had not completed a formal grievance report and had not documented the concern in the resident's electronic medical record (EMR). CNA #1 said she did not inform the grievance official about Resident #1's concern.The social services director (SSD) and the regional clinical resource were interviewed together on 4/1/26 at 4:00 p.m. The SSD said she was involved with the grievance process, along with the NHA. The SSD said grievance forms were readily available at the front desk and at each nurses' station. She said to facilitate the grievance process, facility staff were trained to assist residents who needed help completing grievance forms when a grievance was reported to them. She said staff could also report a resident grievance directly to her or the NHA. The SSD said she had not received any grievances from Resident #1.The regional clinical resource said all grievances should be reported immediately to the SSD or the NHA. She said grievances should be resolved within three days of receiving them. The regional clinical resource said CNA #1 should have reported Resident #1's concern regarding her care preferences immediately to the SSD or the NHA. The regional clinical resource said the facility would immediately offer education about the grievance policy to all staff.IV. Facility follow-upOn 4/6/16 at 9:54 a.m. the NHA provided an undated grievance educational in-service sheet.-The provided grievance education in-service sheet was not signed by CNA #1, who was the CNA who failed to report Resident #1's grievance concern. -Additionally, the education was not provided to staff until after the grievance concern was brought to the attention of the facility during the survey.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for activities of daily living (ADL) received the necessary care and services out of 53 sample residents.Specifically, the facility failed to utilize language communication tools to support effective interaction for Resident #1 during care. Findings include:I. Facility policy and procedureThe Non-Discrimination-Effective Communication and Modification for Disabilities policy and procedure, dated 1/1/26, was received from the nursing home administrator (NHA) on 4/7/26 at 4:24 p.m. It revealed in pertinent part, It is the policy of this facility to take reasonable steps to ensure that individuals with disabilities are not discriminated against and provided with the appropriate services to enhance communication.The facility must ensure that its health programs and activities provided through information and communication technology are accessible to individuals with disabilities, unless doing so would result in undue financial and administrative burdens or a fundamental alteration in the nature of the health programs or activities. If an action required to comply with this section would result in such an alteration or such burdens, the facility shall take any other action that would not result in such an alteration or such burdens but would nevertheless ensure that, to the maximum extent possible, individuals with disabilities receive the benefits and services of the health program or activity provided by the facility.All staff will be provided notice of this policy, and staff that may have direct contact with individuals with disabilities will be trained in effective communication techniques, including the effective use of an interpreter and how to access appropriate auxiliary aids and services.The facility will conduct a regular review of the language access needs of our resident population, as well as update and monitor the implementation of the policy, as needed. Considerations for policy review include, but are not limited to: a. Changes in demographics of the resident population. b. Mechanisms for securing interpreter services. c. Equipment used for the delivery of language assistance. d. Complaints filed by individuals with limited English proficiency (LEP). e. Feedback from residents.II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included amyotrophic lateral sclerosis, anxiety disorder, depression, tracheostomy, and acute respiratory failure with hypoxia (a condition where tissues and organs do not receive adequate oxygen).The 2/10/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for toileting, personal hygiene, and eating.B. Resident interviewResident #1 was interviewed on 4/1/26 at 1:50 p.m. Resident #1 said that several certified nurse aides (CNAs) assigned to her care could not understand her due to their limited ability to speak English.Resident #1 said that due to her medical condition, she was not able to use her hands to demonstrate or assist the staff in understanding her needs. She said that the CNAs did not utilize any tools or devices to translate or facilitate communication. Resident #1 said she had often become frustrated and angry because her needs were not being met in a timely manner. She said she had informed the facility's scheduler of her concern a week prior, but had not heard back. Resident #1 said she continued to have CNA's who were not able to understand her. Resident #1 said she told CNA #1 that she was frustrated and it made her angry when they could not understand what she asked for during her care. The resident said several CNAs would just nod their heads and keep going with her care. Resident #1 said she informed CNA #1 last week that she was tired of not being understood, but nothing had changed.C. ObservationOn 3/31/26 at approximately 12:20 p.m., Resident #1 was in bed when her lunch arrived. CNA #4 set the lunch tray on the bedside table, and while she was exiting the room, Resident #1 asked the CNA #4 if she had forgotten to bring her beverage with her meal. CNA #4 did not answer, walked out of the room and continued with the meal pass. The staff members passing room trays were observed speaking to one another in a language other than English and did not pause their conversation and tasks to acknowledge the resident's concern. Resident #1's body remained immobile due to her medical condition, and she was not able to use her voice and hand gestures to point toward her needs. CNA #4 did not attempt to utilize any alternative communication aids, such as a translation device, picture board, or simplified verbal cues. D. Record reviewResident #1's communication care plan, last revised on 4/2/26, revealed Resident #1 had expressed frustration with communication due to difficulty understanding some accents. Interventions included supporting Resident #1's understanding and comfort, monitoring and documenting the resident's satisfaction with communication, and adjusting caregiver assignments as appropriate to support effective interactions. -The care plan failed to address Resident #1's specific communication barriers with non-English speaking staff. Review of Resident #1's electronic medical record (EMR) did not reveal documentation indicating that staff members utilized alternative communication methods when they were unable to understand the resident's verbal requests. TIII. Staff interviewsThe regional clinical resource was interviewed on 4/1/26 at 2:45 p.m. The regional clinical resource said that all facility staff had been trained to utilize alternative means of communication to ensure resident needs were understood.The regional clinical resource said her professional expectation was that staff use the facility's language line devices, which were currently stored in the speech therapy department. The regional clinical resource said she would ensure that the language line devices were moved to and maintained at the nursing station for immediate staff access. The regional clinical resource said she would immediately initiate staff education regarding communication protocols and would update Resident #1's care plan to include specific interventions and the use of assistive devices to bridge the language gap.The director of nursing (DON) was interviewed on 4/6/26 at 5:50 p.m. The DON said the facility had recently hired several bilingual staff members to assist with the diverse needs of the resident population. She said it was her expectation that any staff member encountering difficulty communicating with a resident should seek assistance from colleagues capable of interpreting. The DON said that staff should have utilized alternative forms of communication, including the facility's language line and communication boards, to facilitate understanding during care. She said when communication barriers were not immediately identified and resolved, it could result in a delay in care and potentially impact the resident's safety and well-being. The DON said she did not know why the staff failed to use other means of communication; however would ensure staff were retrained to be aware of the tools available for them to use. License practical nurse (LPN) #1 was interviewed on 4/6/26 at 6:15 p.m. LPN #1 said she had not observed staff using any communication devices or assistive tools when providing care to residents. LPN #1 said that several CNAs had difficulty understanding English, which created barriers during resident interactions. LPN #1 said while she had occasionally intervened to assist with communication, she was not able to do so consistently because she was often busy with other resident care responsibilities when the CNAs required assistance.

Based on observations, record review and interviews, the facility failed to ensure two (#24 and #80) of seven residents received treatment and care in accordance with professional standards of practice out of 53 sample residents.Specifically, the facility failed to:-Ensure physician's orders for wound care were followed for Resident #24; and,-Ensure Resident #80 was consistently administered pain medication per physician's orders.Findings include:I. Failed to ensure physician's orders for wound care were followed for Resident #24 A. Facility policy and procedureThe Wound Treatment Management policy, revised 4/7/26, was provided by the nursing home administrator (NHA) on 4/7/26 at 4:24 p.m. The policy read in pertinent part, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.B. Resident #241. Resident statusResident #24, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included an unspecified open wound on the right lower leg, lymphedema (swelling due to the fluid building up in the body's tissues) and unsteadiness on feet.The 3/27/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment indicated the resident was independent with completing most of his activities of daily living (ADL).The assessment indicated the resident had one venous and/or arterial ulcer (open wound that developed on the lower legs due to problems with blood circulation).2. Wound care observationsDuring a continuous observation of Resident #24's wound care on 4/2/26, beginning at 9:20 a.m. and ending at 9:49 a.m., the following was observed:The assistant director of nursing (ADON) and registered nurse (RN) #1 were observed providing wound care to Resident #24. The ADON collected wipes and began wiping down the treatment cart in the hallway. After wiping down the treatment cart, she placed a clean chuck (a disposable absorbent pad placed on a bed or chair to protect it from moisture) pad over the treatment cart where she laid out 4 by 4 gauze pads and rolled gauze.The ADON performed hand hygiene with alcohol-based hand rub (ABHR), applied a gown and gloves and entered Resident #24's room. The ADON began wiping down the resident's bedside table with disinfectant wipes and asked the resident if he had any pain. The ADON removed her gloves, performed hand hygiene with ABHR and put on new gloves. RN #1 handed the ADON two chucks pads. The ADON placed one chuck pad on the bedside table with the edges hanging over the table. The second chuck pad was placed under Resident #24's right lower leg. The ADON advised the resident if he had pain to let her know throughout the process.The ADON began by taking off an Ace bandage from around Resident #24's right lower leg, then removed the rolled gauze which was noted to have dry serosanguineous (a thin and light pink watery fluid coming from a wound) drainage to it. She removed three abdominal (ABD - a large thick padded dressing) pads from around Resident #24's leg. The ABD pads were noted to have copious amounts of serosanguineous drainage.The ADON removed her gloves, performed hand hygiene with ABHR and put on new gloves.RN #1 entered Resident #24's room with no gown or gloves and placed supplies on the bedside table consisting of 4 by 4 gauze pads, skin prep, rolled gauze, a medicine cup labeled silver sulfadiazine (a cream applied to the skin to prevent or treat infection in wounds) and a cup labeled with Dakin's solution (specialized wound solution). The ADON opened one package of non-woven 4 by 4 gauze pads and placed it into the cup with the Dakin's solution in it to soak the gauze. She then took one gauze pad out of the cup and used the gauze pad to wipe the resident's wound. She discarded the gauze pad and collected another gauze pad. She performed this action three times, each time using a new gauze pad. She then opened a new package of 4 by 4 gauze pads and took a dry gauze pad out and dried the wound. She removed her gloves, performed hand hygiene with ABHR and put on a new pair of gloves. RN #1 left Resident #24's room and returned a few minutes later with adaptic (a non-stick gauze dressing placed directly on a wound). The ADON added the silver sulfadiazine to the adaptic and placed it on the Resident #24's right leg.RN #1 pulled out a roll of tape from her scrubs pocket with her bare hands, cut a piece of the tape and placed it on the curtain. The ADON asked RN #1 about ABD pads. RN #1 said the ABD pads had not been ordered. The ADON continued to place the adaptic on Resident #24's right leg, wrapped it with the rolled gauze and taped it with the pieces of tape that RN #1 had placed on the curtain. -The ADON failed to follow the physician's order for Resident #24's right leg wound treatment. She failed to use skin prep around the peri wound (skin around a wound) and failed to apply ABD pads prior to wrapping the resident's leg with the rolled gauze (see physician's orders below).3. Record reviewReview of Resident #24's April 2026 CPO revealed the following physician's orders: Wound care right lower extremity: quarter strength Dakin's, plus skin prep, plus 1% silver sulfadiazene (silvadene), plus adaptic, plus ABD and Kerlix (a soft and absorbent gauze roll used to cover and hold dressings in place). Every shift for wound care and as needed for soiled/dislodged, ordered 4/2/26.-However, the ADON failed to use skin prep and apply the ABD pads to the resident's wound (see observations above). C. Staff interviewsThe ADON was interviewed on 4/2/26 at 10:42 a.m. The ADON said she rounded weekly with the wound physician. After reviewing Resident #24's order for wound care to the right lower extremity, the ADON acknowledged she did not use an ABD pad at the time of the dressing change for Resident #24's wound. She said the ABD pad was important to use for the resident as he had a lot of drainage coming from his leg wound. She said the ABD pad was also to help prevent the pulling of new tissue growth from the wound when removing old dressings. She said she would go back and apply the ABD pads to the resident's wound.The director of nursing (DON) was interviewed on 4/6/26 at 5:57 p.m. The DON said the importance of following the physician's order for wound care was to prevent an infection. She said the ADON should have reviewed the treatment order for Resident #24's leg wound prior to providing wound care. She said the facility provided in-service training for wound care on 4/2/26 (during the survey). She said the wound care nurse had gone back and redone Resident #24's wound dressing (on 4/2/26).II. Failed to ensure Resident #80 was consistently administered pain medication per physician's ordersA. Facility policy and procedureThe Pain Management policy, revised 4/7/26, was provided by the NHA on 4/7/26 at 4:24 p.m. The policy read in pertinent part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will:-Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; and,-Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to:-Facial expressions (grimacing, frowning, fright, or clenching of the jaw); and, -Behaviors such as: resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal.The Unavailable Medications/Emergency kit (Ekit) policy, revised 4/7/26, was provided by the NHA on 4/7/26 at 4:24 p.m. The policy read in pertinent part, This facility shall use uniform guidelines for unavailable medications. The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications. A STAT (medical term meaning right away or immediately) supply of commonly used medications is maintained in-house for timely initiation of medications. As a first intervention, the nurse shall check the Ekit for availability of the medication before proceeding with other steps. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications.B. Resident #801. Resident statusResident #80, age less than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included chronic pain syndrome, spinal stenosis (narrowing in the spine that could press on nerves and cause pain or numbness) at cervical region (related to the neck area of the body) and alcoholic polyneuropathy (damage or disease affecting many nerves in the body at the same time).The 1/21/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment indicated the resident was independent with completing his ADLs.The MDS assessment indicated the resident had pain or hurting during the assessment look-back period. 2. Resident interviewResident #80 was interviewed on 3/30/26 at 2:03 p.m. Resident #80 said he had not received his morphine (pain medication) for 24 hours because the facility ran out of medication and they did not order it. Resident #80 said he was in pain, specifically down on his left leg. Resident #80 said he had not received his pain medication several times in the past because the facility ran out of pain medication and did not order it on time.3. Record reviewResident #80's pain management care plan, revised on 3/6/26, revealed the resident was at risk for pain related to a medical diagnosis of chronic pain. Interventions included administering medications as ordered, monitoring for possible adverse effects of pain management interventions, assessing pain every shift and as indicated and positioning for comfort.Review of Resident #80's April 2026 CPO revealed the following physician's order: Morphine Sulfate ER (extended release) oral tablet extended release 30 milligrams (mg). Give one tablet by mouth three times a day related to chronic pain syndrome, ordered 9/4/25. Review of Resident #80's January 2026 medication administration record (MAR) revealed Resident #80 did not receive his scheduled morphine on 1/1/26 and 1/2/26.Review of Resident #80's March 2026 MAR revealed Resident #80 did not receive his afternoon scheduled morphine on 3/30/26. The nursing progress note, dated 3/30/26 at 11:58 a.m., documented morphine sulfate oral tablet extended release 30 mg was waiting on reorder.-However there was no documentation indicating the reason the morphine medication was not administered to the resident on 1/1/26 and 1/2/26.C. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 4/2/26 at 1:04 p.m. LPN #4 said the facility should not run out of medication. He said if a medication was not available, he would check the facility's Ekit and contact the pharmacy to get the access code to obtain the medication from the Ekit. LPN #4 said the physician's order should already be in place but sometimes the pharmacy delivery ran late. He said he would call the physician to follow up and ensure the pain medication prescription was sent to the pharmacy for an existing physician's order. LPN #4 said Resident #80's morphine order was already in the system but there was a delay in delivery of the medication. He said medications could sometimes take more than five hours to be delivered. LPN #4 said Resident #80 needed pain medication on 3/30/26 but the morphine ER 30 mg was not available at that time. He said there was only morphine ER 15 mg available in the Ekit. LPN #4 said he could not administer it to Resident #80 because it was not consistent with the physician's order. He said he should have gotten a new physician's order to administer the morphine 15 mg that was in the Ekit.LPN #2 was interviewed on 4/6/26 at 10:19 a.m. LPN #2 said Resident #80 did not get his morphine on 3/30/26 due to the medication being unavailable. LPN #2 said when he noticed it, he notified the physician who was present in the facility at that time. He said the physician did not place a new order because an order was already pending. LPN #2 said the Ekit had only morphine ER 15 mg but he could not administer it to Resident #80 because there was no order for that dose.The pharmacist was interviewed on 4/6/26 at 3:16 p.m. The pharmacist said the pharmacy made two deliveries per day and followed specific order cut-off times for each delivery. She said orders received before 11:00 a.m. were included in the 1:00 p.m. delivery run, if they had no issues. She said it could take three to four hours for medications to be delivered to the facility. The pharmacist said even though morphine ER 15 mg was available in the Ekit, she did not expect the nurses to administer it to Resident #80 to make it 30 mg. She said a one-time physician's order would be required to administer the morphine ER 15 mg dose.The DON was interviewed on 4/6/26 at 5:57 p.m. The DON said if nurses noticed a resident had run out of pain medication at the time of administration, they should check the Ekit and medication storage. The DON said if the medication was available, they would have administered it to Resident #80. The DON said because the Ekit had morphine ER 15 mg, the nurse could have administered two tablets to Resident #80 to make the 30 mg dose.IV. Facility follow up The NHA provided the following information on 4/7/26 at 4:24 p.m., after the survey exit. The documentation provided revealed Resident #80 did not receive his afternoon dose of morphine on 3/30/26 because the facility ran out medication. The nurse documented that the medication was reordered. Resident #80 had no increase in pain related to the missed dose as evidenced by his pain being reported as 0 out of 10 on the following dose and the next day. The documentation indicated the nurse was provided re-education with the expectation that the physician be notified of missed medications and the expectation that the Ekit be utilized if medication was not available. -However, the morphine was a scheduled medication and the facility failed to order it on time to prevent missed doses of the medication.-Additionally, the re-education was not provided to staff until after the concern was brought to the attention of the facility during the survey.-The facility failed to include documentation of the in-service education provided to staff.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically, the facility had a medication error rate of 7.41%, which was two errors out of 27 opportunities.Findings include:I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment . Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration . To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights : 1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.II. Facility policy and procedureThe Medication Administration policy, revised 4/7/26, was provided by the nursing home administrator (NHA) on 4/7/26 at 4:24 p.m. It read in pertinent part, Review the medication administration record (MAR) to identify the medication to be administered.Compare the medication source (bubble pack, vial) with the MAR to verify the resident's name, medication name, form, dose, route, and time. Refer to the drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. Administer the medication within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Observe the resident consumption of the medication.III. Observations On 4/1/26 at 8:57 a.m. LPN #6 was preparing to administer medications for Resident #1. LPN #6 said she did not have the diclofenac external gel 1% (a topical nonsteroidal anti-inflammatory drug (NSAID) used to treat arthritis pain in joints such as the hands, knees and ankles) available in the medication cart. LPN #6 said she would re-order the medication and hopefully the medication would be delivered that day. -LPN #6 administered the remaining medications to Resident #1 and was unable to give the diclofenac.On 4/2/26 at 8:43 a.m. licensed practical nurse (LPN) #5 went into Resident #43's room. Resident #43 said she had eaten breakfast already. LPN #5 checked Resident #43's blood sugar. The blood sugar was 205 mg/dl (milligrams per deciliter). LPN #5 went back to the medication cart and retrieved Resident #43's medications. On 4/2/26 at 9:11 a.m. LPN #5 pulled an insulin lispro vial out of its packaging in an attempt to prepare it for Resident #43. The insulin vial was empty. LPN #5 said she would call the pharmacy to get another vial of insulin. -However, LPN #5 did not call the pharmacy, inform a supervisor or check other areas of the facility for insulin at that time. -LPN #5 administered the remaining medications to Resident #43 but did not administer the insulin lispro.Cross-reference F760 for failure to ensure residents were free from significant medication errors.IV. Record reviewReview of Resident #1's April 2026 CPO revealed the following physician's order:Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical). Apply to bilateral upper extremities topically three times a day for chronic pain. Apply 2 grams (gm) each administration, ordered 2/5/26.Review of Resident #1's April 2026 MAR revealed diclofenac sodium external gel was not documented as given, but instead was documented as 9 (other) for both the morning and afternoon due times.The 4/1/26 at 9:16 a.m. progress note revealed the diclofenac sodium external gel was ordered. The 4/1/26 at 1:25 p.m. progress notes revealed the physician was notified.Review of Resident #43's April 2026 CPO revealed the following physician's order:Insulin Lispro Injection Solution 100 units/ml (Insulin Lispro). Inject 20 units subcutaneously before meals for type 1 diabetes. Check blood glucose prior to administration and record glucose level, ordered 3/1/26.Review of Resident #43's April 2026 medication administration record (MAR) revealed LPN #5 documented Resident #43's blood sugar as 125 mg/dl and that she gave the insulin lispro on 4/2/26.-However, Resident #43's blood sugar was 205 mg/dl and the resident did not receive the insulin lispro on 4/2/26 (see observations above).V. Staff InterviewsLPN #6 was interviewed on 4/1/26 at 9:26 a.m. LPN #6 said diclofenac sodium gel treated chronic pain and was placed topically on the pain site. LPN #6 said she would call the pharmacist and notify the nurse practitioner (NP) that Resident #1 did not receive the medication.On 4/2/26 at 11:54 a.m. LPN #5 was interviewed to follow-up on Resident #43's omitted insulin administration (see observation above). LPN #5 said she had not had time to give the insulin to the resident yet.Cross-reference F760 for failure to ensure residents were free from significant medication errors.On 4/2/26 at 12:10 p.m. the director of nursing (DON) and the regional clinical resource were alerted that Resident #43 had not received her morning dose of lispro insulin. The DON said LPN #5 should have retrieved insulin lispro from the facility's emergency kit (E-kit) which had multiple insulin vials available. The DON said LPN #5 should have reached out to other staff members for help to retrieve the insulin. The DON said LPN #5 could have then administered the insulin. The DON said staff should not document that a medication was given on the MAR if the medication was not given. The regional clinical resource said the facility would let the physician know that Resident #43 did not receive her morning dose of insulin. She said Resident #43 would have her blood sugar checked and receive her afternoon dose of insulin.The DON and the regional clinical resource were interviewed together a second time on 4/2/26. The regional clinical resource said residents' blood glucose levels were recorded just before nurses administered insulin to residents. The DON said LPN #5 was an agency staff member and it was her first shift at the facility. The DON said agency staff received verbal education on policies and procedures before working at the facility. The DON said education was also uploaded to the care system for agency staff to view. The DON said she would review the agency nurse education and orientation that was in place for agency staff. The pharmacist was interviewed on 4/6/26 at 3:16 p.m. The pharmacist said insulin was a hormone naturally created in the body. She said type 1 diabetes was a disease where the pancreas did not produce enough insulin to control the blood sugar in the body. The pharmacist said insulin medication was used to get residents' blood sugar levels to a normal level. The pharmacist said it was important for residents to receive insulin before eating because every time people ate there were carbs and sugars in the food consumed. The pharmacist said it was important to give the insulin before eating to help counteract the escalation of blood sugar right after a resident ate. The pharmacist said if a resident missed a dose of insulin, generally it would cause an increase in the resident's blood sugar and if blood sugar levels got high enough, a resident could go into a coma.The pharmacist said diclofenac was a topical NSAID used for inflammation and arthritis. The pharmacist said that in a resident who had chronic pain syndrome, a missed dose would cause a lack of anti-inflammatory effects. The pharmacist said this could lead to an increase in pain and swelling.The DON and the regional clinical resource were interviewed together again on 4/6/26 at 5:26 p.m. The DON said nurses should follow the five rights of medication administration. The DON said the five rights of medication administration were right person, right time, right route, right dose and right reason.The DON said if residents ran out of pain medication, the nurses could go to the facility's emergency kit and look for the medication there. The DON said it was important to receive pain medication timely so residents did not have pain. The DON said nurses should contact the physician if the pain medication was unavailable.

Based on observations, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#43) of four residents out of 53 sample residents. Specifically, the facility failed to ensure Resident #43 was administered an insulin medication per physician's orders.Findings include:I. Facility policy and procedureThe Medication Administration policy, revised 4/7/26, was provided by the nursing home administrator (NHA) on 4/7/26 at 4:24 p.m. It read in pertinent part, Review the medication administration record (MAR) to identify the medication to be administered.Compare the medication source (bubble pack, vial) with the MAR to verify the resident's name, medication name, form, dose, route, and time. Refer to the drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. Administer the medication within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Observe the resident consumption of the medication.II. Resident #43A. Resident statusResident #43, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included type 1 diabetes mellitus (a condition where the pancreas makes little to no insulin, which was required to allow glucose into cells to produce energy), hypothyroidism (low thyroid levels) and asthma (chronic long-term respiratory disease).The 3/18/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment revealed Resident #43 was receiving insulin.B. ObservationsOn 4/2/26 at 8:43 a.m. licensed practical nurse (LPN) #5 went into Resident #43's room. Resident #43 said she had eaten breakfast already. LPN #5 checked Resident #43's blood sugar. The blood sugar was 205 mg/dl (milligrams per deciliter). LPN #5 went back to the medication cart and retrieved Resident #43's medications. On 4/2/26 at 9:11 a.m. LPN #5 pulled an insulin lispro vial out of its packaging in an attempt to prepare it for Resident #43. The insulin vial was empty. LPN #5 said she would call the pharmacy to get another vial of insulin. -However, LPN #5 did not call the pharmacy, inform a supervisor or check other areas of the facility for insulin at that time. -LPN #5 administered the remaining medications to Resident #43 but did not administer the insulin lispro.Cross-reference F759 for failure to ensure the facility was free from a medication error rate of five percent (5%) or greater. On 4/2/26 at 12:43 p.m. registered nurse (RN) #1 was observed checking Resident #43's lunch time blood sugar level. RN #1 cleaned Resident #43's finger with alcohol, drew a drop of blood from the finger, and used the glucometer to test the blood sugar. The glucometer read 191 mg/dlC. Record reviewReview of Resident #43's April 2026 CPO revealed the following physician's order:Insulin Lispro Injection Solution 100 units/ml (Insulin Lispro). Inject 20 units subcutaneously before meals for type 1 diabetes. Check blood glucose prior to administration and record glucose level, ordered 3/1/26.Review of Resident #43's April 2026 medication administration record (MAR) revealed LPN #5 documented Resident #43's blood sugar as 125 mg/dl and that she gave the insulin lispro on 4/2/26.-However, Resident #43's blood sugar was 205 mg/dl and the resident did not receive the insulin lispro on 4/2/26 (see observations above).Review of Resident #43's progress notes on 4/2/26 at 2:21 p.m. revealed the physician was notified that Resident #43 missed a dose of insulin in the morning. The note revealed no adverse reactions were noted. -However, the progress note was not documented until after the concern of the morning insulin dose not being administered to Resident #43 was brought to the facility's attention on 4/2/26 (see interviews below).III. Staff interviewsOn 4/2/26 at 11:54 a.m. LPN #5 was interviewed to follow-up on Resident #43's omitted insulin administration (see observation above). LPN #5 said she had not had time to give the insulin to the resident yet.On 4/2/26 at 12:10 p.m. the director of nursing (DON) and the regional clinical resource were alerted that Resident #43 had not received her morning dose of lispro insulin. The DON said LPN #5 should have retrieved insulin lispro from the facility's emergency kit (E-kit) which had multiple insulin vials available. The DON said LPN #5 should have reached out to other staff members for help to retrieve the insulin. The DON said LPN #5 could have then administered the insulin. The DON said staff should not document that a medication was given on the MAR if the medication was not given. The regional clinical resource said the facility would let the physician know that Resident #43 did not receive her morning dose of insulin. She said Resident #43 would have her blood sugar checked and receive her afternoon dose of insulin.The DON and the regional clinical resource were interviewed together a second time on 4/2/26. The regional clinical resource said residents' blood glucose levels were recorded just before nurses administered insulin to residents. The DON said LPN #5 was an agency staff member and it was her first shift at the facility. The DON said agency staff received verbal education on policies and procedures before working at the facility. The DON said education was also uploaded to the care system for agency staff to view. The DON said she would review the agency nurse education and orientation that was in place for agency staff. The pharmacist was interviewed on 4/6/26 at 3:16 p.m. The pharmacist said insulin was a hormone naturally created in the body. She said type 1 diabetes was a disease where the pancreas did not produce enough insulin to control the blood sugar in the body. The pharmacist said insulin medication was used to get residents' blood sugar levels to a normal level. The pharmacist said it was important for residents to receive insulin before eating because every time people ate there were carbs and sugars in the food consumed. The pharmacist said it was important to give the insulin before eating to help counteract the escalation of blood sugar right after a resident ate. The pharmacist said if a resident missed a dose of insulin, generally it would cause an increase in the resident's blood sugar and if blood sugar levels got high enough, a resident could go into a coma.The DON and the regional clinical resource were interviewed together again on 4/6/26 at 5:26 p.m. The DON said nurses should follow the five rights of medication administration. The DON said the five rights of medication administration were right person, right time, right route, right dose and right reason.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of four residents received adequate supervision to prevent accidents out of four sample residents.Specifically, the facility failed to ensure staff did not leave Resident #1, who had a history of falls and required maximal assistance with showering, alone in the shower room during her showers.Findings include:I. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included paraplegia, type 2 diabetes mellitus, muscle weakness, major depressive disorder, and pressure ulcer of the left buttocks.The 10/10/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting and transfers and required substantial to maximum assistance with showering, dressing, and bed mobility. It indicated the resident used a power wheelchair for mobility and required supervision during showers.B. Observation and resident interviewOn 10/13/25 at approximately 2:30 p.m. Resident #1 was observed sitting on a shower chair heading to the main shower room. She was being assisted by certified nurse aide (CNA) #2. CNA #2 pushed the shower chair along the hallway into the shower room and shut the door behind them.CNA #2 and Resident #1 were in the shower room for approximately 12 minutes.At 2:42 p.m., CNA #2 was observed leaving the shower room while Resident #1 remained alone in the shower room with the shower door closed.At 2:45 p.m., CNA #2 returned to the shower room with a couple of bath sheets.At 2:48 p.m., CNA #2 completed the shower and exited the shower room with resident #1 seated on the shower chair, covered with a bath sheet.At 2:50 p.m., Resident #1 arrived in her room with the assistance of CNA #2.At 2:52 p.m., CNA #2 left the resident's room for approximately two minutes and returned with CNA #1. Both CNAs entered the Resident's room and closed the door behind them.At 2:58 p.m., Resident #1 was observed lying in her bed.Resident #1 was interviewed on 10/14/25 at 10:34 a.m. Resident #1 said staff often left her alone in the shower room with the door closed to go and get shower items when they forgot to bring them into the shower . The resident confirmed she had been left alone in the shower room the previous day (10/13/25). She said the shower room call light was out of her reach and that scared her because she would be unable to call for assistance when she needed help when the CNA was gone and the bathroom door was closed. Resident #1 said she had a history of falls, and so it made her uncomfortable and afraid when she was left alone in the shower room with the door closed.C. Record reviewThe fall risk care plan, initiated 7/18/23 and revised 10/2/25, documented Resident #1 was at risk for falls due to paralysis, paraplegia, neuralgia, polyneuropathy, and thoracic vertebrae injury at the level of 11 and 12 (T-11 to T12) and use of high risk medications. Interventions included anticipating and meeting the resident's needs, ensuring the call light was within the resident's reach, and encouraging the resident to use her call light for assistance.-Despite the resident's fall risk, observation and resident interview revealed the resident was left unsupervised in the shower room for extended periods of time (see observations above).-However, per Resident #1, she was left unsupervised in the shower room for extended periods of time with the call light out of the resident's reach (see interview above).II. Staff interviewsCNA #1 was interviewed on 10/13/25 at 2:55 p.m. CNA #1 said all dependent residents could not be left alone unsupervised during showers. CNA #1 said Resident #1 had a diagnosis of paraplegia and was unable to walk. CNA #1 said the resident had a history of falls and should not be left unsupervised during showers. CNA #1 said all shower supplies should be gathered and readily available before starting a shower. CNA #1 said leaving a dependent resident unattended in the shower room could result in a fall, causing serious injuries.CNA #2 was interviewed on 10/13/25 at 3:00 p.m. CNA #2 said she was familiar with Resident #1 and had been educated to provide showers for dependent residents. CNA #2 said she left the shower room when Resident #1 had requested a bath sheet. CNA #2 said Resident #1 was a fall risk, but she was not aware that the resident could not be left alone in the shower room. CNA #2 said she did not place the call light within the resident's reach because she was going to be right back. CNA #2 said she could have used the call for assistance for another staff member to pick up the bath sheet. She said the resident could have fallen while she was in the shower room unsupervised. The assistant director of nursing (ADON) and the regional clinical resource were interviewed on 10/13/25 at 4:20 p.m. The ADON said Resident #1 was dependent on staff for showers and should not be left unsupervised during showers. The regional clinical resource determined that, due to Resident #1's intact cognitive level, she could be left unsupervised during showers. The regional clinical resource said that the resident was not a fall risk, as was indicated by the resident's care plan. She said she did not know whether the resident's care plan was updated to reflect her statement. The regional clinical resource said she expected the facility staff to follow every resident's care plan.The regional clinical resource was interviewed again on 10/14/25 at 10:15 a.m. The regional clinical resource retracted her earlier comments and said Resident #1 had a history of falls and should not be left unsupervised in the shower room to prevent accidents. The regional clinical resource said all nursing staff had been educated on safety precautions during showers, but she did not know why the staff left the resident unsupervised. She said the staff member who left Resident #1 unattended in the shower room would be immediately trained on shower safety precautions.

Based on record review and interviews, the facility failed to ensure four (#1, #2, #3 and #4) of four residents reviewed for abuse out of four sample residents were free from abuse. Specifically the facility failed to: -Prevent verbal and physical abuse between Resident #2 and Resident #4. -Protect Resident #1 from physical abuse by Resident #2; and, -Protect Resident #3 from physical abuse by Resident #4. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/8/25 at 11:33 a.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy and procedure, revised September 2022, was provided by the NHA on 5/8/25 at 11:33 a.m. It read in pertinent part, Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. II. Incident of verbal and physical abuse between Resident #2 and Resident #4 on 1/31/25 A. Facility investigation The 1/31/25 physical abuse investigation documented a witnessed resident-to-resident verbal and physical altercation between Resident #2 and Resident #4. Resident #2 and Resident #4 were in the smoking area during a supervised smoking session. Resident #2 walked up to Resident #4, who was standing with his back against the wall, and yelled at him. Resident #4 then called Resident #2 an expletive. Resident #2 attempted to push Resident #4, which caused Resident #2 to fall to the ground. Resident #2 then stood up and attempted to slap Resident #4. The staff separated the two residents. The two residents were assessed and no injuries were identified. The investigation indicated both residents were started on psychosocial visits and denied fear. Both of the residents were being followed by behavioral health services (BHS), and their behaviors related to agitation were being addressed. Resident #4 was suspended from smoking during the investigation. The facility unsubstantiated the allegation of physical abuse at the conclusion of the investigation due to no bodily harm noted during the investigation. -However, physical abuse occurred when Resident #2 pushed Resident #4 against the wall and verbal abuse occurred when Resident #4 called Resident #2 an expletive. B. Resident #2 (assailant and victim) 1. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included epilepsy (seizure disorder), chronic obstructive pulmonary disease (COPD) and dementia. The 4/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with eating, toileting, personal hygiene, transfers and bed mobility. The assessment did not indicate the resident exhibited physical or verbal behaviors towards others. 2. Resident interview Resident #2 was interviewed on 5/8/25 at 9:32 a.m. The resident exhibited speech that was difficult to understand. Resident #2 said he did not remember the incident in the dining room. He said there was a resident that had been ramming him with his walker and yelling expletives at him. He said I told him to stop that. 3. Record review The behavior care plan, initiated 4/7/25, documented Resident #2 had a history of being verbally aggressive to staff and residents due to ineffective coping skills and poor impulse control. Interventions included administering medications as ordered, analyzing triggers and what de-escalated his behavior, providing positive feedback for good behavior, redirecting by staff away from tasks for staff and resident safety and offering supervised opportunities for him to participate in cleaning tasks. -However, the behavior care plan was not initiated until after a second resident-to-resident incident occurred on 4/5/25 (see 4/5/25 incident below). The 1/26/25 nursing progress note documented Resident #2 was heard shouting in the dining room and hitting the dining room door. He was agitated and shouting that he was being mistreated by everyone on the staff. He was unable to provide details. He said staff were changing his medications and taking medications away from him. The 1/31/25 nursing progress note documented the director of nursing (DON) interviewed the Resident #2 regarding the resident's fall/incident. Resident #2 denied onset of pain and denied feeling threatened or fearful. -However, the nursing progress note documentation did not reveal what occurred during the resident-to-resident altercation that occurred on 1/31/25 with Resident #4. The 2/1/25 at 6:00 p.m. nursing progress note documented Resident #2 was on follow-up for a resident-to-resident altercation on 1/31/25. Resident #2 was observed not to be aggressive towards staff or other residents. The 2/1/25 at 9:52 p.m. nursing progress note documented Resident #2 was on monitoring after a resident-to-resident altercation. The resident appeared angry and agitated but took his medications. The resident was in his room. The 2/2/25 nursing progress note documented Resident #2 continued to be agitated and angry when approached for assessment. He denied pain or discomfort. The 2/3/25 nursing progress note documented Resident #2 was on a 72-hour assessment after a resident-to-resident altercation. The resident was in his room and had no complaints. He was upset over not being allowed to leave when he wanted. A comprehensive review of Resident #2's electronic medical record (EMR) did not reveal documentation of any interdisciplinary team (IDT) notes after the 1/31/25 resident-to-resident altercation with Resident #4. C. Resident #4 (assailant and victim) 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included stroke, COPD and dementia. The 3/7/25 MDS assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. He had moderate impairment for daily decision making with poor decision making and required cues and supervision per staff assessment. He was independent with eating, toileting, bed mobility, personal hygiene and transfers. The assessment did not indicate the resident exhibited physical or verbal behaviors towards others. 2. Record review The behavior care plan, initiated 11/2/21 and revised 2/25/25, documented Resident #4 had a history of behaviors related to a traumatic brain injury (TBI), anxiety disorder and dementia. He could be physically aggressive towards staff during supervised smoking when times were late or missed and had been involved in resident-to-resident altercations. Interventions included behavioral monitoring (5/19/21), providing opportunity for positive interaction (5/19/21), encouraging to express feelings appropriately, (5/19/21), explaining procedures before starting (5/19/21), discussing behaviors if being reasonable (5/19/21), providing a program of activities (4/27/22), referring to behavioral health service for psychological interventions to decrease physical altercations (1/22/24), moving to a private room to prevent further occurrences (3/14/24) and laboratory work (labs) for a physically aggressive episode (3/18/25). The smoking care plan, initiated 3/14/25 and revised 3/17/25, documented Resident #4 required supervision during smoking due to his cognitive impairment. Interventions included assessing ability to smoke safely, explaining smoking policy, smoking apron and supervising while resident was smoking. -However, the smoking care plan was not initiated until 3/14/25. Review of Resident #4's EMR revealed there was no progress note of the incident that occurred on 1/31/25 with Resident #2. The 2/1/25 at 6:00 p.m. nursing progress note documented Resident #4 was on follow-up for a resident-to-resident altercation from 1/31/25. Resident #4 was ambulating in hallways without complaints or visible injury. The 2/1/25 at 9:49 p.m. nursing progress note documented Resident #4 was on monitoring after a resident-to-resident altercation. Resident #4 denied pain or discomfort or injury. The 2/3/25 at 12:56 a.m. nursing progress note documented Resident #4 continued to be monitored after a post-altercation with another resident (Resident #2). No complaints or behaviors were identified. III. Incident of physical abuse between Resident #2 and Resident #1 on 4/5/25 A. Facility investigation The 4/5/25 physical abuse investigation documented a witnessed resident-to-resident physical altercation between Resident #2 and Resident #1. The staff observed the two residents arguing after Resident #1 closed a window in the dining room. Resident #2 slapped Resident #1, which caused Resident #1 to lose his balance and fall to the ground. The staff separated the two residents and Resident #1 was assessed head-to-toe by a registered nurse (RN). Redness to Resident #1's eye was observed but no other injuries were identified. The investigation indicated Resident #2 and Resident #1 lived on different hallways but both residents would have staff monitoring during meals and when in close proximity to each other. The facility substantiated the allegation of physical abuse at the conclusion of their internal investigation. B. Resident #2 (assailant) 1. Record review The 4/6/25 at 3:51 a.m. nursing progress note documented a resident-to-resident physical altercation between Resident #2 and Resident #1 occurred on 4/5/25 at 7:30 p.m. Resident #2 initiated the physical aggression and got into an argument with Resident #1 and then slapped Resident #1 and pushed him to the ground after Resident #1 closed the window in the dining area. Resident #1 was assessed head-to-toe by a RN and had redness to his right eye. No other injuries were noted. The physician was notified. Resident #1 denied pain. A review of Resident #2's May 2025 medication administration record (MAR) revealed a physician's order for behavior monitoring for antipsychotic medications with the target behaviors of afraid, angry, agitated, mood changes, noisy, restless, withdrawn, crying and combative to check each shift and document in the nursing progress notes every shift, ordered 3/28/25. -However, behaviors were documented as did not occur for each shift for 4/5/25. C. Resident #1 (victim) 1. Resident status Resident #1, age 75, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included dementia and traumatic brain injury (TBI). The 4/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with eating, toileting, personal hygiene, bed mobility and transfers. The assessment did not indicate the resident exhibited physical or verbal behaviors towards others. 2. Resident interview Resident #1 was interviewed on 5/7/25 at 1:05 p.m. Resident #1 said Resident #2 liked to sit in the dining room next to the windows and liked them open. He said he had said something to Resident #2 about bums having beards since Resident #2 had a beard. He said Resident #2 got mad at him and hit him in the face with his fist. He said he did not remember any difficulty with his eye afterwards. He said he had never had an issue with Resident #2 before. He said he avoided Resident #2 because he did not like him. 3. Record review The behavior care plan, initiated 1/2/19 and revised 4/25/25, documented Resident #1 was extremely impulsive, was difficult to direct and was verbally aggressive towards other residents due to a TBI and dementia. Interventions included redirecting the resident away from situations with verbal aggression (9/17/24), reminding him to speak kindly and be careful of word choice (9/19/24), administering medication as ordered (8/21/24), anticipating needs (1/2/19), assisting the resident to develop more appropriate coping (1/2/19), encouraging him to express feelings appropriately (1/2/19), explaining procedures (1/2/19), praising progress improvement (1/2/19) and providing him with an activities program (1/2/19). -A review of Resident #1's comprehensive care plan did not reveal any new personalized interventions after the 4/5/25 altercation with Resident #2 to prevent further abuse (see facility abuse investigation above). The 4/6/25 at 12:09 a.m. nursing progress note, documented on 4/5/25 at 6:30 p.m., revealed a certified nurse aide (CNA) brought to the attention of the RN that there was an altercation between two residents. Resident #1 had received physical aggression from Resident #2. Resident #1 had reported he closed the window because it was cold and Resident #2 was upset because he closed the window and they got into an argument. The CNA said Resident #2 slapped Resident #1 on the right cheek and pushed him to the ground before staff could get there and separate them. Resident #1 was assessed and had redness noted to his right eye. No other injuries were noted. The DON, the NHA and the physician were notified. IV. Incident of physical abuse between Resident #4 and Resident #3 on 3/17/25 A. Facility investigation The 3/17/25 physical abuse investigation documented a witnessed resident-to-resident physical altercation between Resident #4 and Resident #3. Resident #4 became upset during supervised smoking time and began cursing and yelling at the social services assistant (SSA) and pushed the smoking cart over. The SSA stepped back to call for staff assistance. Resident #3 was looking at Resident #4 and Resident #4 began yelling at her, flipping her off and calling her expletives. Resident #4 then walked over to Resident #3 yelled at her and hit her hand which was resting on her wheelchair. The two residents were separated. Resident #3 was assessed by a RN for injuries and no injuries were identified. Staff stayed with Resident #4 until the resident's representative could sit with him until he laid down for a nap. The investigation indicated Resident #4's representative would provide a vaporizer (vape) pen for him for when his cigarettes ran low and the IDT was to monitor Resident's #$'s smoking materials to ensure he did not run out. The facility substantiated the allegation of physical abuse at the conclusion of the investigation. B. Resident #4 (assailant) 1. Record review Review of Resident #4's behavior care plan revealed the facility updated the care plan with an intervention to obtain labs for a physically aggressive episode (3/18/25). The 3/17/25 nursing progress note documented that Resident #4 was involved in an altercation with another resident (Resident #3). Resident #4 was witnessed hitting Resident #3 on her left arm during smoking time, after being informed he was out of cigarettes. Resident #4 was escorted back to his room. The DON, the physician and the resident's representative were notified. The 3/18/25 at 8:48 a.m. behavior progress note documented Resident #4 was informed of the removal of his smoking privileges following the resident-to-resident altercation with Resident #3. Resident #4 became extremely angry and began yelling and cursing. An attempt was made to speak with him regarding alternative methods with the resident's urge to smoke. Resident #4 threw his coffee at the progress note writer's face and the resident punched the writer twice on the right side of his neck and face. The family representative was notified and spoke with the resident for a few minutes and calmed him down. Resident #4 asked the family representative if he could smoke and was told not right now. Resident #4 then threw the cell phone down the hallway, went to his room, got under the sheets and went to sleep. The family representative arrived and sat with the resident until he had calmed. The 3/18/25 at 5:48 p.m. behavior progress note documented no further behaviors were noted after Resident #4 became angry with the staff earlier. The resident allowed blood to be drawn for lab tests. A review of Resident #4's May 2025 CPO documented a physician's order for behavior monitoring for target behaviors of aggression, impulsivity and yelling out. Staff were to check each shift and document in the nursing progress notes every shift, ordered 4/18/23. -However, review of Resident #4's MAR documented behaviors did not occur on 3/17/25. C. Resident #3 (victim) 1. Resident status Resident #3, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 CPO, diagnoses included COPD, diabetes mellitus, morbid obesity, stroke and schizoaffective disorder. The 3/5/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent with transfers, substantial/maximal assistance with toileting, personal hygiene, bed mobility and required set up assistance for eating. The assessment did not indicate the resident exhibited physical or verbal behaviors towards others. 2. Resident interview Resident #3 was interviewed on 5/7/25 at 1:45 p.m. Resident #3 said Resident #4 was in the smoking area and flipped over the cart (on 3/17/25). She said she yelled for someone to call the police and Resident #4 came over and hit her on the arm and it hurt. She said she had had no further interactions with him and avoided him. She said nothing seemed to happen to correct the situation because Resident #4 was back out smoking in the smoking area the next day. She said the social worker seemed to be very afraid of him when he did not have any more cigarettes. She said she could not enjoy her smoke breaks when Resident #4 was out there. 3. Record review The psychosocial behavior care plan, initiated 2/27/25 and revised 3/10/25, documented Resident #3 had a history of making false allegations and using vulgar language against other residents and staff and became agitated when other residents were sitting at the same table. Interventions included providing diversional activities (2/27/25), anticipating needs (2/27/25), being aware of surroundings when pushing her wheelchair through doorways (2/27/25), documenting and recording behavioral episodes and responding to call light timely (2/27/25), establishing a rapport with the resident (2/27/25), providing cares in pairs (2/27/25) and following through on all allegations to ensure safety (2/27/25). -A review of Resident #3's comprehensive care plan did not reveal new interventions after the 3/17/25 altercation with Resident #4 to prevent further abuse (see facility abuse investigation above). -A review of Resident #3's EMR did not reveal nursing progress note documentation of the resident-to-resident altercation with Resident #4 on 3/17/25 or the RN assessment performed after the incident. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/8/25 at 9:05 a.m. LPN #1 said Resident #4 was pleasant but could become easily agitated if things did not go his way. She said issues around smoking were triggers for his behaviors, especially if he ran out of cigarettes. She said he would try to get cigarettes from other residents and they would not give him one. She said Resident #4 had a tendency to try to take things that were not his. She said the smoking area was supervised and two staff people should be out there at all times. She said Resident #2 was impulsive and reactionary in the moment and was sorry for his behavior afterwards. RN #1 was interviewed on 5/8/25 at 9:20 a.m. RN #1 said when resident-to-resident physical altercations occurred, staff first separated residents to ensure their safety and then notified the DON and the NHA. She said she was not aware of any special interventions for Resident #2 or Resident #4 for their behaviors around their recent resident-to-resident altercations. She said frequent behavioral monitoring was only done in certain situations, such as when someone was having suicidal ideation. She said she was not aware of any special behavior monitoring for residents involved in resident-to-resident physical altercations. CNA #1 was interviewed on 5/8/25 at 9:55 a.m. CNA #1 said Resident #4 was independent. She said he just liked to go to his room and be left alone. She said she was not aware of any recent behaviors or resident-to-resident altercations involving Resident #4. She said she was not aware of any special interventions for his behaviors. She said when residents became aggressive with one another, staff separated and redirected them. The medical records director (MRD) was interviewed on 5/8/25 at 10:05 a.m. The MRD said she was part of the staff assigned to the resident smoking sessions supervision, which was assigned rotationally amongst the managers and other staff. She said she was at the smoking cart (on 1/31/25) and had her back to the residents. She said she heard raised voices and Resident #2 was on the ground and angry. She said Resident #4 was apologetic. She said she tried to help Resident #2 off the ground and he resisted so she went to get other staff to assist. She said there were usually 10 to 12 people during a smoking session, which was manageable since there was a routine and everyone knew the routine. She said she now kept an eye out for Resident #2 and Resident #4 but did not know if there were any special interventions for those two residents when they were in the smoking area. The NHA and the clinical resource director (CRD) were interviewed on 5/8/25 at 10:51 a.m. The NHA said if alleged resident-to-resident abuse occurred, the facility would obtain witness statements and begin with an initial investigation and immediately report it. He said if the allegation proved to be false, the facility would unsubstantiate it. He said if actual abuse occurred, the residents involved were separated so their safety was ensured. He said RN assessments were conducted to determine if any injury occurred. The NHA said any alleged abuse was reported to the NHA, the DON and the social services director (SSD). He said the facility would conduct a formal investigation that included interviews and a chart review. He said there was an IDT review to put in place the appropriate interventions and determine long-term interventions. He said the interventions were then care planned. He said there was no formal IDT documentation in the chart. He said the IDT review of an incident was done during the morning meeting and the IDT note with interventions was kept on a spreadsheet. He said each resident-to-resident altercation should be placed in the care plan and interventions that were identified for each resident should be care planned. The NHA said Resident #2 believed he worked at the facility and was very protective and particular about how the building was kept. He said in the 4/5/25 altercation between Resident #2 and Resident #1, Resident #2 had sat down in the dining room by the window and had opened the window. He said Resident #1 went to shut the window after Resident #2 had opened it. He said Resident #2 became very angry and he slapped Resident #1, which caused Resident #1 to trip over his walker and fall to the ground. The NHA said the incident was witnessed by staff. He said there was a scheduled appointment for Resident #2 with behavioral health services (BHS) and they had been involved with his behavioral management. He said Resident #2 and Resident #1 did not interact much and they lived on separate hallways. He said the altercation should be documented in the care plans with the appropriate identified interventions and documented in the nursing progress notes. He said there should also be a 72-hour follow-up behavioral documentation after a resident-to-resident altercation. The NHA said the resident-to-resident physical altercation between Resident #4 and Resident #3 on 3/17/25 happened during a smoking session. He said the SSA was supervising the smoking session. He said Resident #4 was smoking to the side of the smoking area and started yelling at the SSA. The NHA said Resident #4 pushed the smoking cart and the SSA fell to the concrete. He said Resident #3 was looking at Resident #4 and Resident #4 walked towards Resident #3 and yelled at her. He said Resident #4 flipped Resident #3 off and swatted at her arm. He said the staff separated them. He said in the smoking area, the amount of staff present during smoking times depended on how many residents were out there smoking. He said for five to six residents there was one staff member. He said for eight to ten residents there should be at least two staff members. The NHA said there was a resident-to-resident altercation between Resident #2 and Resident #4 in the smoking area on 1/31/25. He said Resident #4 was leaning against the building and Resident #2 was in the courtyard. He said Resident #2 walked up to Resident #4 and pushed Resident #4 on the chest which caused Resident #2 to fall backwards onto the ground. He said the incident was verified based on camera footage. The NHA said the altercation should be care planned and documented. The NHA said the facility would be looking at how to document the IDT reviews of resident-to-resident physical altercations going forward, with emphasis on ensuring documentation was completed on the root cause of the incident and ensuring interventions were put into place after each altercation and updated on the residents' care plans. The CRD said the facility would be doing an audit of their care plans and looking into their process for behavior tracking and documentation.

Based on record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for abuse were kept free from abuse out of five sample residents. Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect, and Exploitation policy and procedure, revised April 2024, was provided by the director of nursing (DON) on 7/11/24 at 12:39 p.m. The policy read in pertinent part, The nursing home administrator (NHA) is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse, neglect, exploitation and misappropriation of resident's property. Policies are in place that prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident's property, establish processes to investigate such allegations, implement staff training and coordinate with the quality assurance and performance improvement (QAPI) committee. Policies address the following as part of abuse, neglect, exploitation and misappropriation prevention: Employee screening, staff training, prevention, identification of violations, investigative processes, protection of residents during investigations and reporting of and response to investigations. II. Facility investigation of the 2/4/24 incident between Resident #2 and Resident #1 The 2/4/24 altercation investigation revealed Resident #2 began getting upset when Resident #1 was looking at him while they were smoking. Resident #2 ran up to Resident #1 and hit him multiple times in the head. Resident #2 was immediately placed on one to one supervision with a staff member. Resident #2 said Resident #1 was talking crap so I hit him and he tried to fight me back. Resident #1 stated Resident #2 had just hit him and he yelled at him to stop. He said he hit his head. III. Resident #2 (assailant) A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and discharged on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included moderate vascular dementia with mood disturbances, alcohol abuse, depression and insomnia. The 3/7/24 minimum data set (MDS) assessment revealed the resident had short term memory problems and his cognitive skills for daily decision making was moderately impaired. He had physical behaviors directed towards others on one to three days during the assessment lookback period and verbal behaviors directed towards others on one to three days. He was independent with all of his activities of daily living (ADL) and received an antipsychotic medication. B. Record review The behavior care plan, initiated 12/18/23 and revised 3/12/24, revealed Resident #2 had the potential to be physically aggressive related to a history of harm to others. Interventions included administering medication as ordered, providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting verbalization of the source of agitation, assisting the resident to set goals for more pleasant behavior, encouraging the resident to seek out a staff member when agitated, referring the resident to behavioral health services and placing the resident on one to one supervision with staff indefinitely. The 2/4/24 nurse progress note, written at 12:49 p.m., revealed the nurse heard screaming down the hallway and, upon assessment, Resident #2 was observed near the smoking area entrance and stated, Resident #1 was talking crap so I hit him and he tried to fight me back. Resident #1 denied hitting Resident #2. The police and emergency medical services were notified. -Further review of Resident #2's progress notes revealed he had been involved in four verbal altercations and four physical altercations with other residents during his four month stay at the facility. IV. Resident #1 (victim) A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included cerebral infarction (stroke), dementia, traumatic brain injury, generalized anxiety disorder, major depressive disorder and muscle weakness. The 6/19/24 MDS assessment revealed, the resident was unable to complete a brief interview for mental status (BIMS). He had short and long-term memory problems. His cognitive skills for daily living decision-making was moderately impaired. He had no behaviors and did not reject care. He was independent with his ADLs. B. Record review The behavior care plan, initiated 11/2/21 and revised 6/26/24, revealed Resident #1 had behavior challenges related to a history of a traumatic head injury and could become aggressive with staff. Interventions included referring the resident to behavioral health services, caregivers to provide opportunities for positive interaction and attention, encouraging the resident to express feelings appropriately and providing a program of activities that were of interest to the resident. The 2/4/24 nurse progress note. written at 12:33 p.m., revealed the nurse heard screaming down the hallway and, upon assessment, Resident #1 was seen holding his head while using profane language towards Resident #2. Resident #1 stated That dumb guy hit me in the head. Both parties were separated and Resident #1 was assessed and denied pain. Resident #1 was unable to recall what led up to the incident. The police and emergency services were notified. A 2/4/24 nurse progress note, written at 5:36 p.m., revealed Resident #1 was hit by Resident #2 in the face several times and would not stop until he was told multiple times to go to his room. V. Staff interviews The medical director (MD) was interviewed on 7/9/24 at 2:04 p.m. The MD said Resident #2 had behaviors that were explosive. He said Resident #2 could be calm and then just act out. He said his behaviors were unpredictable. He said the facility put scheduled smoking times in place, which helped with structure. Registered nurse (RN) #1 was interviewed on 7/9/24 at 4:48 p.m. RN #1 said Resident #2 was placed on one to one supervision with a staff member indefinitely related to his aggressive behaviors. She said Resident #1 liked to sing while walking down the hallway and in the dining room. She said at times other residents would yell at him to shut up. The DON was interviewed on 7/9/24 at 5:29 p.m. The DON said Resident #2 was easily agitated. She said he did not have triggers that could be identified and would just snap. She said he was placed on one to one supervision with a staff member on 1/13/24. However, she said Resident #2's one to one staff member was discontinued when he was not showing any behaviors or aggression towards others. The DON said Resident #2 was again placed on one to one supervision with a staff member indefinitely following his altercation with Resident #1 on 2/4/24. The NHA was interviewed on 7/9/24 at 5:45 p.m. The NHA said Resident #2 had a history of aggression towards others prior to his admission to the facility. He said Resident #2 would go from a calm mood with no issues to extreme aggression towards others. He said Resident #2 was placed on one to one supervision with a staff member until the interdisciplinary team (IDT) felt he was no longer a risk to others. The NHA said, following his altercation with Resident #1, Resident #2 was placed on one to one supervision indefinitely. He said Resident #2 had no identified triggers, which made it difficult to anticipate his aggressive behaviors. The NHA said, following an attack on his one to one certified nurse aide (CNA), Resident #2 was discharged from the facility on 3/7/24 to a facility who was able to provide increased psychiatric services for the resident.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for one (#9) of three residents out of 14 sample residents. Resident #9 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and type II diabetes mellitus with diabetic chronic kidney disease. On 2/29/24, Resident #9 was identified to have developed a stage 3 pressure ulcer to his left heel. Record review and interviews revealed the facility failed to identify the skin breakdown on the comprehensive care plan and identify and implement person-centered interventions to prevent the worsening of the pressure injury to the left heel. Additionally, the facility failed to implement interventions ordered by the wound care physician (WCP). Due to the facility's failures to implement interventions recommended by the WCP, Resident #9's stage 3 pressure wound to the left heel worsened. 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 5/16/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. For individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using a device specifically designed for heel suspension, offloading the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. Once a pressure injury develops, pressure relief on the heel is needed to promote perfusion and healing. Pressure on Category/Stage III, IV, and unstageable heel pressure injuries and deep tissue pressure injuries of the heel should be completely offloaded as much as possible. II. Facility policy and procedure The Prevention of Pressure Ulcers policy and procedure, dated 2001, was provided by the director of nursing (DON) on 5/16/24 at 11:54 am. It read in pertinent part, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Review the interventions and strategies for effectiveness on an ongoing basis. III. Resident #9 A. Resident status Resident #9, age 77, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included alcohol dependence with alcohol-induced persisting dementia, chronic obstructive pulmonary disease (COPD) and type II diabetes mellitus with diabetic chronic kidney disease. The 4/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He was independent with transfers, walking and bed mobility. The assessment indicated the resident was at risk for developing pressure ulcers and had actual skin breakdown of one stage three pressure ulcer not present upon admission. The assessment indicated the resident did not refuse care within the review period. B. Observations On 5/13/24 at 1:26 p.m., Resident #9 was laying in bed on his back. He had non-skid socks on his feet. His heels were not floated. The resident's left heel was observed lying directly on the mattress. At 2:24 p.m., the resident continued laying in bed on his back and was covered with a blanket. He asked if his food was ready and said he was going to get up because he was hungry. He kicked off the blanket revealing his feet were directly on the mattress. His heels were not floated or off loaded. At 3:40 p.m. Resident #9 was sitting in the dining room at a table. He said he was waiting for his plate. His heels were observed directly touching the floor. He was wearing non-skid socks and his feet were not elevated or off-loaded. At 4:33 p.m. the resident continued to sit in the dining room at the table. His heels were directly on the floor, not elevated. On 5/14/24 at 10:31 a.m. Resident #9 was lying in bed on his left side. His heels were lying directly on the mattress and were not being floated. At 11:30 a.m. the resident was sitting at a table in the dining room. The balls of his feet were resting on the legs of the table and his heels were pressed directly against the floor. He was wearing non-skid socks. -Resident #9 declined to allow his wound to be observed during the survey. C. Record review The skin integrity care plan, initiated on 4/18/14 and revised on 1/27/15, documented Resident #9 was at risk for skin breakdown related to incontinence of bowel and bladder and had a diagnosis of diabetes. It indicated Resident #9 refused full skin assessments at times. The interventions included administering medication for benign prostatic hyperplasia (BPH) as ordered and monitoring for side effects, administering vitamins as ordered, assisting or giving reminders to the resident for repositioning as needed, providing labs and x-rays as ordered and reporting the results to the physician, monitoring and recording weekly skin checks, monitoring the resident's skin for changes in integrity with routine care and offer fluids with medication pass, meals, activities and at bedside. -Resident #9's comprehensive care plan did not address the resident's actual skin breakdown nor did it provide person-centered interventions to prevent the development and worsening of pressure injuries. The weekly nursing summary, dated 2/26/24, revealed the resident's skin was intact. The resident did not have any open areas or wounds. The 2/29/24 e-interact change of condition communication form documented the resident had an open wound on the left heel. The February 2024 CPO revealed the following physician's order, dated 2/29/24, for wound care to the left heel: Clean with wound cleanser; apply Medihoney and foam dressing two times per day. The WCP's progress note, dated 3/6/24, documented Resident #9 developed a stage 3 pressure injury to the left heel. The wound measurements documented were 3.4 centimeter (cm) length by 3.5 cm width by 0.4 cm depth with 100% granulation. The physician recommended to offload the pressure injury, elevate the resident's legs and float his heels in bed. -The facility failed to ensure these recommendations were transcribed into the resident's comprehensive care plan and made part of his plan of care. The WCP's progress note dated 3/13/24 indicated wound measurements of 3.0 cm length by 2.8 cm width by 0.3 cm depth with 100% granulation. The WCP's progress note dated 3/27/24 indicated that the stage 3 pressure ulcer to the resident's left heel had worsened. The wound measurements were 3.0 cm length by 3.2 cm width by 0.3 cm depth with 50% granulation, 30% slough and 20% eschar. The physician continued to recommend the resident's legs be elevated and to float his heels. -The facility continued to fail to ensure the interventions and recommendations made by the WCP were documented in the physician's orders or implemented on the resident's plan of care. The skin evaluation dated 4/3/24 indicated improvement in the wound with measurements of 2.2 cm length by 2.6 cm width by 0.1 cm depth and 100% granulation. The 4/24/24 WCP progress note documented that Resident #9's stage 3 pressure injury to the left heel had worsened. The wound measurements were 2.4 cm length by 2.8 cm width by 0.1 cm depth with 50% granulation, 30% slough and 20% eschar. The interventions recommended by the WCP documented that the resident's heels should be offloaded, elevate the resident's legs and float the resident's heels. The 5/1/24 WCP progress note documented that the stage 3 pressure ulcer to the left heel was stable. The wound measurements were 2.4 cm length by 2.5 cm width by 0.1 cm depth and 100% granulation. The WP continued to recommend offloading/floating of the heels and elevating the resident's legs. The WCP's treatment order, dated 5/10/24, read: Left heel: cleanse with wound cleanser; apply Medihoney (wound treatment) to the wound bed and cover with bordered gauze and Kerlix (gauze dressing) daily and as needed (PRN). -The facility failed to implement the WCP's consistent recommendations to prevent the worsening of Resident #9's stage 3 pressure injury to the left heel. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/14/24 at 1:55 p.m. CNA #1 said Resident #9 did not require a lot of assistance with personal care. She said she provided reminders to the resident when to come out of his room for meals. She said she did not know if Resident #9 had any pressure injuries. She said wound interventions should be documented in the electronic medical record (EMR). Licensed practical nurse (LPN) #1 was interviewed on 5/14/24 at 2:12 pm. LPN #1 said wound interventions should be documented on the treatment administration record (TAR). She said Resident #9 received treatment for the stage 3 pressure injury to his left heel daily. She said he had a foam dressing on the left heel to protect the wound. She said the resident was not compliant with floating his heels. -However, the resident's medical record did not reveal any documentation that the resident refused or was non-compliant with the WCP recommendation and did not document the intervention to prevent the worsening of the wound. The DON was interviewed on 5/14/24 at 3:12 p.m. The DON said upon the identification of a new wound, a skin assessment and new treatment orders should be documented in the residents' medical record. She said the wound nurse would evaluate the wound and address the treatment orders if needed. The DON said the resident would be added to the WCP's caseload. The DON said the wound nurse was responsible to review the WCP's progress notes and document any new treatment orders in the resident's medical record. She said every wound should be addressed in the comprehensive care plan with person-centered interventions. She said the interventions should be documented on the kardex (tool utilized by staff to provide person-centered care) for the CNAs. The DON said Resident #9's stage 3 pressure wound to the left heel was not addressed in his comprehensive care plan prior to 5/13/24 and the recommendations from the provider to offload the wound, elevate feet and float heels were not documented in the interventions of his plan of care. The WCP was interviewed on 5/16/24 at 4:35 p.m. The WCP said the origin of the wound on Resident #9's left heel was from pressure. He said during his visits with Resident #9, he stressed to the resident and the nurse caring for him the importance of offloading the pressure on the left heel and elevating his feet. The WCP said the resident could be difficult to work with and some weeks did not allow him to examine his wound. The WCP said he recommended floating the heels on multiple occasions to prevent the worsening of the stage 3 pressure injury. He said he was disappointed that the interventions he had recommended multiple times were not in place. IV. Additional information The updated skin integrity care plan, (updated 5/13/24 at 6:00 p.m., during the survey) documented Resident #9 had a stage 3 pressure ulcer to his left heel and was at risk for further breakdown. The updated interventions (dated 5/13/24) included administering medications as ordered, administering treatments as ordered, nutritional or hydration interventions to manage the resident's skin problems and the WCP to follow. -The care plan interventions, updated 5/13/24, still did not include the treatments of offload wound, elevate feet and float heels, as ordered by the wound care physician.

Based on record review, observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (#8) of three out of 14 sample residents. Specifically, the facility failed to follow infection control practices while providing wound care to Resident #8. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, page 1265, retrieved on 5/23/24 Clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice. II. Resident #8 status Resident #8, age less than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis (disease affecting the central nervous system), stage 4 pressure ulcer of right hip, stage 4 pressure ulcer of left buttock, stage 4 pressure ulcer of right buttock and chronic obstructive pulmonary disease (COPD). The 5/1/24 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. He required total assistance with bed mobility and transfers. A. Record review According to the May 2024 CPOs, wound care orders were as follows: -Right buttock: cleanse with wound cleanser, apply Calcium Alginate Silver (wound dressing), cover with Island dressing (wound dressing) daily and as needed (PRN); -Right hip: cleanse with wound cleanser, apply Calcium Alginate with Silver, cover with Island dressing; and, -Left buttock: cleanse with wound cleanser, apply Calcium Alginate Silver, cover with Island dressing. B. Observations On 5/15/24 at 9:00 a.m the wound care nurse (WCN) entered the room of Resident #8 to perform treatments to the pressure injuries to the right hip and right buttocks. The WCN had the treatment supplies in a plastic bag upon entering the resident's room and donned (put on) a gown and gloves. The WCN removed the old dressings from both of the resident's wounds (right hip and right buttocks), threw them in the trash, removed her gloves, sanitized her hands and donned a clean pair of gloves. She cleaned the right hip wound with gauze and wound cleanser. Using the same gauze, the WCN folded the gauze in half and cleaned the wound to the right buttocks. She did not change gloves and sanitize her hands between wounds. The WCN changed gloves and cleaned both wounds again, using the same gauze for both wounds and wearing the same gloves. The WCN doffed (took off) her gloves, washed her hands and donned new gloves. She applied Calcium Alginate Silver, per orders, to each wound using the same gloved finger. She covered each wound with Island dressings. She dated each dressing prior to the application. III. Interviews The WCN was interviewed on 5/15/24 at 9:45 a.m. The WCN said she used the same gauze for both wounds to Resident #8's right hip and right buttocks. She said she did not change gloves in between wounds. She said she usually brings a lot of gauze when performing treatments, but tried not to be wasteful. The WCN said she did not understand that each wound should be treated separately, completing one dressing change before moving on to the other wound, to avoid cross contamination. The DON was interviewed on 5/15/24 at 9:46 a.m. She said the WCN should have treated each of Resident #8's wounds separately. She said the WCN should have cleaned the wounds with different pieces of clean gauze. She said the WCN should have sanitized her hands and changed her gloves in between treatments for each wound to prevent potential cross contamination between the wounds.

Based on observations, record review, and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#3) out of three out of seven sample residents. Specifically, the facility failed to ensure a self-administration assessment was completed for Resident #3 to perform her own wound care treatments. Findings include: I. Facility policy and procedure The Self-Administration of Medications policy and procedure, revised February 2021, was provided by the director of nursing (DON) on 3/19/24 at 4:33 p.m. It documented, in pertinent part, Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate. If deemed safe and appropriate it is documented in the medical record, the care plan and reassessed periodically. If the team determines that a resident cannot safely self-administer medication, the nursing staff will administer the resident's medication and the IDT evaluates options which allow residents to safely participate in the medication administration process. II. Resident #3 status Resident #3, under age 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), the diagnoses included cellulitis (skin infection) of the right and left lower legs. The 2/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required partial/moderate assistance with dressing and personal hygiene. There were no behaviors or refusals documented during the assessment period. A. Resident interview and observations Resident #3 was interviewed on 3/19/24 at 9:00 a.m. She said she had an infection in her lower legs for about two years. She said they drain constantly and she had to change the dressing frequently because they were soiled. She said she changed the dressing herself when the nursing staff did not have time. She said the nursing staff left the extra supplies in her room, such as the cream and powder, so she was able to perform dressing changes as the bandages became soiled. Resient #3 pulled up her blanket to expose her legs. She said she did the dressing change earlier that morning because the previous dressing was soiled. A bottle of wound cleanser, medicated fungal powder and two medication cups unlabeled with a pink cream in each were observed on the bedside table. Both unlabeled cups had an application stick inside. Resident #3 said there was zinc cream in the cups. Resident #3 opened the drawer of her bedside table to reveal the drawer full of pads, tape and wraps for the dressing changes. B. Record review The skin integrity care plan, revised 2/7/24, documented that the resident had impaired skin integrity present on admission as evidenced by bilateral (both sides) lower extremity cellulitis. The interventions included administering treatments as ordered; monitoring for effectiveness; checking the resident's skin during daily care provisions; providing supplements as ordered by the physician; and consulting a wound care provider as indicated. The March CPOs documented the following treatment order: -BLE (bilateral lower extremity): cleanse with wound cleanser, mix antifungal cream/powder with zinc and apply to the wound bed. Apply adaptic emulsion dressing. Apply calcium alginate over emulsion dressing, cover with ABD (highly absorbent sterile dressing), wrap with kerlix, and then wrap with ace bandage - once every day shift and as needed - ordered 3/15/24. A review of the resident's electronic medical record (EMR) did not reveal documentation that an assessment for self-administration had been completed, nor an order from the physician for the resident to self-administer leg wound treatments obtained. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/19/24 at 3:55 p.m. She said Resident #3 was not able to self-administer medications. She said Resident #3 was not appropriate because she did not follow the provider's orders accurately and completely at times when she did her own dressing changes. She said she was aware Resident #3 would do her own treatments to the wounds on her legs. LPN #1 said an assessment needed to be completed for self-administration along with a physician's order prior to a resident self-administering medications or treatments. She said education should be provided to the resident and it should be included in the comprehensive care plan. The DON was interviewed on 3/19/24 at 4:20 p.m. She said a nursing evaluation, interdisciplinary (IDT) team review, and a physician's order were needed prior to a resident self-administering medications or treatments. She said education should be given to the resident on the procedure of the treatment, the side effects and safe storage. She said the self-administration should be documented in the resident's comprehensive care plan. The DON said Resident #3 was not appropriate for self-administration of medications. She said an evaluation to determine the appropriateness of self-administration of wound treatments had not been conducted by the facility. She said nursing staff were bringing the resident wound care supplies and leaving it in her room if she refused the wound care. She said it was not appropriate for the nurses to do so without a self-administration evaluation completed and physician's order.

Based on observations, record review and interviews, the facility failed to ensure services provided to two (#3 and #4) of seven sample residents met professional standards of practice. Specifically, the facility failed to ensure wound care dressings were dated for Resident #3 and Resident #4. Findings include: I. Resident #4 status Resident #4, under age 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), his diagnoses included cellulitis (skin infection) of the right and left lower legs and open wound to the right and left lower legs. The 2/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. A. Resident interview and observations Resident #4 was interviewed on 3/18/24 at 9:20 a.m. He said the nursing staff were not doing his wound care daily. He said his treatments were being done every couple of days. Resident #4 was observed for wound care on 3/19/24 at 11:00 a.m. with licensed practical nurse (LPN) #1. LPN #1 removed the ace wrap that kept the dressing in place. The dressing was not dated. LPN #1 confirmed the dressing was not dated. B. Record review The March 2024 CPOs documented the following treatment order: -RLE (right lower extremity): cleanse with wound cleanser and protect periwound with skin prep. Apply xeroform (dressing soaked in petroleum jelly) to open areas. Apply kerlix and wrap with ace bandage- daily and as needed for saturated/soiled/dislodged dressings- ordered 3/13/24. -LLE (left lower extremity): cleanse with wound cleanser and protect periwound with skin prep. Apply 8x8 hydrofera blue (antibacterial wound dressing) to cover open areas. Apply kerlix and wrap with ace bandage- change daily and as needed for saturated/soiled/dislodged dressings- ordered 3/13/24. II. Resident #3 status Resident #3, under age 65, was admitted on [DATE]. According to the March 2024 CPOs, the diagnoses included cellulitis (skin infection) of the right and left lower legs. The 2/8/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required partial/moderate assistance with dressing and personal hygiene A. Observations Resident #3 was observed for wound care on 3/19/24 at 3:20 p.m. with LPN #1. LPN #1 removed the ace wrap that kept the dressing in place. The dressing was not dated. LPN #1 confirmed the dressing was not dated. B. Record review The March CPOs documented the following treatment order: -BLE (bilateral lower extremity): cleanse with wound cleanser, mix antifungal cream/powder with zinc and apply to the wound bed. Apply adaptic emulsion dressing. Apply calcium alginate over emulsion dressing, cover with ABD (highly absorbent sterile dressing), wrap with kerlix, and then wrap with ace bandage - once every day shift and as needed - ordered 3/15/24. III. Staff interviews LPN #1 was interviewed on 3/19/24 at 11:05 a.m. She said treatments should be dated and initialed by the nurse performing the treatment. She said this was important to be able to tell when the dressing change was last performed. The DON was interviewed on 3/19/24 at 4:20 p.m. She said she did not expect nursing staff to date and initial wound care dressings. She said she could easily tell the last time a wound was dressed based on what it looked like. -The DON did not recognize the standard of practice to date and initial the treatments when they were completed.

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. Specifically, the facility failed to ensure infection control practices were observed during wound care for Resident #4 and Resident #3. Findings include: I. Facility policy and procedure The Handwashing/Hand Hygiene policy and procedure, revised October 2023, was received from the director of nursing (DON) on 3/19/24 at 4:33 p.m. It documented, in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated immediately before touching a resident, before performing an aseptic (sterile) task, after touching a resident, after touching a resident's environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. The use of gloves does not replace hand washing/hand hygiene. II. Failure to perform proper hand hygiene during wound care treatment A. Wound care was performed on Resident #4 by licensed practical nurse (LPN) #1 on 3/19/24 at 11:00 a.m. LPN #1 obtained Resident #4's verbal consent, explained the procedure, gathered supplies and then re-entered the resident's room. She washed her hands and placed a clean pad under his right lower leg. She donned gloves and removed the soiled dressing. The old dressing was visibly soiled with wound drainage. She cleansed with a wound cleanser. -She did not remove the visibly soiled gloves or perform hand hygiene before cleansing the wound. LPN #1 applied skin prep and then removed her soiled gloves. She performed hand hygiene and donned new gloves. She applied the new dressing and wrap. She removed the gloves, washed her hands and donned new gloves. She removed the left lower leg dressing and cleansed with a wound cleanser. She applied skin prep. She removed the visibly soiled gloves and donned new ones. -She did not perform hand hygiene before donning new gloves. LPN #1 applied the clean dressing and wrapped the resident's leg with ace wrap. She removed the gloves and performed hand hygiene. B. Wound care was performed on Resident #3 by LPN #1 on 3/19/24 at 3:20 p.m. LPN #1 obtained Resident #4's verbal consent, explained the procedure, gathered supplies and then re-entered the resident's room. She then performed hand hygiene. She donned gloves and placed a clean pad under the resident's left leg. The resident started taking off the soiled dressing and the nurse assisted. The nurse began to cleanse the wound with wound cleanser and dry gauze. She grabbed the cup of cream and applicator and applied the medication around the wound. -The nurse did not change gloves when moving from dirty to clean. There was no hand hygiene performed between moving from dirty to clean. LPN #1 removed her gloves and went to the treatment cart outside the room to gather more supplies. -She did not perform hand hygiene. She donned new gloves and applied the clean dressing. She removed the gloves to gather more supplies at the treatment cart. -She did not perform hand hygiene. LPN #1 donned new gloves and applied the wrap to the resident's left leg. She moved the pad under the resident's leg to a dry spot and began to remove the soiled dressing on the resident's right leg. The nurse cleansed the wound with wound cleanser and dry gauze. She removed her gloves to go to the treatment cart for more supplies. -She did not perform hand hygiene. LPN #1 donned new gloves and grabbed the cup of cream, an applicator and applied the medication around the wound. She removed her gloves. -She did not perform hand hygiene. LPN #1 donned new gloves and applied the dressing to the wound. She removed her gloves and went to the treatment cart for more supplies. -She did not perform hand hygiene. LPN #1 donned new gloves and wrapped the resident's right leg with the dressing. She removed the gloves and performed hand hygiene. III. Staff interviews LPN #1 was interviewed on 3/19/24 at 3:55 p.m. She said hand hygiene should be performed before and after wound care and after removing gloves. She said hand washing should be performed when hands were visibly soiled. The DON was interviewed on 3/19/24 at 4:20 p.m. She said hand hygiene should be completed before wound care, after removing the soiled dressing, at the end of the wound care treatment, and in between gloves changes. She said this was important to prevent the spread of infection.

Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for two (#80 and #281) of two residents reviewed for psychosocial well-being out of 44 sample residents. Both residents had expressed suicidal ideations. The facility's failures in response created a situation of immediate jeopardy for serious harm. -The facility failed to ensure Resident #80 received the appropriate level of support and supervision to ensure she did not engage in self-harm after making a suicidal ideation with a plan to self-harm. Resident #80 was admitted with diagnoses of bipolar disorder and major depressive disorder and had a history of suicide attempts. The resident met with the behavioral health practitioner (BHP), the director of nursing (DON), the social services director (SSD), and the operations manager (OM) on 12/12/23 to discuss her psychotropic medications. Resident #80 stated that Lorazepam (Ativan), discontinued by the BHP on 12/10/23, was the medication that worked for her and she requested it be restarted. Resident #80 said she would try and kill herself if not given the Lorazepam to address her anxiety. Issues of manipulative and drug-seeking behaviors were raised in the meeting. When Resident #80's request to restart the medication was denied, the resident began sobbing and said she would end her life and had a plan that she would not divulge. She said she had cut her wrists in the past. The resident left the meeting and walked to her room, unattended and without staff supervision. Some moments later, when the BHP suggested someone should be with the resident, Resident #80 was found with scissor cuts on her wrist. -The facility failed to ensure Resident #281 was properly assessed, care planned, and timely referred for behavioral health services after she stated she was going to kill herself. Resident #281 was admitted to the facility with a diagnosis of generalized anxiety disorder. On 1/3/24, she asked the certified nurse aide (CNA) for a knife and said she was going to kill herself. The nursing progress note documented that the resident was assessed and sharp objects were removed from the resident's room. No other documentation was found in the resident's medical record, including a care plan. Interviews with the SSD, nursing home administrator (NHA), and OM confirmed that on 1/3/24 after Resident #281 said she was going to kill herself, the resident was not assessed by a licensed clinician but rather by a social worker and the OM, who were not licensed clinicians and who determined the resident was no longer a threat to self-harm. The facility's failures in response to Resident #80 and #281's suicidal ideations created a situation of immediate jeopardy for serious harm. Findings include: I. Immediate Jeopardy A. Situation of immediate jeopardy The facility failed to provide the appropriate level of support and supervision for Resident #80, who had a history of self-harm, when she voiced an active threat to harm herself. After the resident's request at a meeting with the BHP, SSD, OM, and DON for a medication that she believed was most effective for her was denied, the resident threatened she would try and kill herself. She returned to her room unattended and unsupervised, and cut her wrist with scissors. The facility's failure to provide support and supervision for the resident contributed to the resident harming herself. The facility failed to adequately evaluate Resident #281's threat level for self-harm after she said she wanted to kill herself and slit her wrist. The facility failed to conduct a lethality assessment, determine the resident's threat level, and timely refer the resident for behavioral health services. Further, the facility failed to identify either resident's suicidal ideation within the comprehensive care plan and develop and implement person-centered interventions. B. Imposition of immediate jeopardy On 1/9/24 at 5:48 p.m., the nursing home administrator (NHA), DON, and OM were notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #80 was kept safe after making a suicidal ideation and ensure Resident #281's threat level had been evaluated following a suicidal ideation. C. Facility plan to remove immediate jeopardy On 1/10/24 at 1:00 p.m., the facility submitted a plan to address the immediate jeopardy. The plan read: 1. Immediate action The DON educated all staff on duty on the policy for who to report to when a resident makes a suicidal ideation and the proper steps to take after a suicidal ideation is made. The facility also put education in the agency education binder. The lethality assessment for Resident #281 was completed, referral to behavioral health services, started fifteen minute checks and placed an order on the resident's medication administration record (MAR) for monitoring target behaviors every shift. The DON or designee will provide education to all staff before their next shift. The NHA provided education on 1/9/24 to the social services director (SSD) and nursing staff on performing a lethality assessment when there is a suicidal ideation statement made. The NHA provided education on 1/9/24 to the SSD on the policy for timely care planning of interventions and submitting timely referrals to behavioral health services. On 1/9/24, the DON performed lethality assessments on all residents in the facility. After the lethality assessments were completed, the SSD and the DON updated everyone's comprehensive care plans and made referrals to behavioral health as indicated by the lethality assessment. The DON completed and placed a step by step instruction of what to do when a suicidal ideation is made at each nursing station. 2. Plan All staff report any threats of suicide immediately to the nurse supervisor/charge nurse. The registered nurse shall immediately assess the situation by doing a suicide lethality assessment and shall notify the charge nurse/supervisor, DON and NHA of such threats. A staff member shall remain with the resident until the nurse supervisor/charge nurse determines the threat level. After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident's attending physician of the resident's threat level based on the lethality assessment. If the resident was determined, through the assessment, to be an immediate threat, the nurse will notify the provider and the resident will be sent for an emergent psychiatric evaluation and shall seek further direction from the physician. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior by immediately placing the resident on one to one and update care plans accordingly, until a behavioral health practitioner has determined that a risk of suicide does not appear to be present. The facility will place an order on the MAR for monitoring targeting behaviors to monitor every shift and for the CNAs visual checks task will be placed for every two hours until the resident is no longer a threat. Staff shall document the details of the situation objectively in the resident's medical record and any referrals that have been sent out. The SSD or designee will be responsible for developing a safety plan for the resident, document in the resident's medical record and be included in the comprehensive care plan. SSD or designee will be responsible for updating the care plans when there is an assessment or statement made with all interventions. The comprehensive care plan will include any history of suicide ideations or attempts of suicide. The comprehensive care plan will include any history of suicide ideations or attempts of suicide. The SSD or designee will ensure that referrals are sent to behavioral health services promptly for those residents that make a suicidal ideation. Staff development coordinator or designee will provide ongoing education with all remaining staff, any new employees and agency staff by 1/26/24. NHA or designee will follow up within 24 hours with all involved parties when there is an suicidal ideation made to ensure that all proper steps have been taken. D. Removal of the immediate jeopardy The above plan was accepted on 1/10/24 at 5:08 p.m. Based on the actions taken and described in the plan, the immediate jeopardy was removed. However, record review and interviews revealed deficient practice remained at a G level, actual harm that was isolated. II. Facility policy and procedure A. The Suicide Threats policy and procedure, revised December 2007, was provided by the NHA on 1/11/24 at 2:00 p.m. It revealed, in pertinent part, Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. The nurse supervisor/charge nurse shall immediately assess the situation and notify the DON of such threats. A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update the care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Staff shall document details of the situation objectively in the resident's medical record. B. The SSD was interviewed on 1/9/24 at 3:04 p.m. She said when a suicidal ideation was made, social services, the DON, OM, and NHA should be notified. She said a lethality assessment should be conducted immediately to determine the resident's threat level of self-harm. She said the lethality assessment should be documented in the resident's medical record. She said after the lethality assessment was completed, the interdisciplinary team (IDT) should develop a safety plan for the resident if the resident was determined not to be an immediate threat. If the resident was determined to be an immediate threat, then the resident should be sent to the hospital for an urgent psychiatric evaluation. She said the facility should determine the resident's triggers and include that with the comprehensive care plan. She said the comprehensive care plan should include person-centered interventions. III. Facility failure to ensure Resident #80 was provided the appropriate level of support and supervision to prevent an incident of self-harm. A. Resident #80 status Resident #80, age 73, was admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. According to the December 2023 computerized physician orders (CPO), the resident's diagnoses included bipolar disorder, major depressive disorder, mood affective disorder, and suicidal ideations. The 12/12/23 minimum data set (MDS) assessment revealed the resident's short-term and long-term memory was intact with modified independence in making decisions regarding tasks of daily life. She required set up or supervision with all activities of daily living. It indicated the resident did not exhibit any behaviors during the assessment period. The PHQ-9, a patient health questionnaire for depression, was not completed. The 11/11/23 MDS documented the resident had little interest or pleasure in doing things every day; felt down, depressed, and hopeless every day; felt tired or had little energy every day and had thoughts she was better off dead or hurting herself in some way every day. The resident scored a 12 out of 27 on the PHQ-9 which indicated the resident had moderate depression. The resident's medications as of 12/23 included the following psychotropic medications: -Olanzapine 5 mg (milligrams) every night; -Buproprion HCI ECR (XL) oral tablet extended release 24 hour 300 mg every day; and -Venlafaxine HCL ER 75 MG CAP ER give three 75 mg tablet every day; The resident's use of an anti-depressant medication care plan, initiated on 6/15/23, documented that the resident required the use of an anti-depressant medication manifested by making negative statements, persistent anger with herself and others, self-deprecation, and repetitive health complaints. The interventions included behavior monitoring; educating the resident and family about the risks, benefits, and then side effects of the medication; PHQ-9 assessment on admission, quarterly, annually, and with a change of condition; and reviewing medications with the interdisciplinary team (IDT) quarterly and attempt a gradual dose reduction when clinically indicated. The mood care plan, initiated on 6/14/23 and revised on 12/18/23 (after discharge), documented the resident had a mood challenge related to bipolar disorder, depression, and anxiety. The interventions included administering medications as ordered; assisting the resident, family, and caregivers to identify strengths, positive coping skills; behavioral health consults as needed; educating the resident's family, caregivers, and family regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation and maintenance; and observing signs and symptoms of mania or hypomania racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep and agitation or hyperactivity. The anxiety care plan, initiated on 6/26/23 and revised on 7/10/23, documented the resident had anxiety. The interventions included setting realistic goals; monitoring the resident's usual response to problems; and providing opportunities for the resident and family to participate in care. B. Resident 80's known history of suicidal attempts and ideations prior to a self-harm attempt on 12/12/23. 1. The 11/2/22 pre-admission screening and resident review (PASRR) level II evaluation documented that the resident stated she had a long history of depression and anxiety, characterizing it as chronic and ongoing. It indicated the resident had attempted suicide in the past, six to seven years prior, and was admitted to an inpatient psychiatric facility. The resident said she had been experiencing sadness and anxiety and she had been isolating herself. 2. The 11/9/23 physician progress note documented that Resident #80 had indicated she had become acutely anxious and had a history of suicidal ideations. It indicated the resident had a history of three suicide attempts. 3. Record review revealed the facility's knowledge of Resident #80's worsening suicidal ideations after the reduction of Lorazepam (Ativan). The 11/13/23 physician progress notes documented that Resident #80 was recently reviewed during a psychological pharmacy meeting and the resident had been having some worsening passive suicidal ideations after coming off an as-needed dose of Ativan. It indicated that the resident responded well on a low dose every 12 hours as needed. -The physician recommended the resident be restarted on this medication: Ativan 0.5 MG every 12 hours as needed for a history of suicidal attempt. 4. The 11/13/23 gradual dose reduction (GDR) meeting notes documented that the interdisciplinary team (IDT) met to review the resident's recent symptoms/behaviors, psychotropic medications, and overall treatment response; specifically assessing whether the resident was on the lowest effective dose for medication. -It indicated a GDR was contraindicated due to the severity of the resident's current symptoms, which would become unmanageable at lower doses. -A referral to behavioral health services was recommended and an 11/13/23 social services progress note documented the resident was referred to behavioral health services. 5. An 11/15/23 initial psychological evaluation completed by a behavioral health practitioner (BHP) documented the resident had a history of three suicidal attempts and five inpatient psychiatric hospital stays. It further indicated that during the evaluation, the resident had a mood score of 4/10, a depression score of 8/10, and an anxiety score of 8/10. It did not indicate what psychological testing measures were used. -It documented the resident endorses suicidal ideation but denies a specific plan. Assessed safety today, deemed the patient to be at moderate risk today. Reported SI (suicidal ideation) and/or behaviors, intent, and/or plan as documented. -It further read, Current protective and risk factors were reviewed, and the patient is currently at clinically significant risk for suicide/homicide. The patient was counseled on emergency resources such as going to the ER (emergency room ) or dialing 911 if experiencing suicidal/homicidal ideation. Patient remains appropriate for continued SNF (skilled nursing facility) placement. -From the standpoint of her being at risk of self-harm, she has a history of three attempts to kill herself and she currently reports suicidal ideation but no plan. Without the history of three previous attempts to kill herself, this clinician would have said she is at moderate risk of a suicide attempt. However, with three previous, documented attempts during her lifetime to kill herself, this clinician believes she should be considered high risk. 6. An 11/16/23 restorative nursing note documented the resident refused services on 11/5/23 and 11/13/23, stating she had too much anxiety. 7. An 11/28/23 BHP progress note documented the resident was administered the PHQ-9 and GAD-7 assessments today with scores of 27 and 21, indicating high levels of depression and anxiety. Patient conveyed today a high level of despair and despondency about the upcoming discontinuation of Lorazepam (Ativan). She thinks this is the only medication that provides her with any relief from anxiety levels which are very high. 8. A 12/10/23 behavior progress note documented that the resident was observed crying in her room around 3:58 a.m. She said that she was depressed and did not know what was wrong. The resident called her sister, however, an hour later was found crying again. The physician was notified and administered a one-time order of Ativan 0.5 mg (milligram). 9. A review of the resident's orders revealed the BHP discontinued the resident's Lorazepam 0.5 MG every day was discontinued on 12/10/23. C. Failures in the facility's response 1. A review of the resident's medical record did not reveal the resident had been questioned about her risk for self-harm on 12/10/23 when she was discovered crying and reported she was depressed; no lethality assessment had been conducted to determine the resident's threat level of self-harm despite her documented history of behavioral health assessments that identified the resident as high risk for a suicide attempt. 2. A review of the resident's care plans for mood, anxiety, and antidepressant use (see above), revealed they failed to identify the resident's history of suicidal ideations and implement person-centered interventions in an attempt to address the resident's history and any potential suicidal ideations. Specifically, the review revealed no evidence of individualized supports to assist the resident during depressive episodes, no plan to increase supervision to monitor her behaviors or identify a plan to ensure the resident's safety. 3. A 12/11/23 physician progress note documented the physician had visited with the resident, who was in bed resting. The resident reported that she had intermittent depressive episodes but denied any suicidal ideation that day or a plan to self-harm. The note indicated that social services was contacted; it was recommended social services meet with the resident to develop a safety plan for when the resident was having an exacerbation of depression. However, a review of the resident's medical record did not reveal documentation that a safety plan had been developed for the resident per the physician's recommendation. D. Incident of self-harm on 12/12/23 Record review and interviews revealed the facility failed to provide Resident #80 with an appropriate level of support and supervision when she was actively suicidal. In a meeting with the BHP, DON, SSD, and OM on 12/12/23, where reference was made to the resident's depression and despondency as manipulative and drug-seeking, and where the resident expressed that if she could, she would end her life, staff allowed Resident #80 to leave the meeting alone and return to her room without any staff supervision. Specifically: 1. Record review a. On 12/12/23, the BHP conducted a psychiatric follow-up visit with Resident #80. Documentation from the visit by the BHP on 12/12/23 read: -Before the BHP visited with the resident that day, staff members had informed him the resident was very depressed. It had also recently come to this clinician's attention through another communication channel that the patient had become known for drug-seeking behaviors while she was at another facility. -The resident was seen in her room and was responsive in both the basic and communicative senses of the word. Her responses to questions were direct with no delays nor word search difficulties. However, the patient's presentation was again of distress and despair indicating that if there were a way to do it, she would end her life, citing high levels of depression and weariness. These sentiments had been expressed to the staff directly by the patient and also relayed on by this clinician to the staff. -In a new twist, she also indicated today she wanted to go to the hospital. It soon became evident in the encounter that this all had more than a little to do with her 0.5 mg Lorazepam (Ativan) being discontinued on 12/10/23. She expressed in the first and second visit with this clinician that it is the only medication that has provided her with any sense of peace and relaxation. -The overriding theme of the patient during the meeting was that she wanted her Lorazepam and that it was the only solution she would consider acceptable. As this clinician left her room, she was sobbing. The BHP documentation further read: - Later in the morning, the DON asked the BHP to sit in on a meeting with the resident, DON, OM, and SSD, which was requested by the resident. Without telling the patient that everyone else in the meeting was already aware of her reputation for drug seeking behaviors and manipulation, this clinician told the patient that the appearance here was that the patient was being manipulative and threatening self-harm in order to get her way on the Lorazepam. Patient went into a sobbing swoon indicating that if she could, she would end her life. She was asked if she had a plan and she indicated if she did that she would not divulge its details, but added that she had cut her wrists in the past. And she decided to leave the meeting. -At the time Resident #80 left the meeting, the DON called the resident's daughter to apprise her of the situation. The resident's daughter requested the resident be given the Lorazepam, per her request. The OM left the office to go to the resident's room, at the BHP's suggestion to take her to the nursing station for monitoring. During that time, the resident had gone to her room and slashed her wrist with a pair of scissors. The resident was sent to the emergency roiagnom on a mental health (M1) safety hold. 2. The 12/12/23 social services progress note documented that at 12:04 p.m., the SSD, DON, and the BHP met with the resident and determined she was on a lot of psychotropic medications. The progress note indicated the resident said she was suicidal, and reported she had a plan, but would not reveal the details. The resident had reported she had previously slit her wrist. The resident said she wanted the Lorazepam to be ordered again. 3. The 12/12/23 nursing progress notes documented that at 12:45 p.m., the nurse was called to the resident's room because the resident had taken a pair of scissors and attempted to slit her wrist. EMS (emergency medical services) was called immediately to place the resident under an M1 hold and transport her to the hospital. E. Staff interviews Staff interviews confirmed the resident returned to her room unattended and without supervision after expressing she wanted to end her life and had a plan. 1. The DON and SSD were interviewed on 1/9/24 at 3:53 p.m. The SSD said she did not know if a lethality assessment was completed for Resident #80. The DON said she was present during the meeting with Resident #80 on 12/12/23. She said the BHP had met with the resident and Resident #80 wanted him to restart the Lorazepam medication to assist with her anxiety. She said the resident said she was suicidal, wanted to end her life, and had a plan but would not tell them. The SSD said a meeting with Resident #80 was held with the BHP, DON, OM, and SSD. She said the resident reiterated her request (that Lorazepam be restarted). The DON said the BHP told the resident she was manipulative and drug-seeking. She said Resident #80 became very upset, started crying, and left the meeting. She said staff did not follow the resident. The DON said Resident #80 became more upset after the BHP said she was manipulative and drug-seeking. She said prior to leaving the meeting, Resident #80 said she wanted to kill herself, and said she had a plan but would not provide the details. The DON said she called the resident's daughter to talk to her, and the daughter also requested the resident be prescribed Lorazepam. She said the BHP said the resident should be placed at the nursing station for observations and the OM left the room. She said the OM was informed by staff, before getting to Resident #80's room, that the resident had taken scissors and slit her wrist. The DON said no one from the meeting followed the resident when she left the meeting to provide her with supervision for her safety. She confirmed Resident #80 slit her wrist with scissors after she left the meeting and while the OM began walking to her room. 2. The NHA and OM were interviewed on 1/9/24 at 4:14 p.m. The OM said he was present during the self-harm incident with Resident #80. He said he was part of the meeting, where the BHP told Resident #80 she was manipulative and drug-seeking. He said the resident left the room after stating she wanted to kill herself and had a plan. He said no one followed the resident. He said one of the staff members in the room should have immediately left with the resident to provide her with the appropriate supervision and prevent an incident of self-harm. The NHA said Resident #80 should have immediately been placed on one-to-one supervision following the suicidal ideation she had made to the BHP prior to the meeting with the rest of the team (see above). He said the resident's room should have been searched for any sharp objects since she had divulged she had slit her wrists in the past. The OM said he did not agree with the BHP calling Resident #80 manipulative and a drug seeker. However, he said no one in the meeting stopped the BHP from making those statements. IV. Facility failure to ensure Resident #281 was assessed, care planned, and referred to behavioral health services after she expressed an intent to self-harm. A. Resident #281's status Resident #281, age 36, was admitted on [DATE]. According to the January 2023 CPO, the resident's diagnoses included diffuse traumatic brain injury without loss of consciousness, failure to thrive, and anxiety disorder. The 12/29/23 MDS assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. She required set-up assistance with eating, substantial to maximum assistance with toileting, bathing, upper body dressing, lower body dressing, and personal hygiene. It indicated she did not exhibit any behavioral symptoms during the assessment period. The PHQ-9 (patient health questionnaire for depression) documented the resident scored an eight out of 27, which indicated the resident had mild depression. It indicated the resident felt bad about herself more than half of the days during the assessment period; felt tired or had little energy every day; and felt down, depressed, and hopeless every day. The use of an antidepressant medication care plan, initiated on 1/3/24, documented that the resident required the use of an antidepressant medication due to a diagnosis of major depressive disorder. The interventions included administering medications as ordered by the physician and observing the resident's mood and response to medication. The 12/27/23 nursing progress note documented that the resident continued to yell and scream out throughout the shift, and remove her brief and void in the bed. The comprehensive care plan did not identify that the resident had any behaviors with any person-centered interventions to address behaviors and diagnosis of major depressive disorder. C. Incident of suicidal ideation The 1/3/24 nursing progress note documented that the certified nurse aide (CNA) notified the nurse that Resident #281 asked for a knife so she could kill herself. It indicated that the resident was assessed, sharp objects were removed and the SSD, DON, and OM were notified. -However, a review of the resident's medical record did not reveal any documentation that a lethality assessment had been conducted to determine the resident's threat level of self-harm. Further, the resident's medical record did not reveal documentation from the SSD or any other staff for follow-up on the resident's suicidal ideation on 1/3/24. The 1/4/24 physician progress notes documented to refer the resident for behavioral health services. -However, the resident's medical record did not reveal documentation that the resident had been referred for behavioral health services following the suicidal ideation made on 1/3/24 and the physician's note on 1/4/24. Rather, the resident was referred on 1/9/23 (during the survey). D. Staff interviews 1. The SSD was interviewed on 1/9/24 at 3:04 p.m. The SSD said Resident #281 had a history of a traumatic brain injury. She said the resident would get really upset when she wasn't able to get a hold of her mom on the phone. She said Resident #281 asked the CNA for a knife to slit her wrists. She said she was in the facility when the event occurred. She said she and the OM went to the resident's room to talk to her. She said neither she nor any other staff conducted a lethality assessment. The SSD said she called the resident's mother and the resident calmed down. The SSD said she felt the resident was fine to be left alone. She said she obtained verbal consent that day from the resident's mom for a behavioral health referral. She presented the consent form and said she had not actually sent the referral until today, 1/9/24, six days after Resident #281 made a suicidal ideation. The SSD said the facility did not follow the protocol for suicidal ideations (see above) and a lethality assessment should have been completed immediately. The SSD said the OM entered a late entry progress note today regarding the incident on 1/3/24. She confirmed other than the late entry progress note, no other documentation was in the resident's medical record regarding the resident's suicidal ideation. She confirmed the resident's suicidal ideation

Based on record review and interviews, the facility failed to have an effective system to identify deviations in performance and adverse events, and to develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct quality deficiencies. Specifically, the QAPI program committee failed to identify and address concerns related to suicidal ideations and the prevention of incidents of self-harm that rose to the level of immediate jeopardy. Cross-reference F740. Findings include: I. Facility policy and procedure The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the nursing home administrator (NHA) on 1/8/24 at 2:00 p.m. It revealed, in pertinent part, Purpose: to evaluate facility quality indicators, identify quality issues, develop corrective action plans and evaluate any action plans for continuous quality improvement. Any concerns, trends or clusters identified should be listed on the QA Concerns List. Document the concern, goal and approaches and interventions to correct the concern on the QA Concern Action Plan. Review monthly any ongoing concerns until resolved. Develop new interventions as needed. II. Cross-reference citation F740 Behavioral Health Services Record review and interviews revealed the facility failed to ensure two residents who expressed suicidal ideation, received necessary behavioral health care and services, to attain and/or maintain their highest practicable level of well-being. Specifically, the facility failed to identify and implement safety interventions; ensure lethality assessments were completed upon suicidal ideations; ensure timely referrals to behavioral health; and ensure person-centered comprehensive care plans were developed to address the suicidal ideation. A. Resident #80 was admitted with diagnoses of bipolar disorder and major depressive disorder and had a history of suicide attempts. The resident met with the behavioral health practitioner (BHP), the director of nursing (DON), the social services director (SSD), and the operations manager (OM) on 12/12/23 to discuss her psychotropic medications. Resident #80 stated that Lorazepam (Ativan), discontinued by the BHP on 12/10/23, was the medication that worked for her and she requested it be restarted. Resident #80 said she would try and kill herself if not given the Lorazepam to address her anxiety. Issues of manipulative and drug-seeking behaviors were raised in the meeting. When Resident #80's request to restart the medication was denied, the resident began sobbing and said she would end her life and had a plan that she would not divulge. She said she had cut her wrists in the past. The resident left the meeting and walked to her room, unattended and without staff supervision. Some moments later, when the BHP suggested someone should be with the resident, Resident #80 was found with scissor cuts on her wrist. The facility failed to ensure Resident #80 received the appropriate level of support and supervision to ensure she did not self-harm herself after making a suicidal ideation with a plan to self-harm. B. Resident #281 was admitted to the facility with a diagnosis of generalized anxiety disorder. On 1/3/24, she asked the certified nurse aide (CNA) for a knife and said she was going to kill herself. The nursing progress note documented that the resident was assessed and sharp objects were removed from the resident's room. No other documentation was found in the resident's medical record, including a care plan. Interviews with the SSD, nursing home administrator (NHA), and OM confirmed that on 1/3/24 after Resident #281 said she was going to kill herself, the resident was not assessed by a licensed clinician but rather by a social worker and operations manager, who were not licensed clinicians and who determined the resident was no longer a threat to self-harm. The facility failed to ensure a proper assessment was completed to ensure the resident's safety and develop a comprehensive care plan to address the resident's suicidal ideation. The facility failed to refer the resident to behavioral health services, until 1/9/24. III. Staff interviews The NHA and the OM were interviewed on 1/11/24 at 5:55 p.m. -The NHA said the QAPI meetings were held monthly. He said that he, the OM, the DON, the infection preventionist (IP), social services, the dietary manager, the pharmacist, and other members of the interdisciplinary team attended the meeting. -The NHA said each department presented a scheduled set of reports at each meeting and the facility attempted to identify the issues throughout the facility and discover trends. -The NHA said if new areas of concern were identified, performance improvement plans (PIP) would be developed and discussed during the next QAPI meeting. -The NHA said he had only been working at the facility for a couple of weeks, but the OM had been at the facility since March 2023. -The OM said the facility had not identified the significance of resident attempts to self-harm during the previous six months. He said the facility missed identifying the issue and failed to put interventions in place to address the failure. He said suicidal ideations and resident safety had not been identified on the monthly QAPI reports and the facility had not identified it as a concern to develop a performance improvement plan. -The OM said the facility did not identify that facility staff were not following the facility policy for suicidal ideations which, (cross-reference F740) provided for prompt reporting of suicidal ideations, staff remaining with the resident until the nurse supervisor/charge nurse arrived to conduct a lethality assessment, physician and responsible party notification, staff monitoring resident mood and behavior, updating the care plan, as well as the development of a safety plan. -The OM said the facility had determined today (1/11/24) that the facility could not handle the residents being admitted to the facility with behavioral concerns who were also physically aggressive, but did not state this was based on analysis of the data revealing issues raised by the facility's response to behavioral health issues. -The NHA said that today (1/11/24) the facility halted all admissions to the facility to ensure proper training was in place and completed to be able to attend to their current resident population. -The NHA said the facility's interdisciplinary team (IDT) decided to create a dementia program at the facility during the hiatus from admissions and to hire a behavioral specialist to assist. He said he would be sure to be out on the floor, speaking to the facility staff and residents to identify their needs and put a plan together on how to address those needs.

Based on interviews, observations and record review, the facility failed to ensure that residents had reasonable access to send and receive mail and packages at the facility. Specifically, the facility failed to ensure residents' personal mail was delivered timely on all days Monday through Saturday. Findings include: I. Resident group interview and observations The resident group interview was conducted on 1/9/24 at 3:08 p.m., with six (#39, #58, #71, #19, #74 and #69) alert and oriented residents. The residents said they had never received mail on Saturdays at the facility. The residents said they would like to receive their mail on Saturdays. The resident's said the mail would sit over the weekend in the mail box and the receptionist would pick it up on Monday morning when she arrived and then distribute it. II. Record review On 1/9/24 at 4:15 p.m. a poster of resident rights were observed posted on the wall by the entrance to the facility. It documented that the residents had the right to receive mail during the weekdays and weekends. III. Staff interviews The receptionist was interviewed on 1/11/24 at 12:55 p.m. She said that she worked Monday through Friday. She said she was in charge of receiving the mail. She said the mail delivered on the weekend was placed in the mailbox and she emptied it on Monday morning when she arrived at the facility. She said residents should be able to receive their mail on Saturdays. The activity director (AD) was interviewed on 1/11/24 at 1:40 p.m. She said she was not sure if mail was delivered to the residents on Saturdays. The nursing home administrator (NHA) was interviewed on 1/11/24 at 1:44 p.m. He said he was unaware that the residents were not receiving their mail on Saturdays. He said it was a resident right to receive mail during the United States Postal Services hours of operation. He said the facility had a mailbox outside and he would have the activity department receive and distribute the mail on the weekend moving forward.

Based on observations and interviews, the facility failed to maintain a clean, comfortable and homelike environment for the residents on four out of four hallways. Specifically, the facility failed to ensure resident rooms, bathrooms and shower rooms were odor free and received necessary repairs. Findings include: I. Observations Observations throughout the survey, conducted on 1/8, 1/9, 1/10 and 1/11/24, revealed the following: A. Individual resident rooms 1. room [ROOM NUMBER] had broken blinds; the wall was scraped where the headboard was placed. There was an odor in the bathroom which smelled of urine, the ceiling fan was not working, the floor was dirty and had not been swept and there was missing tile at the base of the floor. 2. room [ROOM NUMBER] had paint chipped walls where the bed was placed. The bathroom had an odor of urine and the ceiling fan was not working. 3. room [ROOM NUMBER] had chipped tile at the entrance of the room. The bathroom ceiling fan was not working. 4. room [ROOM NUMBER] had the wall patched under the window, but was not repainted, the window sill had cracks where the window was and the ledge was missing. The towel bar in the room was patched but had not been painted. The bathroom had an odor of urine. 5. room [ROOM NUMBER] walls had paint chipped where the bed was positioned and the window ledge was missing and the wall had been patched but not painted. The bathroom had an odor of urine and the base board around the toilet was missing. 6. room [ROOM NUMBER] had paint chipped on the walls where the bed was located. There was an odor of urine smell in the bathroom. 7. room [ROOM NUMBER] had paint chipped on the walls where the bed was placed. The bathroom had a pad on the floor and an odor of urine. 8. room [ROOM NUMBER] had the wall scratched up by where the bed was placed. The bathroom had an odor of urine. 9. room [ROOM NUMBER] the wall was scratched up by where the bed was placed. The floor had black markings on it, the floor was dirty and needed to be cleaned/scrubbed. B. Shower rooms Observations of the three shower rooms, revealed baseboard missing by the tub and broken blinds in one of the shower rooms. The shower room floor had blue liquid on the floor. There was a wash cloth with dark brown matter left on the floor of the shower. II. Environment tour and staff interview The environment tour was conducted on 1/11/24 at 3:13 p.m. with the maintenance supervisor (MS). Regarding all observations above, the MS said that they were waiting on approval to do renovations. He said he walked the facility every day that he was there. He then said he was able to see the repairs needed to the hallways, but was not aware of the repairs needed to resident rooms. He said that he was notified of work orders by mailbox, paper wise and through direct supplies TELS (computer prgram) work order forms. He said he was not aware of some of the concerns and no one had pointed things out to him. He said he was aware of the need to upgrade the facility. He said the operations manager was aware of the renovations that needed to be done and he said he was waiting on approval to do renovations. He said he was not aware of the concerns that were shown to him.

Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (#2) of three residents reviewed out of 13 sample residents. Resident #2 was admitted to the hospital from his mother's home on 5/8/23 due to alcohol intoxication with vomiting and inability to control his secretions. The resident's blood alcohol level was 257 (0.257), almost four times the legal limit. Resident #2 had a history of alcohol abuse and seizures with alcohol withdrawal. The facility admitted the resident on 5/9/23, less than 24 hours after he was admitted to the hospital highly intoxicated. The facility failed to monitor Resident #2 for withdrawal symptoms including seizures, provide timely treatment for withdrawal symptoms, and provide the resident a nurse call light. The medical director (MD) said a nursing facility was not the appropriate place for a person in acute alcohol withdrawal per guidelines. He said they were not prepared to follow Clinical Institute Withdrawal Assessment (CIWA) guidelines used for alcohol withdrawal that included frequent assessments and vital sign monitoring. As a result of the facility's failures Resident #2 suffered nausea, pain, increased anxiety, seizure activity, and complained of unknown withdrawal symptoms without timely treatment, physician notification or further assessment. Additionally, the facility failed to document the reason a PRN (as needed) medication for Resident #2 was administered. Findings include: I. Professional reference According to the National library of Medicine, Alcohol Withdrawal, retrieved 8/20/23 from:https://www.ncbi.nlm.nih.gov/books/ (2023) in pertinent part, Withdrawal has a broad range of symptoms from mild tremors to a condition called delirium tremens, which results in seizures and could progress to death if not recognized and treated promptly. Alcohol withdrawal can range from very mild symptoms to a severe form, which is named delirium tremens. Mild symptoms can be elevated blood pressure, insomnia, tremulousness, hyperreflexia, anxiety, gastrointestinal upset, headache, palpitations. Moderate symptoms include hallucinations and alcohol withdrawal seizures (rum fits) that can occur 12 to 24 hours after cessation of alcohol and are typically generalized in nature. There is a 3% incidence of status epilepticus in these patients. About 50% of patients who have had a withdrawal seizure will progress to delirium tremens. Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an altered sensorium with significant autonomic dysfunction and vital sign abnormalities. It includes visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. Symptoms of delirium tremens can last up to seven days after alcohol cessation and may last even longer. The Clinical Institute for Withdrawal Assessment for alcohol revised scale (CIWA-Ar) is a tool used to assess the severity of alcohol withdrawal symptoms. The tool allows clinicians to monitor for the signs and symptoms of withdrawal and determine who needs medical therapy. The features that are used for the CIWA-Ar scale include the presence of: Nausea and vomiting, headache, auditory disturbances, agitation, sweating, visual disturbances, tremor, clouding of senses, orientation.The following patients should be admitted : History of withdrawal seizures, concomitant psychiatric problems, abuse of other substances, suicidal ideations. Because chronic alcohol use is widespread in society, all healthcare workers, including the nurse and pharmacist, should be familiar with the symptoms of alcohol withdrawal and its management. Nurses monitoring alcoholic patients should be familiar with signs and symptoms of alcohol withdrawal and communicate to the interprofessional team if there are any deviations from normal. II. Facility policy The facility policies for alcohol withdrawal were requested from the operations manager (OM) on 8/176/23 at 1:17 p.m. He said the facility did not have a policy, procedure or protocol for acute alcohol withdrawal. III. Resident #2 A. Resident status Resident #2, under age 65, was admitted on [DATE] and discharged to the hospital without return to the facility on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included epilepsy (seizures), alcohol abuse, opioid abuse, psychoactive medication abuse, history of falls and traumatic brain injury (TBI). The 5/14/23 minimum data set (MDS) assessment did not include the resident's cognitive status. The nursing admission assessment dated [DATE] documented the resident was alert and oriented to person, place and time. The MDS assessment documented the resident required supervision with bed mobility and transfers. He required limited assistance with dressing and extensive assistance with personal hygiene. Toileting was documented as only having occurred once or twice, with no amount of assistance was documented. The 5/9/23 nursing admission note documented the resident was incontinent of bladder. B. Record review The hospital notes dated 5/8/23 at approximately 3:00 p.m. documented the resident was intoxicated, tachycardic (rapid heart rate), and nauseated. He was restrained due to aggressive behavior with the hospital staff. His blood alcohol level was documented as 257. The laboratory results further documented a blood alcohol level of 50 to 100 was toxic, greater than 100 caused depression of the central nervous system and greater than 400 was fatal. He was discharged to the facility on [DATE]. The facility nursing admission assessment documented the resident was admitted [DATE] at 12:00 p.m., less than 24 hours after he was admitted to the hospital for alcohol intoxication. The resident complained of withdrawal symptoms on admission. There were no specific symptoms or physician notification documented. There was no follow up assessment or documentation. His admission blood pressure was 105/61 and his pulse was 91 beats per minute (BPM). The assessment documented the resident was oriented to his room and call light. The fall risk assessment dated [DATE] documented the resident was at high risk for falls due to his history of falls, wheelchair use, dependence on staff assistance for transfers and incontinence, changes in cognition and medications. On 5/9/23 at 9:17 p.m. a daily skilled nursing note documented the resident had tremors, a low grade fever, and tachycardia (elevated heart rate) at 111 BPM. The only temperature documented was 97.9, below normal. On 5/9/23 at 9:34 p.m. a nurse documented a nursing weekly summary note. His vital signs were documented as 110/80 and his pulse was elevated at 111 BPM. The summary documented the resident's pain level was a six on a scale of one to ten. He had generalized pain. The resident had just been admitted at noon that day. -The weekly summary note did not document any information on the resident's withdrawal symptoms, or seizure activity. Review of the medication administration record (MAR) revealed the resident was not given anything for pain (see below). There were no further assessments of the resident documented throughout that night. On 5/10/23 at 5:11 a.m. the nurse practitioner (NP) documented Resident #2 presented to the emergency department on 5/8/23 for alcohol intoxication. Emergency medical services (EMS) was called by his mother for vomiting and being unable to clear his own secretions. The MD documented upon admission to the emergency department Resident #2 arrived in restraints, and was hostile and threatening to the staff. He had slurred speech. The resident had a history of head injury, alcohol abuse with seizures and heroin overdose in 2020. He had a stroke in 2020 and alcoholic hepatitis. He admitted to the facility on [DATE]. The NP further documented the resident would be monitored closely for alcohol withdrawal symptoms and consider sending him to the ER for additional management should this happen. She documented he had a tremor and was fatigued. Her note said to continue Keppra (anti seizure medication). -However, the facility had not administered his Keppra the previous night as ordered (see below). -There were no nursing notes or assessments documented of the resident condition until the primary care provider (PCP) came to see the resident. On 5/10/23 at 3:26 p.m. the nursing notes documented the primary care provider (PCP) who was also the medical director (MD) was at the facility to see the resident. The PCP requested the resident be sent to the ER due to withdrawal symptoms and the resident expressing concern that he felt he may have a seizure at any time. The nurse called 911 and the resident was sent to the hospital. -There were no nursing notes documented when the resident returned from theER on [DATE]. The orders from the emergency room in the resident medical record were dated 5/10/23 at 4:19 p.m. The orders documented: Clorazepate 15 mg by mouth, take 1-2 tablets every 4 hours as needed on day one, take 1 tablet every 6 hours as needed on day two, take 1 tablet every 8 hours as needed on day three, take 1 tablet every 12 hours as needed on day four, and one tablet daily after that, On 5/11/23 at 5:22 a.m. licensed practical nurse (LPN) #7 documented in the nursing progress notes, Resident #2 had called 911 EMS on his phone because he was having alcohol withdrawal symptoms and did not have a call light in his room. The nurse documented Resident #2 was given some as needed medication for his withdrawal symptoms and moved to a room with a call light. -The specific withdrawal symptoms were not documented. -However, the resident did not receive medication for withdrawal symptoms on the morning of 5/11/23 as the nurse documented in the progress notes. He had been prescribed Clorazepate PRN (as needed) for alcohol withdrawal symptoms and seizures. The nurse documented at 4:44 a.m. the resident was given PRN (as needed) Tylenol 325 mg by mouth, two tablets and PRN Hydroxyzine 25mg by mouth for anxiety. The MAR did not document Clorazepate was given until 6:49 p.m. (see below). On 5/11/23 at 7:54 a.m. the NP documented the resident was sent to the ER for high risk seizure activity due to alcohol withdrawal. She documented the resident at this time was in bed resting and he complained he did not feel well. The NP documented the Clorazepate had just arrived from the pharmacy and would be started as soon as possible. She further documented the resident's vital signs would be taken every four hours and he would be monitored closely. -However, there were no vital signs documented, and the resident did not receive the PRN Clorazepate for withdrawal symptoms and seizures until 6:49 p.m. that night on 5/11/23. On 5/12/23 at 6:26 a.m. the PCP documented he was following up after his history and physical two days ago. He documented Resident #2 was at high risk for alcohol withdrawal seizures. He would be clinically appropriate for the ICU setting. He had an alcohol level of 250 prior to admission. He had a history of alcohol withdrawal seizures. The PCP documented at the time of his history and physical the resident was having tremors, tachycardia (elevated heart rate), diaphoresis (sweating) and anxiety. The resident was evaluated in the ER and was sent back to the facility several hours later with Clorazepate. He documented the nursing staff had been doing vital signs every four hours. -However, there were no vital signs, monitoring or assessments of Resident #2 documented by the licensed nursing staff. On 5/13/23 at 10:22 p.m., the nursing notes documented the resident representative had called the facility because the resident was concerned he had not been getting his medication. The note did not document which medication or what action was taken. There was no follow up documentation or investigation for review (cross-reference F585 grievances). On 5/14/23 at 2:32 a.m. the nursing notes documented the resident had called 911; he felt he was about to have a seizure. The resident did not return to the facility. -The nursing progress notes between 5/9/23 and 5/14/23 did not include any monitoring of Resident #2 for falls, seizure activity or alcohol withdrawal symptoms. The May 2023 medication administration record (MAR) was reviewed and revealed the following: The resident had orders for Keppra (anti seizure medication) ordered twice per day on 5/9/23. -He did not receive the evening dose of Keppra on 5/9/23. The MAR was coded with a nine, which indicated to see nurse's notes. However, there was no nurse's note. On 5/10/23 the MAR was blank for the evening dose of Keppra. -On 5/10/23 at 8:04 p.m., the MAR documented the resident was given Ondansetron 4 mg (milligrams), one tablet for nausea. The medication was documented as ineffective. -There was no further documentation or follow up in the nurses notes. On 5/10/23 at 8:04 p.m. the resident was given Tylenol 325 mg two tablets by mouth for a pain level of six. The medication was documented as ineffective. -There was no further documentation or follow up in the nurse's notes. -On 5/11/23 at 4:44 a.m., the nurse's notes documented the resident had been given medication for withdrawal symptoms. According to the MAR, the resident did not receive medication for withdrawal symptoms on the morning of 5/11/23. He had been prescribed Clorazepate PRN (as needed) for alcohol withdrawal symptoms and seizures on 5/10/23. The MAR documented the resident was given PRN Tylenol 325 mg by mouth PRN, and Hydroxyzine 25mg by mouth for anxiety PRN. On 5/12/23 the MAR documented the resident did not receive the Keppra evening dose because he was hospitalized . -There was no documentation in the medical record indicating the resident was in the hospital on 5/12/23. On 5/15/23 at 7:00 a.m. the MAR documented the resident received Keppra, Clorazepate, Tamsulosin and Thiamine. -However, the resident was not at the facility on 5/15/23. He had been sent to the hospital on 5/14/23 and never returned to the facility. Resident #2 had no care plan for falls, seizures or alcohol withdrawal. His baseline care plan, dated 5/9/23, did not address seizures or alcohol withdrawal. The baseline care plan had limited information to care for the resident, and was not signed by the resident. IV.Interviews LPN #7 was interviewed via telephone on 8/15/23 10:15 am. She said she did not recall Resident #2 very well. LPN #7 said when she administered Onestsatan for nausea on 5/10/23 at 8:04 p.m, and it was ineffective, she did not follow up with the physician. She said she passed it onto the next shift in the morning at 6:00 a.m. LPN #7 said she remembered on 5/11/23 in the early morning, the resident had called 911 because he said he was having withdrawal symptoms and he did not have a call light to call the nurse. She said she moved him to a new room with a nurse call light. LPN #7 said she did not ask the resident what withdrawal symptoms he was having. LPN #7 said she had never had a resident in acute alcohol withdrawal or any training in alcohol withdrawal symptoms or what to monitor. On 8/16/23 at 10:22 a.m. a voice message was left for LPN #5, who sent Resident #2 to the hospital on 5/10/23. No return call was received. LPN #4 was interviewed on 8/16/23 at 11:51a.m. He said he had no education or training from the facility on residents in acute alcohol withdrawal. He said he did not know what the symptoms of withdrawal were. LPN #4 said he thought the symptoms were probably isolation and depression. LPN #2 was interviewed on 8/16/23 at 11:55 a.m. She said she had no experience in alcohol withdrawal, no idea what symptoms the resident might have, or what monitoring should have been done. Registered nurse (RN) #1 was interviewed on 8/16/23 at 1:23p.m. She said she had heard of Clinical Institute for Withdrawal Assessment for alcohol (CIWA). She said she thought it was a protocol for how often to do vital signs, neurological checks, and medications needed when a person was withdrawing from alcohol. She said she did not know if the facility had any type of protocol for alcohol withdrawal. LPN # 3 was interviewed on 8/16/23 at 1:25 p.m. She said she had no idea what symptoms to look for when a resident was in alcohol withdrawal. She said she had not had anyone in that situation. The director of nursing (DON) was interviewed on 8/15/23 at 12:03 p.m. She said Resident #2 was admitted into a room without a call light. The DON said Resident #2 was a high fall risk and in alcohol withdrawal with a history of seizures. He was moved to another room with a call light on 5/11/23, after he had called 911 for symptoms of withdrawal and due to no call light in his room. She said the nurse documented maintenance was notified. The DON said she was hired at the end of June 2023, but did not start until the end of July 2023. She said the previous DON (PDON) had approved the resident's admission while still in his first 24 hours of alcohol withdrawal. The DON said she would not admit someone in acute alcohol withdrawal and seizure history as the facility used a lot of agency nursing staff and she did not know if the staff had training in alcohol withdrawal. She said the facility had not been able to establish support resources for the current residents such as AA (Alcoholics Anonymous). The DON reviewed the resident's nursing notes. She said there was no monitoring of the resident for seizures and the only time vital signs had been taken were on 5/9/23 and 5/12/23. The DON said according to the admission notes and nursing notes, the resident was at risk for seizures related to his alcohol withdrawal. She said he had no nurse call light from admission on 5/9/23 through 5/11/23. The DON said he had a cell phone, but she did not know if he had the number to call the facility and get a hold of a nurse if had symptoms or felt he was going to have a seizure. She said he had not called the facility, but called 911 according to the nursing notes. The DON said when PRN (as needed) medication was administered, the reason for the medications and the effectiveness should be documented. The DON said if the medication was not effective the resident's provider should be contacted for further orders. She did not know anything further about Resident #2. The medical director (MD) was interviewed on 8/16/23 at 9:48 a.m. The MD said a nursing facility was not the appropriate place for a person in acute alcohol withdrawal per current guidelines. He said the nursing facilities were not equipped to monitor a resident in acute alcohol withdrawal. He said they were not prepared to follow CIWA guidelines including frequent assessments and vital sign monitoring. He said nursing facilities did not have access to benzodiazepines that may be required to treat withdrawal symptoms. The medical director said it was an inappropriate admission to the facility and Resident #2 was at risk due the facility not knowing alcohol withdrawal protocols. The MD said when he evaluated the resident and reviewed his medical history, he was worried about seizure activity. He said he had him sent to the ER, and he was sent back to the facility with medication orders for withdrawal symptoms and seizures. The MD said he was shocked the facility had taken the admission to begin with. The MD said he was not aware of medications that were not given timely. He said that could have put him at further risk. The OM was interviewed on 8/16/23 at 1:17 p.m. He said the facility had a quality assurance and process improvement (QAPI) committee meeting on 7/27/23. The OM said he was employed by the facility when Resident #2 was admitted , but he did not recall any of the details around his admission. He said the facility had not identified concerns with admissions related to acute alcohol withdrawal or staff training that would be needed. He further said the facility had not completed a facility assessment to identify the care required by the resident population, considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, resources available, or staff training and competencies that would be needed. Cross-reference F838 for facility assessment. The OM said the facility had not checked all the other resident's rooms to ensure there were call lights. He said the facility did random call light audits once monthly and he would provide a copy. A frequent visitor was interviewed on 8/18/23 at 3:44 p.m. She said many residents had expressed concerns with call lights not being answered timely. She said this was an ongoing problem at the facility. The frequent visitor said she had spoken to Resident #2 while he was at the facility. He had expressed concerns with call light response time and late medications. V. Facility follow up On 8/15/23 at 2:45 p.m. the OM provided a document titled Nurse Call Audit dated 5/11/23; no time was documented. The audit listed 12 room numbers. No other information was documented, except a list of room numbers. It was unclear what was audited. room [ROOM NUMBER] was not listed on the audit.

Based on record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#4) of three residents reviewed for catheters of 13 sample residents. Specifically, the facility failed to obtain physician orders, a diagnosis, urology follow up or document catheter care for Resident #4. The resident had a history of liver transplant and was taking immunocompromising (lowered immune system response to fight infections) medications. Observations revealed the resident's catheter bag was lying on the floor in the hallway under his chair. He suffered repeated urinary tract infections with fever and falls. The resident had been to the emergency room twice in the last two months since his admission in May 2023. He had been diagnosed and treated for urinary tract infection (UTI) both times. Additionally, the facility failed to ensure: -Resident #4's catheter was cared for with an aseptic technique; and, -Ensure Resident #4 was placed on enhanced precautions to prevent infection due to an indwelling medical device and being immunodeficient (absence of parts of immune system) following a liver transplant. Findings include: I. Professional reference According to Centers for Disease Control (CDC), Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes retrieved 8/20/23 from: https://www.cdc.gov/hai/containment/faqs (July 2022) in pertinent part, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. II. Facility policy and procedure The Urinary Catheter Care policy, revised August 2022, was received from the operations manager (OM) on 8/16/23 at 3:27 p.m. The policy documented in pertinent part, Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use. Remove the catheter as soon as it is no longer needed. Use soap and water or bathing wipes for routine daily hygiene. Use aseptic technique when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor. Secure catheter with catheter securement device. -A policy for enhanced barrier precautions was requested from the OM on 8/16/23, and not received within 24 hours after the survey exit on 8/16/23. III. Resident #4 A. Resident status Resident #4, age 66, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included liver transplant with immunodeficiency, history of falls and chronic pain. The 5/1/23 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of seven out of 15. He required extensive two person assistance with bed mobility, transfers, dressing and toileting. He required extensive one person assistance with personal hygiene. The assessment documented the resident had an indwelling catheter and did not have a urinary tract infection. B. Observations On 8/14/23 at 11:05 a.m. the resident was in the hallway in a reclined wheelchair. An unidentified certified nurse aide (CNA) was shaving him. The catheter bag was observed face down under the resident's chair with the opening to the catheter resting on the hallway floor. The urine was amber color. On 8/16/23 at 11:43 a.m., Resident #4's room was observed. There was no personal protective equipment (PPE) near or inside the room. C. Record review On 5/7/23 the nursing admission note documented Resident #4 admitted with a foley catheter for urinary retention. On 5/17/23 at 3:00 a.m. the primary care provider (PCP) documented the nursing staff had reported bright red urine yesterday. He documented the urine was pink with sediment today. The PCP documented he would ensure the indwelling catheter was changed every 30 days. -However, there were no orders for the catheter (see below). The PCP documented a note on the resident at least eight times between 5/10/23 and 5/24/23. Each note documented a plan to do a void trial (removal of catheter and assess for retention) in one to two weeks. -No documentation of a void trial was found in the nursing progress notes. On 5/18/23 at 3:08 a.m., the nursing notes documented the resident's urine was very dark in color. At 4:04 a.m. the nursing notes documented Resident #4 on the floor face down next to his bed. No injuries were noted. On 5/24/23 at 4:33 p.m. Resident #4 slipped out of his wheelchair. He complained of back and neck pain. He was sent to the hospital. At 9:18 p.m. the nursing notes documented the hospital had called. Resident #4 had a UTI. He was given intravenous (IV) antibiotics and would be sent back to the facility with orders for antibiotics. On 7/27/23 at 4:39 p.m. the nursing notes documented the resident's catheter had brown yellow discharge with no urine output that shift. The PCP was notified. Oxycodone was given for pain. At 4:41 p.m. the resident had a fever of 101.7 degrees fahrenheit and his pulse was elevated at 102 beats per minute. At 5:08 p.m. the nursing progress notes documented the resident was to be sent to the hospital for urosepsis (serious infection of urinary tract where the bacteria has entered the blood). At 6:02 p.m. the nursing notes documented the urine in the resident catheter bag was odorous with sediment. There was seropurulent (clear drainage that becomes cloudy, milky, varying color) drainage at the opening of the bag. On 7/28/23 at 1:00 a.m. the resident returned to the facility with orders for an antibiotic due to a urinary tract infection. The physician orders were reviewed for August 2023. There were no orders for an indwelling catheter, no diagnosis, no orders for the type and size of catheter, when to change the catheter or catheter care. The treatment administration records were reviewed for May 2023 through August 2023. There was no documentation of catheter care administered and no orders for catheter use including when to change the catheter or what size to use. The indwelling catheter care plan initiated 5/16/23 documented the resident had an indwelling catheter. The care plan documented he was at risk for urinary infections. Schedule a urology appointment. Change the catheter as needed for displacement, infection or obstruction. Check the tubing for kinks with care each shift. Provide enhanced barrier precautions due to the resident being immunocompromised post liver transplant and use of immunosuppressant medications. The staff were to utilize gowns and gloves for high-contact resident care activities such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or wound care and skin care. Monitor for pain or discomfort. Monitor for signs of urinary infection and report to the physician. Catheter care every shift, ensure the catheter is unobstructed, secured and draining. -However, the resident was not on enhanced precautions despite his indwelling catheter and immunocompromised status, had not had a urology appointment, catheter care was not documented, and there were no orders to change the catheter. IV. Interviews Licensed practical nurse (LPN) #4 was interviewed on 8/16/23 at 11:51 a.m. He said the resident was not on any type of enhanced precautions. He looked up the resident's physician orders on his laptop. He said the resident had an indwelling catheter, but he could not find an order for the catheter, catheter care or a diagnosis. LPN #4 said the catheter should have a diagnosis and orders for when to change the catheter and to provide catheter care. The director of nursing (DON) was interviewed on 8/16/23 at 1:53 p.m. with the infection preventionist (IP). When advised of the catheter being on the floor and not secured the DON said that was an issue because the resident just returned from the hospital with an infection, urosepsis. She said she had reviewed the resident's medical record on her computer prior to the interview. She said there was no diagnosis for the catheter, no follow up urology appointment, no orders for the catheter and no catheter care documented. She said the resident was not on enhanced precautions but thought he should be because he had an indwelling catheter and was immunodeficient due to a liver transplant. The IP said the catheter bag on the floor in the hallway increased the resident's risk of infection.

Based on record review and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and that two of three sample residents (#1 and #2) received adequate supervision and assistive devices to prevent accidents. Specifically the facility failed to: -Ensure that resident #1 was transferred in a manner to prevent injuries during a transfer. Resident #1 fell from bed while being repositioned, suffered a broken leg, hospitalization , and pain. -Ensure that the efficacy of safety measures to prevent falls for residents were reviewed, revised and communicated to staff. -Develop effective and appropriate fall interventions for resident #2. The root cause of the resident's fall was not evaluated and interventions were not implemented following the fall resulting in a fracture. -Provide safety measures and housekeeping services in a timely manner to ensure resident safety after urine was discovered on a bathroom floor. The findings include: I. Facility Policies and In-Services 1. Policies The undated Safe Resident Handling and Movement Policy (HCM-587) documented (in pertinent part), "To ensure residents are cared for safely, while maintaining a safe work environment for employees. To accomplish this, direct care staff should not individually lift a resident over 40 lbs (pounds) from a seated position. A care giver must avoid lifting a resident from a horizontal position such as a resident lying in a bed or on the floor. Mechanical lifts must be used to prevent the lifting and handling of a resident as outlined in the resident's Care Plan or as directed by the charge nurse ...Avoid hazardous resident handling and movement tasks whenever possible. If unavoidable, consult with your supervisor ...Training will be completed with all staff initially, then annually, and as required to correct improper use/understanding of safe resident handling and movement. All training must be documented ..." 2. Mandatory In-Services The Mandatory Annual In-services for CNAs (Certified Nursing Aides) documented that lifting and transfer training was done during the month of May and fall prevention during the months of October and November. The Silver Chair Orientation Training for New Employees documented that within seven days of being hired the staff member had to complete the Preventing Slips, Trips, and Falls program and within 14 days of being hired the staff member had to complete the Bed Positioning Protocol. On 6/13/13 the In-service Training Record documented that the nurses from all shifts had signed the roster for in-service training that had been held during the nurses' meeting. The topic was on the introduction of the Resident Transfer Assessment form and the Post Fall Assessment forms. On 8/7/13 the In-service Training Record documented that the staff from all shifts had signed the roster for training regarding the transfer status of a resident. A letter was attached to the rosters, dated 8/7/13, and was labeled Transfer Status. The letter documented the following (in pertinent part), "It is each and every employee's responsibility to know the transfer status of a resident before attempting a transfer. This information is located in the care plan on each resident. Failure to know the status and transferring a resident incorrectly can result in serious bodily injury to both the resident and the staff member. Remember that all Sit to Stand and Hoyer transfers require two staff present ..." On 10/11/13 and 10/12/13 the In-service Training Record documented that staff from all shifts had signed the roster for training on transfers and spills. The 10/11/13 roster had the subject line of (in pertinent part) "Transfers follow No Lift Policy. Use two persons to all Sit to Stand and Hoyer transfers ..." The attached letter labeled Staff In-service regarding transfers/spills dated 10/11/13. The letter documented the following (in pertinent part), "Company policy is for any sit to stand lift or Hoyer lift to use two staff persons to assist in the transfer. This is non-negotiable. If a transfer occurs involving a lift that did not have two persons and an injury results it is considered neglect and the staff member will be turned in to the board of nursing for neglect. (This is a requirement under the abuse regulations of OBRA (Omnibus Budget Reconciliation Act of 1987)). II. Resident Specific Failures 1. Resident #1 Resident #1, a [AGE] year old female, was admitted to the facility on [DATE] with the following diagnoses, per the face sheet; Parkinson's disease, diabetic polyneuropathy, and diabetes mellitus type II. On 9/25/13 the Quarterly Minimum Data Set (MDS) documented that the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated she was cognitively intact for decision-making abilities. The resident was totally dependent with two persons assist with transfers and locomotion on and off the unit. The resident was totally dependent with one person assist with toileting, personal hygiene, and bathing. The resident required extensive assistance of two persons with bed mobility. The resident required extensive assistance of one person with dressing. The resident had no impairment to functional limitation in range of motion to the upper extremities. The resident had functional limitation in range of motion to the one side on the lower extremities. Her primary mobility device was the wheelchair. Record Review: On 10/10/13 at 11:50 a.m., the Assistant Director of Nursing (ADON) provided the original fall reports for review. On 9/21/13 the Incident Report documented that the Certified Nursing Aide (CNA) was educated, but did not describe the specific education given. The report continued to document the following: The family and physician had been notified and the resident had been immediately transferred to the hospital for treatment after a fall. The hand written witness statement attached to the report was written by the CNA, involved in the incident, and documented that he was trying to get the resident ready for a transfer, by sitting her on the side of the bed. He had the gait belt around her waist. He was trying to be more efficient by having the resident ready so when the other CNA arrived they could transfer the resident using the Stand Pivot lift. The resident started to slide off the bed and her foot was under the lift, which he did not realize until he tried unsuccessfully to get her back in bed on his own. The resident told him that she thought she broke her knee after sliding off the bed. He then thought he could not transfer her back to bed due to her weight. He ensured her safety then went and got the nurse (LPN). Once the assessment was done by the LPN, the two CNAs lifted her back into bed using the gait belt. See the Director of Nursing (DON) interview below. On 9/23/13 the Incident Report Follow Up documented that the DON had educated the CNA on "waiting for assistance before helping resident to edge of bed." On 9/23/13 the Post Fall Assessment documented that the fall was an isolated event and the CNA was educated on not moving the resident without another CNA or staff member present. On 9/25/13 the In-service Training Record subject line documented, "Waiting for second staff member before getting resident up to transfer on sit-stand lift. Importance of keeping resident safe. Was spoken to by nurse (LPN) on 9/21/13. Formal in-service done by ADON." The CNA had signed the form during his shift the day of the event. The attached form documented the specifics of the training: "In-service with (staff initials) regarding proper transfer procedure for resident #1. Goal: Keep resident and staff member safe during transfer. A. Do not attempt to move her to sitting position at edge of bed without assistance from another staff member. Leave her in bed until staff member arrives. B. Wait until staff member is present, and then you may assist her to a sitting position in preparation for transfer with sit to stand lift. C. Follow procedure for use of sit to stand mechanical lift." The CNA and the ADON had signed the form. On 9/21/13 the Resident Transfer Form documented that the resident was transferred to the hospital due to a fall with possible fracture to left tibia/fibula. On 9/21/13 at 9:05 a.m., the Nurses' Notes documented, "Spoke with the physician at 0830 (8:30 a.m.), received order to send to hospital for evaluation of left tib/fib (tibia/fibula) for possible fx (fracture). Spoke with spouse at 0835 (8:35 a.m.) to notify him of fall with possible fracture and order to transfer resident for evaluation. Call placed to ambulance company at 0840 (8:40 a.m.) but unavailable for transport. Call placed to another ambulance company, ambulance arrived at 0850 (8:50 a.m.) and departed 0900 (9:00 a.m.) with resident. Resident aware and spouse who is also aware and agrees with plan." On 9/21/13 at 10:43 a.m., the Nurses' Notes documented, "v/s (vital signs); B/P (blood pressure) 138/86, T (temperature) 97.2 (degrees Fahrenheit), P (pulse) 75, R (respirations) 20, sat (oxygen saturation) 97% on room air. CNA was working with resident CNA stated that he assisted resident on the side of the bed, resident slipping off bed while resident's foot stuck under the lift. CNA assisted resident to the floor. Assessment done. Physician and family called. Resident sent to hospital for evaluation." The nurse was a LPN who signed the nurses' note. On 9/21/13 at 8:12 p.m., the Nurses' Notes documented, "v/s; B/P 132/76, p 79, R20, T 98.7, 92% on room air. Resident return from the hospital to the facility approximately at 1800 (6:00 p.m.) accompany by two paramedic and husband. No change in medications, resident has a long leg cast on her left leg due to fracture of left tibia/fibula. Physician notify no new orders at this time, resident ate 100% of diner took all meds as schedule, Oxycodone 5 (five) mg (milligram) given for pain result effective FSBS (finger stick blood sugar) 256 will cont (continue) to monitor." No mention of the resident requiring a Hoyer Lift transfer with assistance of two persons. On 8/20/13 the Physical Therapy (PT) Progress Notes documented that the resident was being trained on sliding board transfers and was tolerating the gym stander. "Pt (patient) will always require assistance for dressing and toileting, but is gaining strength in legs and general mobility." She would be discharged to Restorative Nursing Program in one to two weeks. On 8/29/13 the PT Progress and Discharge Summary documented that the "pt will always require assistance for all transfers and toileting and dressing ...Pt has plateaued in all areas of PT given her limited ability." She was discharged with home exercise program. The Current Level of Function summary documented that the resident's discharge bed mobility supine to sit status was "pt transfers from w/c (wheelchair) to gym stander with slide board and one person max (maximum) assist (assistance), second person mod (moderate) assist." On 9/25/13 the Therapy Screen Form documented "Pt (patient) sustained a fall from bed to floor as CNA was setting up sit-to-stand mechanical lift, which is routine for this pt. Pt sustained left tib (tibia) plateau fx (fracture) and is fitted with a cast from toe to mid thigh with zero degree knee flexion. Pt fitted with elevating foot rest, and is reporting that she is comfortable. No PT (Physical Therapy) warranted at this time." No mention of the resident requiring a Hoyer Lift transfer with assistance of two persons. On 4/16/13 and 7/4/13 the resident scored a ten which indicated a high risk of falling on the Fall Risk Assessment form. On 10/8/13 the resident scored an 11 which indicated a high risk of falling on the Fall Risk Assessment form. On 10/1/13 the Pain Assessment form identified that the resident had pain due to chronic reasons and a broken leg. She had pain every day and it interfered with her sleeping ability. Narcotics were effective for treating the pain. On 10/8/13 the Resident Transfer Assessment form documented that the resident required "total mechanical lift (Hoyer type) for all transfers." The RN MDS Coordinator signed the form. No form found prior to this date. See DON interview below. On 8/4/10 (date onset) the Activities of Daily Living (ADLs) Care Plan documented that the resident required extensive to total assistance with dressing, transfers, bed mobility, locomotion, bathing and toileting due to Parkinson's disease, old back injury with pain, left shoulder pain, and diabetic neuropathy. She was morbidly obese and required a w/c for mobility. The approaches included the following: "- Set up and place necessary equipment within reach ... - ...The resident needs total assist of two for transfers, assist of one for bed mobility ..." On 8/4/10 (date onset) the Impaired Mobility Care Plan documented that the resident was at risk for falls, was unable to walk, and used a w/c for mobility. The resident had Parkinson's disease and daily narcotic use. On 9/21/13 a note documented that the resident had a witnessed slipping off the bed fall, was sent to the ER (emergency room ) for evaluation, returned from hospital and required two person for assistance. The approaches included the following (in pertinent part): "- ...PT and OT (Occupational Therapy) referral as indicated. - The resident requires total assist of two for transfers and bed mobility ... - ...The resident has full leg cast. - Nurse to check CMS (circulation, motion, sensation) on left leg. - The resident is a Hoyer lift two person transfer." The Care Plan did not have documentation reflecting her prior lift needs (before the fall) with the stand pivot machine. On 10/10/13 at 10:57 a.m., the Resident Transfer Need form was observed posted on the cork board in the Nurses' Station. It had not been updated with the resident's current transfer status. The form documented that the resident was a stand pivot transfer when in fact she was a Hoyer lift transfer. The form did not identify if a resident required one to two persons for assistance with transfers, only if they required a mechanical lift for transfers. It was last updated on 8/16/13. No physician progress notes [REDACTED]. Failures: The resident had been sat on the side of the bed with the assist of one person and the resident slid out of the bed, her leg was caught under the lift machine causing the leg to break, which caused the resident to be hospitalized and in pain. The Resident Transfer Needs form posted in the nurses' station was not updated to reflect resident's current status. There was not a documented way for the staff to communicate residents' transfer needs. The record documented the transfer should never have been done without assistance of two persons in the room at that time. The care plan did not reflect the resident's current safety needs including bed in lowest position and fall mats on the floor beside the bed. The care plan did not have the resident's transfer needs prior to the fall regarding the Sit to Stand mechanical lift. Resident Observation/Interviews: On 10/10/13 at 8:36 a.m., the resident was in bed sleeping. The head of bed (HOB) was upright at 90 degrees. The call light was attached to the blankets on her lap. The bed was in the lowest position. The fall mat was up against the wall at the foot of the bed. Observations on 10/10/13 at 8:50 a.m., of the resident transfer showed, two Certified Nursing Aides (CNAs), with the resident dangling above her bed in the Hoyer lift sling. The CNA's used the proper technique to get her positioned into the wheelchair (w/c). Once they had her in the w/c both CNAs took turns placing the resident's legs onto the foot rests. The resident had a full length leg cast to the left leg. The resident groaned during the placement of her left leg on the footrest. Placing the left leg on the footrest appeared to cause the resident pain as evidenced by her moaning. Once the resident's left leg cast was in position they lifted her cast again and placed a pillow under it and on top of the foot rest. The resident reported that the CNAs always used two persons before sitting her up in bed prior to the fall. She reported that she remembered warning the CNA to wait for assistance before sitting her on the side of the bed but he did not listen to her. She reported that she was not able to hold herself up when sitting on the side of the bed without the assistance of both CNAs prior to the fall. She reported that the CNA who helped her sit up on the side of the bed told her that they were in a hurry to get her transferred because they were running behind. She reported that the CNA was trying to get her ready for the transfer and told her that another CNA was coming after he finished with another resident. She reported that she did not remember how long they had been waiting but it felt like a long time. She reported that she could feel herself slipping off the edge of the bed and the CNA could not stop her from sliding off the bed. She reported that she/he (the CNA) did remember the gait belt. She remembered that when it was over she could feel the pain in her left leg when it was broken. She reported that the CNA had left her alone to go get help and when the nurse arrived she had instructed the CNAs to put her in the bed. She reported that the nurse told her that she would be transported to the hospital for evaluation of the left leg. Staff Interviews: On 10/10/13 at 9:56 a.m., the floor nurse, an LPN, assigned to the resident reported that the resident had not fallen, the CNA was with the resident the entire time and had a gait belt around her and he was getting her ready for a shower. She reported that she was the nurse on duty during this event. The shower chair was beside the bed and so was the lift. She stated the CNA had sat the resident up on the side of the bed while waiting for another CNA to help him with her transfer using the lift. The resident's legs spasm and she began to slide off of the bed. The bed was in lowest position when she entered the room so the resident had not fallen. The CNA tried to prevent a hard hit to the floor by using the gait belt to lower her rest of the way to the floor. The nurse reported that she was outside the door and saw most of it happen. She reported that the CNA went down with the resident due to her obesity. She reported that the resident had not fallen and was lowered to the floor. She reported that the resident's left leg got stuck under the lift which was sitting beside the bed and that is how the left leg broke. She reported that she immediately had the CNAs lift the resident back into the bed and then made the calls to get the resident transported out to the hospital for treatment. She reported that she had verbally notified the supervisor but did not feel it was necessary to have the Registered Nurse (RN) assess the resident since the resident was being sent immediately to the hospital for treatment. At 10:40 a.m., the floor nurse reported that they communicated transfer status with the CNAs during report at the beginning of the shift. She reported that in the case of this resident she was transferred by the stand pivot machine prior to the fall and a Hoyer lift after the fall. After the fall, PT evaluated the resident and trained the staff on how to do her transfers. She reported that PT had told the staff that the resident was changed to a Hoyer lift transfer, since she could not bear weight on the left leg due to the fracture and cast. (See PT interview below.) She reported that all staff directly caring for the resident knew where the care plans were kept and could access them when they needed to. She reported that she thought the ADON was responsible for updating the Transfer Forms posted at the nurses' station but the nurses could update if needed. On 10/10/13 at 10:57 a.m., a CNA reported that she received report from her nurse at the start of her shift. She reported that this resident was a Hoyer lift transfer resident and required assistance of two persons. She reported that she knew a resident's transfer needs by the posted Resident Transfer Needs form. It was posted on the cork board in the nurses' station above the computer. The resident was listed under the Sit to Stand category of transferring. The CNA reported that she had worked with the resident and on that unit for more than three years so she knew what her transfer status was prior to the fall and after the fall. She reported that she would not sit any resident on the side of the bed without a second staff member with her if the resident was a two person transfer. She reported that she would not get a resident ready for a transfer without a second staff member present in the room. She reported that she knew where the care plans were and if she had a question about a resident's transfer status she would ask the nurse and not look at the care plans unless the nurse did not know. On 10/10/13 at 11:33 a.m., the Director of Rehab reported that she was not sure if the discharge (d/c) summary would document the training done with the staff regarding the Hoyer lift. She reported that she would have to look into where this would be documented. On 10/10/13 at 12:15 p.m., the Director of Rehab reported that they did not do a full evaluation, on the resident, after her return from the hospital, so they would not have recommended the Hoyer transfer. Nursing would have determined that. She reported that a screen is more of an interview with the resident and a brief look at the resident's status to determine if therapy is needed for the resident. She reported that the resident was not referred on to Restorative services due to her total assistance with all cares. The resident had plateaued by the time she was d/c from PT. On 10/10/13 at 11:50 a.m., the ADON who was also the Restorative Services Director (RSD) reported that the resident had not been on Restorative services in the past or at the present time. She reported that she felt this incident was an isolated event. On 10/10/13 at 12:10 p.m., the Director of Nursing (DON) reported that the Transfer Assessment was a new form that they initiated annually but found out a few months ago it was to be done quarterly. They started the form sometime in 12/12. The nurses on the floor were responsible for updating the Resident Transfer form posted on the units. On 10/10/13 at 12:25 p.m., the DON reported that they identified that there was a delay when a resident went from PT to Restorative services so they met every Thursday to facilitate the transition. This was started last Thursday. She reported that nursing in coordination with therapy would have determined a resident's transfer status. She reported that in this case nursing would have determined that the resident required a Hoyer lift, but she (the DON) would make sure that during their QA process they would solidify the process for determining the transfer status with change of condition and not only annually, on admit, and quarterly but also as needed. She reported that she would have expected the transfer status to be documented on the care plan to reflect the stand pivot machine used prior to a fall and updated after the fall when the resident was to be a Hoyer lift transfer. She reported that she would expect the nurses to update the care plan as needed and the MDS Coordinator was responsible for establishing and updating the care plans. She reported that she would expect the nurse to update the Resident Transfer Needs form that is posted at the nurses' station with any changes, but would make sure Quality Assurance (QA) addressed the need to designate one individual with the responsibility of updating the form. She reported that she understood that the CNAs used the form, but since she had stable staff luckily this had not caused a problem in the past, with staff knowing what a resident's transfer status was. She reported that in the instance of this resident, and her accident, that the CNA was educated on waiting for assistance until moving the resident. She reported that in the past the resident was able to sit at the edge of the bed prior to another CNA helping with the actual transfer, but in this case it did not happen. On 10/10/13 at 4:33 p.m., the DON reported that they did not identify this fall as a system failure but as an individual problem which was corrected with the educational piece with the CNA. She reported that she could see the issue with the failure of communicating the resident's transfer status to the CNAs and nursing staff. She reported that she would be working on trying to solidify this issue. On 10/10/13 at 4:38 p.m., the CNA, who was the second CNA to assist with the transfer during this event, reported that he remembered the CNA asked him to help him with the resident but he was working with another resident and asked for a few minutes. He reported that a few minutes later he was told the resident was on the floor. He reported that he was told by the CNA that she was on the floor. He reported that it was the same time as the nurse was being told. He reported that he was not completely sure but he believed that the gait belt was used to put the resident to bed. He reported that the stand pivot machine was in front of the resident when he entered the room. He reported that if a person is a two person assist then it should have been two staff members before the transfer was started. According to the first CNA he was just prepping her for the transfer. He reported that he would not have done the two person assist transfer without the second person being in the room. On 10/10/13 at 4:58 p.m., the CNA, who was directly involved during the fall, reported that before he started moving the resident he told the other CNA that he needed help with the transfer. The CNA was in another room helping another resident. He stated, "It was taking him a while so I decided to put the sling under the resident until he could help me with the transfer." He reported that he put the gait belt on her before he sat her up to assist with sitting her up on the edge of the bed. He reported that he turned around to grab the sling once he had her sitting on the edge of the bed and that was when the resident said she was slipping. He reported that normally he would not start any transfer without two CNAs being present. He reported that he tried to reposition her in the bed but she kept sliding to the floor. He reported that once she was on the floor the resident told him her knee popped. He reported that he put a pillow under her leg and tried to get her as comfortable as possible until he could go get the nurse. He reported that he opened the resident's door and saw the nurse a couple of doors down in the hallway at her medication cart so he told the nurse what had happened during their walk to the resident's room. He reported the other CNA was passing by and that's when he was told of the fall and then all three went into the resident's room together. He reported that the stand pivot machine was right in front of her but behind him before the fall. He reported that he noticed the one foot was on top of the lift and the other foot was on one of the screws on the lift when he reached around to move the bed and the lift out of the way to make her comfortable. He reported that after the nurse gave the 'ok' to move the resident they used the gait belt and double armed her back into bed. He reported that the resident did not complain of any extra pain during the manual transfer to the bed. He reported that he put pillows under her leg to make it more comfortable for her. He was really behind and made a mistake to get her ready and thought the other CNA would have been in there sooner. He reported that if he had to wait any longer he would have put the call light on to remind him he needed assistance or asked the nurse for assistance. He reported that he would not have left her side. He reported that he never left her side during the entire time of having her sit up on the edge of the bed. He reported that when he turned around to grab the sling before he knew if the resident was sliding out of the bed. He reported that he was not sure if she was sitting too close to the edge of the bed. He could not think of any other way for her to slide that fast off the edge of the bed unless she was close to the edge of the bed. He reported that he had not in the past sat her up on the edge of the bed without assistance but thought he would be able to assist the resident safely. On 10/10/13 at 5:35 p.m., the Nursing Home Administrator (NHA) reported that she would look for the Hoyer lift physician order [REDACTED]. She reported that she would provide the physician order [REDACTED]. 2. Resident #2 Resident #2, a [AGE] year old male was admitted to the facility on [DATE] with a re-admission of 9/17/13. His admission [DIAGNOSES REDACTED]. On 9/24/13 the Re-admission Minimum Data Set (MDS) documented the resident's Brief Interview for Mental Status (BIMS) score was 13 which indicated a minimally impaired cognitive status. The resident required extensive assistance of two persons with bed mobility, transfers, toileting and bathing. The resident required extensive assistance of one person with dressing and personal hygiene. He had no impairment to functional limitation in range of motion to upper extremities but did have impairment to one side on lower extremities. The resident's primary mobility devices were walker and wheelchair (w/c). Resident Observation/Interviews: On 10/10/13 at 8:05 a.m., the resident was standing up beside his bed without assistance using a front wheeled walker (FWW). He was unsteady when walking and had the wheelchair (w/c) in his path to the bathroom. He was half dressed missing his pants and shoes. He had stocking feet; dress socks not non-skid socks. He had not used his call light to call for assistance. He wanted to talk after breakfast. A CNA was asked to check on the resident. The CNA was observed assisting the resident getting ready for the day and transferred him into the w/c. At 9:00 a.m., the resident allowed the interview. He reported that he fell after walking back to his room from the dining room after breakfast (on one other day), using his FWW. He reported there were no wet floors and no obstacles. He reported that he lost his balance and fell and broke his left hip. He reported that when he went to the hospital they had to repair the left hip since it was fractured. He reported that he had always walked with a FWW and was independent. He reported that he would not ask for assistance now unless he thought he could not move without assistance. He ended the conversation because he was anxiously awaiting therapy. Record Review: On 9/14/13 at 7:44 p.m., the Nurses' Notes documented (in pertinent part), "Pt (patient) sent out to Hospital after a witnessed fall at 1812 (6:12 p.m.), Pt was unable to flex left leg and was c/o (complaining of) left hip pain 10/10. Called 911, ambulance arrived approximately 1830 (6:30 p.m.) to transport to ED (Emergency Department). Called in report to the ED and spoke with Charge RN (Registered Nurse)..." On 10/10/13 at 2:30 p.m., the Assistant Director of Nursing (ADON) was asked a second time for the post fall investigation. She reported that she was still looking but could not locate it. She reported that she remembered doing the report after the resident's fall. On 9/17/13 the Resident Transfer Assessment form documented that the resident did not require assistance with transfers and needed a gait belt and supervision for transfers since he had a hip replacement. This form specified that the resident was independent and required assistance. The undated Resident Transfer Assessment form documented that the resident did not require assistance with transfers and he had a hip replacement. On 9/17/13 the Fall Risk Assessment form documented that the resident scored eight which indicated a moderate risk of falling. On 9/17/13 the Pain Assessment form documented that the resident had moderate intermittent pain to the left hip. He r

Based on record review, staff and resident review, the facility failed to ensure that two of six sample residents (#1 and #3) received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility: -Failed to ensure resident #3 received the appropriate care and services in a timely manner. The failures contributed to the resident's 8/6/12 hospitalization with urosepsis, acute [MEDICAL CONDITIONS], coagulopathy, non-anion gap metabolic acidosis, [MEDICATION NAME] with failure to thrive, [MEDICAL CONDITIONS] reflux disorder, constipation, pneumonia, urinary tract infection, and bilateral [MEDICAL CONDITIONS] - occlusive on the right leg and non-occlusive on the left with the right leg [MEDICAL CONDITION]ly acute. The resident subsequently passed away on 8/14/12 in the hospital. -Failed to appropriately manage pain in a timely manner for resident #1, when he rated his pain at a 9 out of 10 (on a scale of 0 - 10, with 10 being the worst pain.) The findings include: 1. Resident #3 According to the face sheet, resident #3, age 75, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of hydro[DIAGNOSES REDACTED], disorder of biliary tract, obesity, adjustment disorder with depression, [MEDICAL CONDITIONS], muscle weakness, hypertension. The resident was responsible for herself. a. Resident Status The 8/6/12 discharge minimum data set (MDS) assessment, documented the resident's memory was intact, she rejected care daily, she was totally dependent on staff for most of her activities of daily living (ADLs), she was occasionally incontinent, she was on scheduled pain medication, she was 67 inches tall, she weighed 152 pounds, and she experienced weight loss, but was not on a physician-prescribed weight loss regimen. b. Care Plan The 1/24/12 care plan documented the risk for complications including [MEDICAL CONDITION], stroke, heart and kidney failure due to a [DIAGNOSES REDACTED]. The goal was to minimize the risk of complications [MEDICAL CONDITION] the next review. The approaches were: - administer [MEDICATION NAME] as ordered, hold for SBP (systolic blood pressure) less than 110, - monitor for side effects including: cough, diarrhea, dizziness, headache, tiredness, document and notify MD (physician) as needed, - exercise as tolerated, - monitor for s/s of complications including: dull headaches, dizzy spells, nosebleeds, chest pain, SOB (shortness of breath), confusion, numbness/tingling, nausea, document and notify MD as needed, - BP (blood pressure) and P (pulse) as ordered and PRN (as needed), - notify MD for systolic BP greater than 170 or diastolic BP greater than 110, - provide regular diet as ordered, - resident had significant BP changes and was being observed closely for changes in BP. c. Record Review/Interviews Record review and interviews, revealed several examples of inadequate monitoring, lack of full assessments and lack of securing physician intervention for changes in the resident's condition. Specifically: 1. The 6/25/12 nursing note at 5:39 p.m. documented, "Res(ident) found on toilet unresponsive. Res unable to respond to voice or sternum rub. While taking res's apical pulse res regained responsiveness at 5:45 p.m. At this time VS (vital signs) (BP - blood pressure) 158/72, (T - temperature) 97.4 (Fahrenheit), (P - pulse) 98, (R - respirations) 22, (oxygen saturation level) 91% on RA (room air). Res A&O (alert and oriented) x 2-3 (to person, place and/or time). Res does not know what happened. Spoke with MD (physician). No new orders. Instructed to monitor res. Family notified. Will continue to monitor." The next nursing entry was dated 7/8/12, more than two weeks after the unresponsive episode. The Director of Nursing (DON) was interviewed on 8/28/12 at 1:45 p.m. The DON said the nursing documentation, "does not reflect monitoring her." 2. The untimed 7/8/12 nursing note documented, "Resident (without) any episodes of dizziness or unresponsiveness for this shift. Denies pain/discomfort also. 'I feel pretty good now ... I fainted earlier.' Denies pain/discomfort, also per resident's roommate, resident was talking to herself & when asked, she doesn't remember any of that. Slept about six hours for this shift & A&O x 3 at this time. VS: (BP) 127/61, (P) 99, (T) 98.7, ? 19 & (oxygen saturation) 90% on room air. We will continue to monitor." However, there was no evidence of nursing monitoring, and no evidence the physician was aware of the [MEDICAL CONDITION] until the next day. During the interview with the DON on 8/28/12 at 1:45 p.m., the DON said the physician was called the next day about dizziness, however, nursing did not call on 7/8/12. 3. The 7/9/12 nursing note at 2 p.m. documented, "VS: (BP) 108/68, (P) 72, (T) 98.1, ? 21, (oxygen saturation) 92% RA. Placed call to (physician) because of resident's complaint of dizzy spells. (Physician) ordered routine labs to be drawn tonight and discontinue [MEDICATION NAME] 7.5 mg when supply exhausted." The subsequent note at 6:30 p.m., documented the laboratory technician could not draw blood from the resident during three trials and another technician from the lab would come to draw the labs; the nurse encouraged the resident with intake of fluids. The subsequent note was on 7/10/12 at 1 p.m. and documented, "VS: (BP) 103/68, (P) 55, (T) 96.8, ? 20. Res cont(inues) on CoC (change of condition) monitoring. No c/o (complaints of) dizziness voiced this shift. Res extremely depressed. (Refused) breakfast. Sleeping all shift. Has privacy curtains pulled all the way around her. (Lab tech) here @ noon to try and redraw blood. Phlebotomist unable to draw. Will return to redraw tonight. Trying to encourage fluids (with) res. She is not receptive. Has only consumed 360 cc H2O from this nurse. Spoke (with) Social Services on need to get more aggressive with psychotherapy. Refused lunch, had only couple sips of broth. Lying in bed @ this time. Denies pain or discomfort. No distress observed." Even though two lab technicians had been unable to draw the resident's blood and it was almost 24 hours after the physician's orders [REDACTED]. The subsequent note was at 10 p.m. and documented, "VS: 132/60, 78, 18, 97.2, 93% RA. Resident continues on constant monitoring for change of condition. Encouraged intake of fluids. Resident eat 25% of supper. (Lab tech) could not draw blood from resident. Another tech will come tonight and draw blood. Resident sleeping at this time and denies any discomfort. Will cont(inue) to monitor." However, there was no evidence the physician was aware the labs were still not drawn. The subsequent note was on 7/11/12 at 4:30 a.m., and documented, "VS: 118/67, 80, 98.4, 20, 90% RA. Res con(tinues) on CoC charting. [MEDICATION NAME] mg PO (orally) for c/o [MEDICAL CONDITION] (with positive) result. Denies pain or discomfort. (No) c/o dizziness. Drank little H2O at non (night). Blood draw is still pending. Phlebotomist has not come yet. Res is sleeping good at this time. (No) SOB or distress. Call light (with)in reach. Encouraged her to use call light and agreed. Cont(inue) to monitor." Even though up to this point, the resident denied pain, discomfort or dizziness and her vital signs were stable, there was no evidence the physician was aware the labs were still not drawn. 4. The 7/11/12 nursing note at 9:10 a.m. documented, "Resident continues to be monitored frequently for change of condition. Placed call to (lab) to draw labs ordered stat. Resident encouraged intake of fluids. Resident had an emesis one time and complained of severe nausea. Administered [MEDICATION NAME] suppository for nausea. Resident on 2 L (liters) of oxygen. VS: 120/70, 50, 97.1, 93% on 2L O2 (oxygen). Will cont(inue) to monitor." Although the resident had by then experienced emesis and severe nausea, there was no evidence the physician was aware of that, and no evidence to show nursing staff monitored the resident during the evening. During the interview with the DON on 8/28/12 at 1:45 p.m., the DON said she would expect the physician to be called about the emesis. She said she would have to check on the timing of the order because labs were ordered. 5. The 7/12/12 nursing note at 2 a.m., documented the resident was alert and oriented to person/place/time, she denied pain, she ate 50% of supper, drank her protein shake and took meds without difficulty. There was no nausea or vomiting. However, the notes showed the resident, "Had loose stool x 2 (with) brownish minimal (illegible). [MEDICATION NAME] given for c/o [MEDICAL CONDITION] (with positive) result. Res is sleeping quietly (with) even and unlabored breathing at this time. Continue to monitor." There was no evidence the physician was aware of the two loose stools. The subsequent note at 9:30 a.m., revealed the resident refused to eat breakfast and she continued to refuse to drink fluids. During the interview with the DON on 8/28/12 at 1:45 p.m., she said she would not expect the physician to be called about one episode of loose stools, but would expect the physician to be called if there were two episodes of loose stools in the same shift. The DON explained that a nurse would use his/her experience and could call the next day. She also expected a nurse would call if blood or melena were in the stool. The DON said the documentation, "could give more details ... something going on with this resident ... will look at chart." 6. The 7/12/12 nursing note at 10:15 a.m., documented, "Resident complained of nausea and had emesis. Administered [MEDICATION NAME] suppository." There was no evidence found or provided to show the physician was aware of the nausea and emesis for this date. 7. On 7/16/12, seven days after the original order for lab work, a physician's assistant (PA) note documented there was no awareness of nausea, vomiting or dizziness. The PA also wrote new orders to, "start [MEDICATION NAME]" and "call (the PA) in 3 days (with) report (about) [MEDICATION NAME]. Is it improving mood/appetite." However, there was no evidence the PA was contacted three days later with results. Moreover, even after the resident had been refusing the [MEDICATION NAME] until August 2012, there was no evidence the PA was aware of the resident's refusals until that following month. During the 8/28/12, 1:45 p.m. interview with the DON, she said, based on what she read in the nursing notes, "They (nursing) did not call." 8. On 7/23/12, then seven days after the PA visited, the resident continued to experience nausea and had loose stools. An untimed nursing note documented, "VS: 91/56, 76, 97.8, 18, (oxygen saturation) 92% on RA. A&O x 3. Up in w/c (wheelchair) to DR (dining room) for meals (with) good appetite. C/o nausea @ (8 p.m.), relieved by PRN [MEDICATION NAME] administered. Cont IFU (incident follow up) scrape to ? arm. No bleeding or (signs/symptoms) infection noted. Will cont to monitor. Loose stool x2. Held laxative this shift." There was no evidence the physician was aware of the two episodes of loose stools. 9. The 7/25/12 nursing note at 9:30 p.m., documented, "VS: 101/58, 82, 97.2, 21, 90% RA. Resident was in the dining room at supper time and complained of slight dizziness. Resident was put to bed by nurse aide and denied more dizziness. Vital signs WNL (within normal limits). Resident eat very little for supper. Resident in bed right now and denies any discomfort. Will notify incoming nurse to monitor resident." There was no evidence the physician was aware of the resident being dizzy, no evidence the resident was subsequently monitored and there were no subsequent nursing notes regarding the resident's status. 10. The resident was seen by a psychologist on 7/30/12, and the psychologist's notes revealed the resident experienced nausea and vomiting on this date. However, there was no evidence to show nursing monitored the resident or that the physician was notified about the emesis. There were no nursing notes on that date. During the 8/28/12, 1:45 p.m. interview with the DON, she said it would be reasonable to expect a nurse's note about the resident's nausea and vomiting on that day, if the nursing staff knew about it. The DON added she did not know if the psychologist conveyed the information to nursing staff. 11. The 8/1/12 nursing note at 1:30 p.m., revealed the resident had two new skin tears on her left upper extremity and she complained of right knee pain. The physician was contacted and ordered a stat x-ray of the right knee and a physical therapy evaluation (after the resident fell ). PA notes dated 8/1/12, documented, "Fall - x-ray to (right) knee (negative for) fx (fracture). Res(ident) denies pain. She is concerned B/C (because) she is unable to bear wt (weight) (request PT/OT eval and treat). Skin tears to (left) arm steri-stripped. (No signs/symptoms of infection). Discuss importance of taking various steps to improve her strength to prevent further falls ... [MEDICAL CONDITION] - grandson able to encourage res(ident) to begin taking her [MEDICATION NAME] (1st dose today). Discussed (with) res(ident) the need for her to let us help her & reminded her that by continuing not to eat/drink can ultimately result in her demise. She agreed that prior to refusing future meds she will discuss (with) me 1st. Monitor for improvement (with) [MEDICATION NAME]." 12. The 8/1/12 nursing note at 11:10 p.m. documented, "Rec(eived) result of X-ray, informed res. Res wanted to go to ER for eval. Explained to res x-ray was showing no fracture. Res demand to go. Placed a phone call to (physician) @ (3:45 p.m.) (with no) call back. Res family member grandson wanted to call 911 to take res to the hospital. RN (registered nurse) supervisor involved/took over. Res grandson calmed down afterward. Placed phone call to (physician) office at (5 p.m.), (with no) call back. Called again @ (6:05 p.m.), got new order for scheduled [MEDICATION NAME] & Tylenol schedule & ice to affected area. Meds administered as scheduled. Res c/o N/V (nausea/vomiting), [MEDICATION NAME] given (with positive) result. C/o ? leg pain, controlled (with) scheduled pain meds. Skin tears to (L) hand (with no) s/s (signs/symptoms) of infection. Pleasant & cooperative (with) care." The resident, who was responsible for herself, wanted to go to the hospital for the pain in her right leg, and she complained of nausea/vomiting. However, the resident was not sent to the hospital per her request and subsequent documented demand to go. Moreover, there was no evidence to show the resident's leg was assessed, given her ongoing complaints of pain. 13. The 8/5/12 nursing note at 7:30 p.m. documented, "BP 88/56 (lower than her usual), T 98.6, P 95, R 19, O2 (oxygen saturation level) 80. Went to check on (resident #3) earlier, she refuses to use O2. Sats 83-88 on RA. Refusing to (elevate) HOB (head of bed), c/o nausea, has small emesis, gave [MEDICATION NAME] PRN as ordered (with) effect. Talked to her about her refusal to take her foods, fluids & meds. She says she's fine. Roommate not particularly helpful, kept interjecting that she's not getting better & on wrong medicine. Resident still not eating, taking sips of H2O. Skin pale, eyes sunken & dark, bruising noted to arms which is not new." There was no evidence found or provided to show the physician was made aware of her low BP, her low oxygen levels, the emesis with ongoing nausea, her refusal of oxygen use and refusals to take her foods, fluids and medications, and the overall appearance of the resident. During the 8/28/12, 1:45 p.m. interview with the DON, she said she did not have an answer regarding no evidence the physician was made aware of the resident's change in condition - and the PA was in to see her. The DON said she would check into this. 14. The 8/6/12 nursing note at 12:45 a.m., documented the resident BP continued to decline; "VS: 64/42, 47, 97.6, 18, Ox sat = 90% (RA). Res observed lethargic. She is refusing to drink any fluids she states, 'I haven't peed all day.' She denies any pain, states she is weak, and 'a little dizzy, water makes me nauseous.' Call placed to (physician) on-call provider, spoke to (other physician), reported res current condition, orders rec(eived) to send res to the ER for eval & tx (treatment) due to low BP (and) the lethargy. Call placed to (ambulance) to transport to (hospital) per res request. Call placed to res granddaughter (name) and grandson (name) notifying them of res transfer to ER." d. Other Interviews: A resident who wished to remain anonymous was interviewed on an undisclosed date and time in an effort to protect the resident's identity. The anonymous resident (AR) explained noticing resident #3's "dramatic loss of weight and she wasn't eating. I would see her order one thing, then another and she wouldn't eat ... leave (the dining room) ... staff encouraged her back (to the dining room, but not with eating) ... the facility had to be aware of her weight loss and not eating ... I was feeling someone should notice and do something." The AR commented about the nurses, "How nurses weren't aware (of resident conditions) is beyond me ... not enough (nurses), or not attentive enough." The AR said in general, things had gotten "very bad here ... I'd just throw everybody (staff) out and start from scratch ... everybody in general ... all act like don't know bad is going on, or don't do anything about it ... (upper management) kept cutting back." An interested person (IP) who knew resident #3 was interviewed on 8/14/12 around 8 a.m. The IP said resident #3 experienced a decline in her condition for which the facility did not adequately assess and treat to prevent dehydration and weight loss. The IP said resident #3 was eventually hospitalized in early August 2012 with kidney failure, dehydration [MEDICAL CONDITION]. The IP recalled in early 8/12 when the House Supervisor, a registered nurse (RN), "got two inches away from (resident #3) grandson's face and said, 'You can't call 911 ... (you cannot) take her to the hospital ... you have no right ... if you do, they're just going to bring her right back here.'" The IP said the House Supervisor also told resident #3's roommate, resident #2, "it was none of her business," when resident #2 expressed concern about resident #3 and inquired about intravenous fluids for the resident who was not eating or drinking enough. A regular visitor (RV) to the facility who knew resident #3 was interviewed on 8/22/12 at 1:50 p.m. The RV said she had been concerned about resident #3's declining condition. The RV said it was his/her perception resident #3 was not getting the care she needed; staff would drop off her meal trays and not provide set up or encouragement for resident #3 to eat. The RV said resident #3's roommate, resident #2, and family encouraged resident #3 to go to the hospital when her condition declined; resident #3 would vacillate and finally agreed to go to the hospital. The RV said resident #3, "was well, then not well, and now she's dead." A day shift certified nurse aide (CNA) was interviewed on 8/28/12 at 12:25 p.m. The CNA said she remembered resident #3 and had taken care of her for several months. She said she thought resident #3 had given up, that she did not want anything, did not want to get up and did not want to eat. The CNA said she would take a room tray to resident #3 and she did not want it, "if I encouraged her, she would report me ... can't force it." The CNA said for a while she took resident #3 in her wheelchair to the dining room, but it did not last. She said she gave resident #3 Ensure and yogurt and the resident would drink/eat for a while. The CNA said resident #3 was vomiting and "I think she was doing it herself ... her roommate (resident #2) said she (resident #3) stuck her (own) finger down her throat. We couldn't force her ... she gave up." The facility's registered dietitian (RD) was interviewed on 8/28/12 at 10:55 a.m. The RD said interventions for weight loss would be documented in the resident's medical record and on the care plan. The RD said she talked to resident #3 frequently and discussed her in the weekly NAR (nutritionally at risk) meeting. The RD said, to suggested interventions, resident #3 would say "sure" at times, other times "no, I won't." The RD said the resident did not want to get out of bed and this was discussed with the physician's assistant. She said, "We could not find a food she (resident #3) would accept ... failure to thrive (diagnosis) before admission ... [MEDICATION NAME] didn't work ... [MEDICATION NAME] didn't work ... she (resident #3) wasn't interested in life ... plenty of things in the kitchen as alternates, she said 'no' ... in her case, we did everything we can." The Physician's Assistant (PA) was interviewed on 8/28/12 at 11:50 a.m. The PA said resident #3 was self isolating and her depression was so severe. She said some of the medications that were tried made her "feel yucky," others did not work, and some there was a little improvement. She said a psychologist was involved who made recommendations. The PA said the resident's [MEDICATION NAME] was low and they, "couldn't get her to eat." She said the resident was weak and very easily persuaded. The PA added the labs did not show the resident was dehydrated and, "we did what we could." The resident had been found unresponsive on 6/25/12, and then continued to experience intermittent dizziness with nausea/vomiting and was refusing food and fluids. By 8/1/12, more than a month after she began experiencing these symptoms, the (cognitively intact) resident requested, then demanded to be sent out to the hospital. However, her request/demand was not acknowledged and by 8/5/12, the resident had declined to the degree whereby, when EMS was called and arrived at the facility, the resident required transport to an acute care setting in closer proximity. Specifically, an 8/6/12 nursing note, at 1:10 a.m., documented, "EMT notified nurse res BP too low to transfer to (hospital), they are taking her to (another hospital)." e. Hospital Records Review of the hospital records, revealed the resident was admitted for vomiting and [MEDICAL CONDITION]. The history of present illness noted, "Vomiting. This started 3 days ago and is still present. It was abrupt in onset and has been constant. She has had nausea. The patient has had vomiting. The vomiting has occurred several times. No diarrhea or abdominal pain ... The illness is described as severe ... atelectasis is seen within the right lower lobe ... persistently hypotensive despite 2L IVF (intravenous fluids) [MEDICATION NAME]. CXR (chest x-ray) showed pneumonia ... 75 (year old female) with pneumonia,[MEDICAL CONDITION], acute [MEDICAL CONDITION] UTI (urinary tract infection) with septic shock ... she also had fallen down on 8/1/12, while being weighed ... bilateral lower extremity [MEDICAL CONDITION], occlusive on the right leg and non-occlusive on the left. Right leg [MEDICAL CONDITION] is likely acute ... COR status. The patient has a MOST form in the chart from the nursing home, that declares her DNR/DNI, but when discussed with the patient she said she wanted everything done and so she has made a full COR ... acute [MEDICAL CONDITION] and oliguria. The resident subsequently passed away on 8/14/12 in the hospital. 2. Resident #1 Sample resident #1 was a [AGE] year old male, admitted to facility on 5/18/12 with diagnoses, according to his face sheet, that included [MEDICAL CONDITION], joint pain, muscle spasm, dysphagia (difficulty swallowing), lack of coordination, debility, general muscle weakness, abnormal posture, depression and [MEDICAL CONDITION] bladder. According to his most recent Minimum Data Set (MDS) an admission assessment completed on 5/25/12 he had a brief interview for mental status (BIMS) score of 15 indicating he was cognitively impaired; he had no physical behaviors noted; had verbal outbursts 1-3 days; refused cares 1-3 days; required physical assistance of one person for bed mobility and transfer (that was upgraded to physical assist of two on 6/10/12); he self catheterized and was only occasionally incontinent of bladder and bowel; and required total assistance of one person with bathing and extensive assistance of 1-2 persons for personal hygiene. He was documented to be paraplegic and while he did have a history of a TBI ([MEDICAL CONDITION]), not on the MDS. His pain was documented to be almost constant, and at the time of the assessment, he rated it a 6/10. He also had a [DIAGNOSES REDACTED]. a. Resident Interview Resident #1 was interviewed off site (in the hospital) on 8/20/12 at approximately 2:00 p.m. The resident said he had returned to the facility from the hospital back on 8/9/12. He complained that he had not been given any pain medication when he returned, at approximately 3:00 a.m. He stated he had been transferred to theER on [DATE] after an appointment with his neurologist at approximately 6:30 p.m. He was seen for abdominal pain and diagnosed with [REDACTED]. He stated, "I asked (name of nurse at facility) for pain medication and sleeping pill. She said the ER nurse told her I had been given [MEDICATION NAME] and [MEDICATION NAME] at 2 a.m. That was not true. I kept telling her I had gotten my regular pain medication at 10 or 11 p.m. Not two a.m.! She just didn't care." The resident stated he was not given his ordered sleeping pill, and said, "No, she said it was too late...like I could help what time I got back! She just didn't care. She made me wait like two or three hours before I got pain meds...and no sleeping pill." Regarding his pain level at the time, he stated, "It was 9 out of 10. And I told her (the nurse at facility) that too!" b. Record Review Record review revealed that resident #1 returned to the facility on [DATE] at approximately 3 a.m. from a local emergency room (where the resident had been treated and released for abdominal pain diagnosed as constipation). Nurse's Notes read in pertinent parts: - On 8/9/12 0300 (3:00 a.m.) "Res. Returned from (name of hospital) ER. Per (name of nurse), RN reports (resident #1) was constipated. Had lg. BM at hospital. NNO (no new orders)...Asking for pain meds. RN at (name of hospital) reports resident had [MEDICATION NAME] & [MEDICATION NAME] approx. at 0210 (2:10 a.m.)... - On 8/9/12 0400 (4:00 a.m.) Res. Cont to ask for pain meds & sleeping pill. Re-informed (resident #1) it was too soon for pain medications, as RN @ (name of hospital) reported she had given him pain meds at approx. 0210. (Resident #1) stated, "She only gave me [MEDICATION NAME]." This writer reminded (resident #1) he was also given [MEDICATION NAME] & he would need to wait for next dose." - On 8/9/12 at 0500 (5:00 a.m.), Res medicated with [MEDICATION NAME] 5 mg & [MEDICATION NAME] 4 mg p.o. (by mouth) for c/o (complaint of) pain @ 9/10 (nine out of 10). Res states, "I'm not going to sleep because I did not get my sleeping pill." I informed (resident #1) that since he arrived back at (name of facility) at 0300, it was too late to give sleeping pill." c. Staff Interview RN/House Supervisor - 1st Interview On 8/21/12 at approximately 3:30 p.m., the admitting nurse for resident #1 on 8/9/12, registered nurse/house supervisor, (RN/HS) was interviewed. She stated she had been employed at the facility for five and a half months as the HS and that she worked both the 2 p.m.-10 p.m. shift and the overnight 10 p.m. - 6 a.m. shifts. The interview was conducted in the presence of the facility Regional Nurse Consultant (RNC) and another surveyor. The entire medical record of resident #1 was available for the RN to review during the interview. Regarding the resident not having been medicated when he stated his pain level was a 9/10 on 8/9/12 at 3:00 a.m., she stated, "I remember it well. He asked for pain medication as soon as he returned from the ER. I had gotten report from the RN at the hospital. She stated she had given (resident #1) [MEDICATION NAME] and [MEDICATION NAME] at 2:10 (2:10 a.m.). It hadn't even been an hour so of course I couldn't give him anything!" The RN stated the resident continued to complain that his pain level was a 9/10 an hour later, at 4:00 a.m. Moreover, she said he continued to state the same level of pain (9/10) two hours later, at 5:00 a.m. The RN said she had not received any paperwork from the ER that documented any medications they had administered. She stated she had not contacted the hospital to confirm that resident #1 had received [MEDICATION NAME] and [MEDICATION NAME] at 2:10 a.m. d. Hospital Records On 8/22/12 at approximately 12:30 p.m., the medical record documentation requested for the resident's ER visit on 8/8/12-8/9/12, was received and reviewed. It documented the following medications were administered to resident #1: - "8/8/12 at 2210 (10:10 p.m.) [MEDICATION NAME][MEDICATION NAME] 25 mg tablet ([MEDICATION NAME] cap/tab) p.o. once. - 8/8/12 at 2210 (10:10 p.m.) [MEDICATION NAME] INJ 1 MG/ML (injectable) ([MEDICATION NAME] INJ) IVP (intravenous push)/once. - 8/9/12 at 0120 (1:20 a.m.) [MEDICATION NAME]/APAP 5-325 mg tab ([MEDICATION NAME] 5-325 mg tab) p.o. once." e. Staff Interview of RN/HS - 2nd Interview On 8/23/12 at approximately 11:30 a.m., the RN/HS was interviewed for a second time. The interview was again conducted in the presence of the facility Regional Nurse Consultant (RNC) and another surveyor. The 8/2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. After her review, she agreed the documentation showed resident #1 had been medicated with a 25 mg of [MEDICATION NAME] and 1 mg of [MEDICATION NAME] at 10:10 p.m. She also agreed the resident had been given one [MEDICATION NAME] 5/325 mg at 1:20 a.m. She acknowledged the resident had not received two strong narcotics one hour prior to discharge from the hospital, and had instead received one milder narcotic two hours before discharge. She stated, after reviewing his facility records, that resident #1 normally received twice, that dose of [MEDICATION NAME], every four hours while at the facility. The RN could offer no explanation as to why she had not confirmed the doses given at the hospital. She further stated she did not give the resident a sleeping pill when he first requested it at 3:00 a.m., because it was too late. She acknowledged that considering that he had been in the ER for over seven hours, she could have given it to him. She stated that when she did medicate the resident at 5:00 a.m. with [MEDICATION NAME] 4 mg she also gave him [MEDICATION NAME] 5 mg. According to the facility MAR, and confirmation of the signed physician's orders [REDACTED]. When asked about the [MEDICATION NAME], she stated, "I gave it because he was so mad when he finally got his [MEDICATION NAME]. He was cursing and yelling." f. Other Staff Interviews Both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed after the RN/House Supervisor later on 8/23/12. The NHA deferred all questions regarding resident care policies to the DON. The DON reviewed all of the pertinent records regarding resident #1 and his level of pain upon return to the facility from theER on [DATE]. Based on the documentation from the hospital she agreed that resident #1 should have been medicated for pain as well as [MEDICAL CONDITION]. When the DON was informed of the findings that the medications administered to the resident while in the ER, even though he complained of severe pain, she stated the RN absolutely should have obtained documentation from the ER. The DON stated that she expected nurses to give the medication ([MEDICATION NAME]) as ordered and that it was inappropriate to give it for behaviors. She further stated the physician should have been called if the resident had behaviors they could not manage.

Based on observations, record review and staff interviews, the facility failed to ensure that one resident (#1) of six sample residents received adequate supervision to prevent accidents. Specifically, resident #1 was able to access his medications, (those not being used), and he was subsequently found unresponsive and sent to the ER where he was diagnosed as having overdosed. The findings include: The facility failed to appropriately secure the (controlled) medications to prevent unauthorized access to the medications. After the resident overdosed, he required hospitalization . Cross reference F204 and F309. Resident #1 was a [AGE] year old male, admitted to facility on 5/18/12 with diagnoses, according to his face sheet, that included [DIAGNOSES REDACTED], joint pain, muscle spasm, dysphagia (difficulty swallowing), lack of coordination, debility, general muscle weakness, abnormal posture, depression and neurogenic bladder. Resident Status According to his most recent Minimum Data Set (MDS) an admission assessment completed on 5/25/12 he had a BIMS score of 15 indicating he was cognitively intact; he had no physical behaviors noted; had verbal outbursts 1-3 days; refused cares 1-3 days; required physical assistance of one person for bed mobility and transfer (that was upgraded to physical assist of two on 6/10/12); he self catheterized and was only occasionally incontinent of bladder and bowel; and required total assistance of one person with bathing and extensive assistance of 1-2 persons for personal hygiene. He was documented to be paraplegic and he did have a history of a TBI (traumatic brain injury) which was not documented. His pain was documented to be almost constant, and at the time of the assessment it was a 6/10 (on a scale of 0 - 10 with 10 being the worst pain). Family Member Interview Prior to entrance at the facility on the afternoon of 8/15/12, the family member of resident #1, that was notified when he was sent to the hospital, stated she was, "so scared he was gonna die." She stated she had spoken with (resident #1) and he insisted that, 'yes,' he took those pills (out of the med room) to prove they were accessible to most residents and not just for himself. The family member stated she did not believe he was suicidal. She did express her concern that the facility had not secured his medications. "Anyone could have gotten to them ...that is their fault." Investigation Review On 8/15/12 one surveyor entered the facility at approximately 1:00 p.m. The Regional Nurse Consultant (RNC), the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were all interviewed immediately due to the severity of the issue. Multiple staff throughout the facility were interviewed regarding any contact they had with resident #1 on 8/9/12. Many stated no, or that they had seen him in passing, etc. None of the staff reported observing the resident acting in any way unusual or making any statements about wanting to harm himself. Record Review On 8/15/12 record review revealed an incident occurred on 8/9/12 which resulted in the resident requiring hospitalization for a drug overdose. Specifically; Nurse's Notes The House Supervisor/Registered Nurse (HS/RN) documented in the Nurse's Notes, in part: -"8/9/12 1520 (3:20 p.m.) C.N.A. to SDC (Staff Development Coordinator) office asking for 'help.' Reporting res is unresponsive & there are pills on the floor & pill bottles all over. When this writer & SDC arrived in res room, res had eyes open and was moving his arms, moving head side to side. SDC RN stayed with res. This RN ran to St 3, called 911. After 911 call, placed call to Dr. (name of PCP) urgent line. Spoke with (name of nurse), LPN to report res sent 911 to hosp for possible OD of pills. This was reported to (name), PA for Dr. (name of PCP). -Approx. 1535 (3:35 p.m.) Noted fire dept here. Directed to resident's room. During conversation with fire dept. (resident #1) stated, 'I didn't take any pills.' All pills and pill bottles bagged & given to fire dept. There were 4 bottles of Warfarin, 1 bottle of doxepin, 1 bottle of Ambien (with 15 pills in the bottle) & 1 empty Seroquel bottle. Pills on the floor and in the cup also placed in bag. (Resident #1) stated at that time, 'If you would have given me my f***(expletive) meds last night, this wouldn't have happened.' 1540 (3:30 p.m.) EMTs arrived, transported to (name of hospital). -At 1700 (5:00 p.m.) Call rec'd from (name of resident #1's family member). Asking this writer, 'What happened, where did he get the pills?' Explained to (family member) I had no idea where (resident #1) got the pills. I stated I cannot give her answers because I did not know. The matter is being investigated. (Name of family member) yelled, 'I could lose my son! I'm calling the state. You better get me some answers. Bye.' & hung up. -1815 (6:15 p.m.) Placed call to (name of hospital). Spoke with (name of nurse) RN. Reports resident is admitted for overdosing. Reported (resident #1) was given Narcan & woke up. Reported initially (resident #1) was tachycardic (very fast heartbeat), started on saline drip (IV at ER). Sats (oxygen saturation levels) dropped to low 80s (normal is high 90s-100%). Now resident is awake and uncooperative. Also stated (resident #1) told hospital staff that the staff at (facility name) gave him pills ...also reported med bottles were from (name of) Pharmacy in (another state) & were dated April 2012." Interviews: Staff Interview/CNA (first on scene) On 8/21/12 at approximately 11:30 a.m., the certified nurse aide (CNA), first on the scene when resident #1 was discovered, was interviewed on the phone. Her written statement was reviewed as well. She stated she had been employed at the facility for seven months as a CNA and that she usually worked the 2 p.m. - 10 p.m. shift. The interview was conducted in the presence of the facility Regional Nurse Consultant (RNC) and another surveyor. The CNA stated that on 8/9/12 at approximately 3:15 p.m., she entered resident #1's room and found him to be unresponsive. She stated there were pills all over the floor, the bed and in his water pitcher. There were also several different pill bottles lying about. The CNA went looking for help. She stated she ran in to the Charge Nurse (an LPN - Licensed Practical Nurse) and told her that resident #1 was unresponsive. The CNA stated she went one way and the Charge Nurse went the other. The CNA found the House Supervisor/RN in the office of the SDC (Staff Development Coordinator) and advised them of the situation. Written statement of Charge Nurse Unit 1 The charge nurse on duty on 8/9/12 on Unit 1 stated (per her written statement) that resident #1 did come to Unit 1 at approximately 12:30 p.m. and asked to use the phone. She told him yes and he came in the Nurse's Station/Med Room. She did confirm that she left the resident alone and went to perform a task elsewhere. When she returned he was gone. She also stated she had only become aware of a specific box under the Nurse's Station desk a few days before. When she asked the HS/RN what it was, she was told it was, "a box of stuff (resident #1) was admitted with." HS/RN On 8/15/12 at approximately 2:30 p.m., the admitting nurse on 8/9/12, (HS/RN) was interviewed in the presence of the facility Regional Nurse Consultant (RNC) and another surveyor. She stated she had been employed at the facility for five and a half months as the HS and that she worked both the 2 p.m. - 10 p.m. shift and the overnight 10 p.m. - 6 a.m. shifts. The entire medical record of resident #1 was available for the RN to review during the interview. Refer to Nurse's Notes above, the original documentation by the same RN. She re-read her documentation and stated she stood by it. The RN maintained that she did not know how the resident wound up with the pills that he turned in to facility when he was admitted . Record review showed that the same RN completed the admission assessment and paperwork when resident #1 was admitted . She stated she could not be sure how the pills got under the nurse's station desk and that she was not aware of the box. SDC (Staff Development Coordinator) On 8/15/12 at approximately 3:45 p.m., the SDC was interviewed. The SDC stated they (she and the RN) immediately went to the room of resident #1 and found him in his bed. The SDC stated he moaned some and turned his head side to side. The SDC took charge and directed the HS/RN to go call 911. The SDC instructed a male CNA to obtain vital signs. She stayed with resident #1 until the paramedics transported the resident to the hospital. The SDC confirmed that the HS/RN called 911 and the Charge Nurse was preparing the transfer paperwork. The paramedics arrived, assessed and stabilized the resident prior to transfer to the ER (emergency room ). She also stated that she determined there were actually pill bottles in that box at the nurse's station, when she collected it a few moments later (after the overdose incident). Review of Staff Statements There were numerous staff interviews conducted. While several nurses confirmed having seen the box in the Nurse's Station, none of them stated they actually knew what was in the box. Only the CNA on duty, the day resident #1 was admitted , recalled there being different medications in the box, that she turned in to the admitting nurse (per her written statement). Resident Interview Resident #1 was interviewed off site on 8/20/12 at approximately 2:00 p.m. Regarding the overdose, the resident stated, "I did not take any of those pills. I was not trying to commit suicide. If that's what I wanted I would have done that right after the accident that paralyzed me." He said when he was admitted back in May 2012, the nurse took the pills from him, explaining he could not self administer them without the physician's permission and a safety assessment. He stated that was not a problem for him, so he gave the medications to the CNA that worked with him at the time he was admitted to the facility. He stated that he had noticed the same box (with some other items in it) under the Unit 1 Nurse's Station desk. The resident was originally admitted to Unit 1 and later transferred to Unit 3. He stated he had seen the box there many times, since his admission, and he decided to take the medications so he could prove that the facility had not stored them correctly and that anyone could have gotten in to them over the past three months. He stated that he went back to the Unit (1) and asked to use the phone. He stated the nurse on duty said it was ok and let him use the phone. He said she left after a few minutes, so he took the pills and went back to his room. The resident stated the facility had over medicated him and that was why he was unresponsive. The resident had received a number of sedating medication, at medication pass, the morning of 8/9/12 between 5 a.m. and 9:30 a.m. A basic drug toxicity screen was run at the hospital, however, it did not specify any particular prescription medications to be screened for. Review of Hospital Records On 8/20/12, after interviewing the resident at the hospital, his medical records were reviewed. The toxicology test results were: -Drug Screen: Ph within normal limits at 6.5 -Alcohol: Negative -Cocaine: Negative -THC (Marijuana): Negative -Amphetamines: Negative -Barbiturates: Negative -Benzodiazepines: Positive* -Opiates: Positive* -PCP: Negative Facility record review showed the resident had received two Benzodiazepines (diazepam/Valium and lorazepam/Ativan) and two opiates (hydrocodone with acetaminophen (Norco) and oxymorphone/Dilaudid) on 8/9/12. They were administered at the facility as follows; per the August 2012 MAR (Medication Administration Record): -8/9/12 5:00 a.m.: Dilaudid 4 mg and Valium 5 mg; -8:30 a.m.: Norco; -9:30 a.m.: Ativan The resident also received Zofran (an anti- emetic) at 1:30 p.m. on 8/9/12. While it was given for nausea, some of the common side effects include dizziness, drowsiness and fatigue. The ER admission record showed the resident was un-arousable upon arrival and had an elevated heart rate. He was administered Narcan (a drug used to counteract the effect of drugs and awaken someone who has overdosed). He came around after approximately two minutes. He was admitted for psychiatric follow up as it was not clear to ER physician whether the resident had deliberately attempted to harm himself or not. The resident continued to deny he took any of the pills he was found with. DON Interview The Director of Nursing (DON) was interviewed after the RN/HS later on 8/23/12. She stated that the facility policy was to ask if a resident had any medications with them, during the admission process. She also stated that unless the resident was assessed to be safe to self administer their medications and the physician authorized it, any medications were to be confiscated. She stated they should have been locked up securely, and the narcotics needed to be under double lock. She acknowledged that having any type of medications accessible was a potential danger to residents and stated she was not aware of the box. She further stated after discussion with the Regional VP, the Regional Corporate Nurse and the NHA, it was determined this was not neglect and therefore not reportable. According to the Occurrence Reporting program manager at the department of health, the event should have been as a Drug Diversion. Given that prescription drugs were accessible by a large number of the residents, that increased the risk of someone taking them, whether it was resident #1 or someone else.

Based on record review and interviews, the facility failed to have evidence that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin, involving one of 45 sample residents (#15) were thoroughly investigated to rule out abuse and/or mistreatment and that steps were taken to protect the resident from further injuries. Specifically: On [DATE], [DATE] and [DATE], resident #15 sustained injuries of unknown origin that were suspicious by location and appearance. There was insufficient evidence that these injuries had been thoroughly investigated to rule out abuse and/or mistreatment, and that steps were taken to protect the resident from further unexplained injuries. On [DATE] at 4:40 a.m., the resident was discovered with a left leg hematoma (10x6 cm) that, when touched, caused the resident to yell out, as well as a bruised and swollen left ankle. Per emergency and hospital records, the resident also sustained a forehead hematoma as well as left elbow and shoulder contusion and a femur fracture. The pain associated with these injuries was not adequately addressed (cross-reference F309) and these injuries of unknown origin were not thoroughly investigated to rule out abuse and/or mistreatment. Findings include: A. Facility Abuse Policy 1. The facility policy and procedure for "Investigation of Allegations of Abuse" read in pertinent part: Purpose: It is the policy of this facility that reports of abuse are promptly and thoroughly investigated. The purpose of the investigation is to determine the circumstances surrounding the alleged incident and the evidence available to make a final determination. Procedure: a. A review of the completed incident report. b. An interview with the person(s) reporting the incident. c. Interviews with any witnesses to the incident. d. An interview with the resident if possible. e. A review of the resident's medical record. f. Interviews with the staff members having contact with the resident during the period/shift of the alleged incident. g. Interview with resident's roommate, family members, and visitors. h. Written statements regarding the alleged incident will be obtained from all persons involved. The facility's "Pathway to Alleged Abuse" read in pertinent part: -Interview witnesses, employees in the area of the incident, at least three interviewable residents for whom the alleged perpetrator has cared for and at least three other co-workers. -Review nursing and social services follow-up documentation of resident status. -In-service staff on abuse protocol as soon as possible. 2. The facility's undated "Injury of Unknown Origin" policy documented the facility was "to investigate injuries of unknown origin to determine possible causes of (the injuries)." The "Pathway to Investigation of Unknown Injuries" was: -"Complete and Incident Report...on any injury..." -"If the cause of any injury (including skin tears, bruises, fractures, etc.) is unknown, complete an Injury of Unknown Origin Investigation..." -"Try to determine time when injury occurred by interviewing the following and document: 1) Resident, if possible, 2) Any employee who cared for the resident in the time frame, 3) Any family or visitor who visited resident in the time frame." -"Try to determine possible factors by assessing: 1) Transfer techniques, 2) Environmental concerns..., 3) Medication regime, 4) Resident combative behavior." -"If causative factor is determined, implement interventions to prevent reoccurrence." -"If abuse is suspected follow abuse protocol." -"Review all investigations monthly at QA&A (Quality Assessment and Assurance) meeting." Attached to the policy was the "Injury of Unknown Origin Investigation" which included the following: -Requested information regarding the resident's activities, equipment, environment, behaviors, restraints, fingernails and medications. -Included space to document observations of staff performing transfers, names of staff/family/visitors to be interviewed, outcome, whether or not abuse was suspected, and preventive measures. 3. Staff Interviews regarding policy and procedure On [DATE] at 10:45 a.m., the social service co-directors #1 and #2 were interviewed. They stated that when an abuse was brought to the facility's attention, the Director of Nurses (DON) completes the investigation and the social service department does the resident investigation. They stated they interview at least three residents and ask questions related to the incident. Sometimes they called the family. Other times, the DON called the family. On [DATE] at 11:25 a.m., the nursing home administrator (NHA) was interviewed about the above policy and procedures. She stated that every morning, the investigations from injuries of unknown origin (incidents) were brought to the morning meeting. She stated that the reports were reviewed to ensure the reports were capturing the data, and identifying any problems. She stated a resident was followed between 48 to 72 hours depending on the injury of unknown origin. She stated that she tracked the trends of injury per resident. B. Failure to Thoroughly Investigate Injuries of Unknown Origin Resident #15, [AGE] years old, was admitted to the facility on [DATE]. According to the ,[DATE] Computerized Physician order [REDACTED]. 1. Resident Status a. Record Review According to the most recent Minimum Data Set (MDS), dated [DATE], the resident had cognitive impairments. She required extensive assistance of two + people with bed mobility, transfers. She was total dependence with the help of one with personal hygiene. She had a behavior symptom not directed at others (verbal/vocal symptoms like screaming). Review of the resident's care plan revealed a care plan for her assistance needs (see above MDS). The resident was care planned for showers twice a week. Interview with Registered Nurse #1 on [DATE] at 10:00 p.m., revealed the resident was last showered the evening of [DATE]. There was no care plan for behaviors, verbal or physical, no documentation on the care plan for assistance with activities of daily living that indicated the resident was combative with cares or resistive to cares. According to the ,[DATE] CPO, the resident received routine medications for pain (Tylenol and [MEDICATION NAME]) and prevention (aspirin). She also had one PRN "as needed" order for pain (Tylenol). [MEDICATION NAME] was ordered for "yelling out." b. Staff Interviews -CNA #5 was interviewed on [DATE] at approximately 2:30 p.m. The CNA stated s/he regularly assisted with the resident's personal care. S/he stated that the resident was unable to move independently and required assistance of two for transfers and bed mobility. -CNA #2 was interviewed on [DATE] at approximately 9:23 p.m., and stated the resident was total care with all ADLs except for feeding. -The Assistant Director of Nurses (ADON), interviewed on [DATE] at approximately 10:45 a.m., and confirmed the resident was a two-person assist. -The Registered Nurse #1 stated on [DATE] at 10:00 p.m., that the resident could not and did not walk. 2. History of unexplained bruising - suspicious by location and appearance. Insufficient evidence of thorough investigations or steps to prevent further, similar injuries a. [DATE] Review of the [DATE] nurses' notes documented the resident was found with bruising on the resident's left inner and outer thigh; two small bruises one measuring 4 x 1.5 cm and one measuring 1.0 cm in diameter on the inner thigh and one on the outer thigh a bruise measuring 2.0 diameter. Record Review: The facility's investigation of resident #15's bruise was reviewed. Even though the resident interview sheet documented "unable to say" to the question of "Can you tell me what happened," the facility failed to follow their investigative policy to further investigate causation and to rule out abuse and/or mistreatment. Specifically, review of the investigation report revealed: -There was no documentation of interviews with all staff members having contact with resident #15 during the period of the alleged incident. -There was no documentation of interviews with the resident's roommate, or family members/visitors regarding the incident. There were no interviews with residents that could be interviewed based on their cognitive status. -The outcome of the investigation was "...res combative while giving care from CNAs (certified nurse aides) pushes CNAs away, bruises easily." Administrative review documented on [DATE], "no evidence of abuse or injury.." Review of the resident's [DATE] and [DATE] behavior tracking sheets documented the resident did not have any physically aggressive or combative behaviors. In addition, see above; the resident was not care planned for such behavior. There were no updates to the resident's care plan to prevent further injury and no plan to review/observe staff interactions with the resident. Interview: In an interview with the ADON on [DATE] at approximately 10:45 a.m., she confirmed the outcome of the facility's investigation, based on interviews with staff that cared for the resident, was that no abuse occurred. However, she was unable to explain how abuse and/or mistreatment was ruled out. She also confirmed the resident required a two person assist with cares. b. [DATE] Review of the [DATE] bruise of unknown origin investigation documented the CNA notified nursing of bruising to both upper arms of the resident, "3 bruising strikes" (lines). Resident unable to say what happened. Cooperative with care. The [DATE] nurses notes also documented the resident was cooperative with care. Record Review: The facility's investigation of resident #15's bruising was reviewed. Even though the resident was unable to say what had happened, the facility failed to follow their investigative policy to further investigate causation and to rule out abuse and/or mistreatment. Specifically, review of the investigation report revealed: -There was no documentation of interviews with all staff members having contact with resident #15 in and around the period of time the bruising was discovered. -There was no documentation of interviews with the resident's roommate, or family members/visitors regarding the incident. There were no interviews with residents that had the cognitive ability to be interviewed. The outcome of the investigation was "...Is there was reason to suspect abuse? No," and, "Was the cause of the injury determined? No." The administrative review of the above investigation on [DATE] documented, "asked for more staff interviews to track cause of injury, look back at least one shift ..XXX,[DATE] investigation complete." Thereafter, three staff members were interviewed. Staff members were to be re-educated on safe procedures for transfers and evidence of abuse and neglect on [DATE]. Review of the [DATE] in-service documented the staff were trained on proper transferring; however, it was not specific to resident #15. The in-service was about transfers in general. There was no care plan (onset of entire plan [DATE]) for skin problems and there were no updates to the resident's care plan to prevent further skin injuries. There was no plan to review/observe staff interactions with the resident. Review of the behavior tracking in and around [DATE] showed no documentation of aggressive or combative resident behaviors. Interview: On [DATE] at approximately 10:45 a.m., during an interview with the ADON, she said the resident was found with a bruise on both of her upper arms; each arm contained three strike marks. The investigation showed the resident was to have "supportive care by CNAs when combative." The ADON said the resident was combative and that staff were in-serviced on transfers. -The ADON stated that behavior tracking was not usually reviewed during the facility's investigation. She confirmed, after reviewing the behavior tracking, that the resident did not show any sign of combative behaviors. -The ADON stated that she could not visualize the bruises of being suspicious. She said she had not assessed the bruises. c. [DATE] Review of the [DATE] nurses notes documented the CNA notified nursing of a bruise on the resident's right breast area measuring 4.5 x 1.6 cm. The resident was unable to explain what happened. Record Review: The facility's investigation of resident #15's bruise was reviewed. Even though the resident was unable to say what had happened, the facility failed to follow their investigative policy to further investigate causation and to rule out abuse and/or mistreatment. Specifically, review of the investigation report revealed: -There was no documentation of interviews with all staff members having contact with resident #15 in and around the period of time when the bruising was discovered. Three of the four staff members interviewed were not assigned to take care of the resident. -The employee interview from RN #3 dated [DATE] documented three CNAs cared for the resident on [DATE] for the 2:00 p.m. to 10:00 p.m. shift. The written report documented the injury occurred on [DATE] approximately 2:30 p.m. -The employee interview dated [DATE] documented by CNA #1 "Were you assigned to care for the resident? No" Who cared for the resident while you were on break? Was off the last two days." "Is the resident combative? No" -The employee interview dated [DATE] documented by unidentifiable CNA documented, "Were you assigned to take care of the resident? No How often do you care for this resident? Only when here." -CNA #2 employee interview dated [DATE] documented, "Were you assigned to take care of the resident? No. How often do you care for this resident? When I am assigned to her but today no." -There was no documentation of interviews with the resident's roommate, or family members/visitors regarding the incident. There were no interviews with residents that were cognitively ability to participate in an interview. The outcome of the investigation was "...Is there was reason to suspect abuse? No" and, "Was the cause of the injury determined? No." The investigation documented no evidence of abuse. Resident has no fear of other resident or staff. There were no updates to the resident's care plan to prevent further injury and no plan to review/observe staff interactions with the resident. And, review of the behavior tracking in and around [DATE], showed no documentation of aggressive or combative resident behaviors. In an interview with the ADON on [DATE] at approximately 10:45 a.m., the ADON said the resident was discovered with a bruise on her left breast and she was unable to say what had happened. She stated that throughout the investigation, the nurse stated the resident was combative. The ADON and surveyor reviewed the behavior tracking in and around [DATE]; the ADON confirmed after looking at the ,[DATE] - [DATE] behavior tracking that the resident was not combative. She stated that she was unable to explain how the resident received the bruises. 3. Unexplained injuries [DATE] that were significant by description (hematomas, contusions, fracture) a. Nurses' and Nurse Practitioner Notes [DATE] Nurses' notes, dated [DATE] at 4:40 a.m., read, "this writer (received report) by CNA (certified nurse aide) (name of CNA) who found bruise and hematoma on (resident #15's) left leg (behind of knee). Size of (hematoma) 10x 6 cm and bruises swollen on her left ankle. The resident refused to (allow) check ROM (range of motion) of leg and yelling out when touching leg. Skin warm and intact. No open area. Medicated Tylenol 650 mg PO (by mouth) for pain." Nurses' notes, dated [DATE] at 3:30 p.m., read in pertinent part, "...upon observation clients left leg [MEDICAL CONDITION], posterior patella area and posterior calf and distal posterior femur area has a faint purple color to it. Pedal pulse present, low ROM left leg. Client flinches in pain when leg touched. Leg supported on 1 pillow. Client medicated with 650 mg PO [MEDICATION NAME]. I continue to monitor client for s/s (signs and symptoms) decline." A note by the Nurse Practitioner dated [DATE], read in pertinent part, "the resident had left knee and posterior ecchymosis, [MEDICAL CONDITION], left hip tender, left lateral ankle with [MEDICAL CONDITION] ...Assessment and Plan:1. Distal femur fx (fracture) - displaced acute - send to ER (emergency room )" CNA #2, who worked on [DATE] (evening shift) stated in an interview on [DATE] at 9:23 p.m., that in addition to the swelling and bruising of the resident's leg and ankle, she (CNA #2) observed the resident had a bruise on her forehead that "looked fresh." b. Emergency Medical Services (EMS) and Hospital Records EMS Report: The EMS report dated [DATE] documented small hematoma noted above left eye and possible bruising to L eye brow. Hospital Record: Review of hospital history and physical dated [DATE], documented in pertinent part: -"..About 4:30 (a.m.) yesterday, she started having increased pain about her left lower extremity and swelling as well as her left elbow and left shoulder..." -Physical exam: "Head: (slight bruise over left eyebrow. Small forehead hematoma.) ... Extremities left thigh: moderate tenderness, mild swelling and medium sized ecchymosis located in the lower thigh. Best motor response : localizes to pain ... " Lft femur X ray (impression: 1 supracondylar [MEDICAL CONDITION] femur.) The x-rays were interpreted by the radiologist ...no associate injuries noted at nursing facility, but EMS (emergency medical services) appreciated small forehead hematoma and slight bruising over eyebrow... " -"Diagnostic impression (page 3 of 3 of history and physical dated [DATE]) documented in pertinent part: (1) Left distal femur fracture (per radiology, in addition to the fracture, severe osteopenia); (2) Left elbow contusion, rule out occult fracture; (3) Left shoulder contusion; (4) [MEDICAL CONDITION]; and (5) dementia. Further record review revealed the resident was transferred from the hospital to the another facility and expired on [DATE]. Review of a report by the county coroner, dated [DATE], revealed the cause of death was [MEDICATION NAME] trauma and pneumonia. 4. Review of the facility's response to the discovery of resident #15's hematomas, contusions, and fracture revealed the facility failed to thoroughly investigate injuries discovered [DATE] to rule out abuse and/or mistreatment and failure to manage the resident's pain associated with these injuries. a. Investigation Failures Record Review: Review of the facility investigation of the resident's injuries of unknown origin on [DATE] revealed that the outcome of the investigation revealed there was no reason to suspect abuse. The cause of the injury was not determined. The administrative review documented, ",[DATE] unable to determine cause of injury, resident at hospital/dc ,[DATE] no further info available. Review of investigation does not reveal cause of fx (fracture) or indicate abuse." The facility failed to follow their investigative policies to rule out abuse and/or mistreatment, even though the resident was unable to say what had happened. Specifically: -There was no documentation of interviews with all staff members having contact with resident #15 in and around the time the resident's injuries were discovered. -There was no documentation of interviews with the resident's family members/visitors, the resident's roommate, or other residents able to be interviewed regarding the incident. -There was no documentation the state agency was notified of the discovery of the resident's injuries. -Review of behavior documentation for [DATE] through [DATE], documented no aggressive or combative behavior. The resident had episodes of "yelling papa." There was no documentation that the lack of documented behaviors was considered in the facility's investigation when ruling out abuse and/or mistreatment. Interview: The ADON was interviewed on [DATE] at approximately 10:45 a.m. The ADON stated that the resident was sent to the hospital and that after she reviewed the investigation, she was unable to determine the cause of fracture or determine that the findings indicated abuse. The NHA interviewed on [DATE] at 11:25 a.m. -She said the facility investigation revealed the resident was not abused, and per the facility investigation, her injuries were related to combativeness and [MEDICAL CONDITION] which caused a spontaneous fracture. And, because there was no abuse, the injuries were not reported to the state agency. -She stated that the resident had other bruises of unknown origin; however, the resident was combative. She said "most" of the staff working on [DATE] had been interviewed during the investigation. b. Failure to address the resident's pain associated with injuries - Cross-reference F309; care and services CNA #2 was interviewed on [DATE] at 9:23 p.m. The CNA stated that s/he worked the evening shift on [DATE], but had not worked [DATE]. S/he stated that the resident was up for dinner and s/he stated the resident said in Spanish to him/her, "my leg (is) hurting" and it "hurts so much." S/he stated the resident kept saying this over and over. CNA #2 stated s/he reported the resident's complaints to LPN #1. CNA #2 stated the resident used to scream; however, this scream was different. "Something was definitely wrong." Registered Nurse (RN) #1 was interviewed on [DATE] at 10:00 p.m. RN #1 stated that s/he worked the night shift and that s/he worked the night of [DATE] and early morning of [DATE]. -S/he stated that at about 5:00 a.m. on [DATE], she was notified by a CNA that the resident was found with a bruise on her left leg. S/he stated that when s/he went to check on the resident, she found a bruise on her posterior (behind her) left knee. -S/he said when s/he assessed the resident, the resident had "guarded" her leg and would not allow him/her to touch the leg; the resident grabbed the RN's hand. CNA #3 was interviewed on [DATE] at approximately 11:00 a.m. S/he stated that on [DATE] during the day shift, s/he recalled the resident having pain. S/he stated when the resident was rolled from side to side, she was in pain. S/he stated the resident did not want her leg touched. S/he stated that the resident had a usual behavior of screaming, however, the screaming that day was a lot more; it seemed more than usual. CNA #5 was interviewed on [DATE] at approximately 2:30 p.m. The CNA stated that s/he came in between 5 to 6:00 a.m. on [DATE]. S/he stated the resident "screamed in pain" when she was changed and every time she was moved from side to side during incontinence care. CNA #4 was interviewed on [DATE] at 9:35 p.m. CNA #4 stated s/he worked the evening shift on [DATE], and the resident was crying out in pain. S/he stated that she reported it to the nurse.

Based on observation, record review and interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being, of two (#15 and #92) out of 45 sample residents. Specifically: -Resident #15's pain was not adequately managed, contributing to the resident experiencing unrelieved leg pain from a fracture. -Resident #92's blood sugar orders were not followed. Findings include: 1. Resident #15, age 98, was admitted to the facility on [DATE]. According to the 11/11 Computerized Physician order [REDACTED]. According to the most recent Minimum Data Set (MDS), dated [DATE], the resident had cognitive impairments. She required extensive assistance of two+ people with bed mobility and transfers and was totally dependent with the help of one with personal hygiene. She had a behavior symptom not directed at others (verbal/vocal symptoms like screaming). The MDS indicated the resident had experienced pain within five days of the completion of the assessment. a. Pain Management Plan The CPO included an order for [REDACTED]. The 11/11 MAR documented, "...if the pain is unrelieved on current regimen, contact physician and document on PRN (as needed) Medication sheet and nursing notes: 0= no pain; 1-3 = little pain; 4-6 = moderate pain; 7-8= severe pain; 9-10= very severe pain." The resident's CPO dated 11/11 and recent Physician Telephone Orders revealed current orders for pain control included: -Tylenol 500 mg twice daily. -[MEDICATION NAME] 5 mg-500 mg twice a day for pain. -Tylenol 325 mg two tablets every four hours as needed for pain. b. Change in Condition 11/12/11 The resident's nurses' notes were reviewed and revealed the resident experienced a change of condition on 11/12/11, resulting in pain in the resident's left leg. -Nurses' notes, dated 11/12/11 at 4:40 a.m., read, "this writer (received report) by CNA (certified nurse aide) (name of CNA) who found bruise and hematoma on (resident #15's) left leg (behind of knee). Size of (hematoma) 10x 6 cm and bruises swollen on her left ankle. The resident refused to (allow nurse to) check ROM (range of motion) of leg and yelling out when touching leg. Skin warm and intact. No open area. Medicated Tylenol 650 mg PO (by mouth) for pain." -Nurses' notes, dated 11/12/11 at 7:00 a.m. read, in pertinent part, "Notified (name of doctor) by VM (voice mail) and called her son and left VM." -Nurses' notes, dated 11/12/11 at 1:50 p.m. read, in pertinent part, "remain on IFU (incident follow-up) for bruise on left posterior knee and left ankle. The pain increases with ROM, (nurse practitioner/NP) notified and TO (telephone order) received for stat (immediate) left knee x-ray..." -Nurses' notes, dated 11/12/11 at 3:30 p.m., read in pertinent part, "...upon observation client's left leg [MEDICAL CONDITION], posterior patella area and posterior calf and distal posterior femur area has a faint purple color to it. Pedal pulse present, low ROM left leg. Client flinches in pain when leg touched. Leg supported on 1 pillow. Client medicated with 650 mg PO [MEDICATION NAME]. I continue to monitor client for s/s (signs and symptoms) decline, esp s/s [MEDICAL CONDITION] (especially signs and symptoms of [MEDICAL CONDITION]. ..client currently resting on her bed." -Nurses' notes dated 11/12/11 at 3:35 p.m., read, in pertinent part, "son and daughter advised of client's change of condition." -Nurses' notes dated 11/12/11 at 4:25 read, in pertinent part, "family here and notified son x-ray here to do x-ray. -Nurses' notes dated 11/12/11 at 6:10 p.m. read, in pertinent part, "x-ray report available and NP (nurse practitioner) for MD (physician) in house. Advise NP of change of condition. Order received to transport to (name of hospital) for further f/u (follow up) ...client currently asleep ..." -Nurses' notes dated 11/12/11 at 11:00 p.m. read, in pertinent part, "left facility at 2000 (8:00 p.m.)." The NP note, dated 11/12/11, documented the resident had arthralgia (joint pain). The note further documented the resident had left knee and posterior ecchynosis, [MEDICAL CONDITION], left hip tender, left lateral ankle with [MEDICAL CONDITION] ...Assessment and Plan:1. Distal femur fx (fracture) - displaced acute - send to ER (emergency room ) ....goal is comfort ..." c. Failure to assess and manage resident #15's pain 1. Assessment Notwithstanding the nurses' notes above for 11/12/11, review of the 11/11 Medication Administration Record (MAR) from 11/1/11 to 11/12/11 through the 10-6 shift documented the resident's pain as a "0" pain level. Review of the pain evaluation (part of the MAR) also documented 0 = no pain. 2. Medication Administration Record Review of the resident's MAR dated 11/11, revealed the resident received PRN Tylenol both before and after her change of condition, including on 11/12/11, when she flinched in pain when her leg was touched (see above nurses' notes) and when her pain was documented as "10 of 10." (See MAR below) Specifically, in addition to her regularly scheduled pain medications, the resident received PRN Tylenol as follows: -On 11/8/11 the resident received one dose of 650 mg of Tylenol at 4:00 a.m. for complaint of leg pain. The MAR failed to document if the medication was effective. -On 11/8/11 the MAR documented the resident received two other doses of the PRN Tylenol; however, the MAR failed to document reason and if it was effective. -On 11/11/11 at 12:00 a.m., the MAR documented the resident received 650 mg of Tylenol for left leg pain. The MAR indicated (via entry at 1:00 a.m.) that the medication was positive. -On 11/12/11 at 5:25 a.m. (following discovery of condition change), the MAR documented the resident received 650 mg of Tylenol for left leg pain. The MAR failed to document if the medication was effective, even though the nurses' note documented the resident was crying out when her leg was touched. -On 11/12/11 at 2:00 p.m., the MAR documented the resident received 650 mg of Tylenol for left leg pain. The MAR documented the resident had a 10 out of 10 pain level. The MAR documented minimal relief and the resident was transferred to the hospital; however, see above nurses' notes, the resident was not transferred to the hospital until 8:00 p.m. (6 hours later). There was no documentation in the resident's record (see nurses notes above and physician orders [REDACTED]. a. Interviews Resident #15's family member was interviewed on 2/6/12 at 9:15 a.m. The family member stated s/he was notified of the change of condition at approximately 3:30 p.m. on 11/12/11 from the evening shift RN. S/he stated that when the family was at the bedside of the resident on 11/12/11 from 4:25 p.m. until approximately 8:00 p.m., the resident was in extreme pain. S/he stated when the bed was touched the resident would scream in pain. The primary care physician was interviewed on 2/7/12 at approximately 2:00 p.m. -The physician stated that the voice mail line was just that, a voice mail and only a message can be left. The physician stated the urgent line should have been called instead of the voice mail line following the discovery of the resident's hematoma, bruising and pain. -The physician stated after reviewing the pain levels (on the MAR and pain evaluation sheet), the resident's pain level should have been evaluated better. The physician stated she would have liked documentation regarding how the resident responded to the Tylenol. She said it was unclear how effective the medication was. And, if the Tylenol had not been covering the pain, the facility should have called for a stronger pain medication. -The physician stated the NP did assess the resident on 11/12/11, and the resident was then sent to the hospital. Licensed practical nurse (LPN) #1 who worked with the resident 11/11/12 (2:00 p.m. to 10:00 p.m.) was interviewed on 2/7/12 at 9:10 p.m. -S/he stated the resident complained of shoulder pain in the evening on 11/11/11 and s/he administered the resident's routine [MEDICATION NAME]. S/he said s/he did not document the pain, stating s/he only documents pain when s/he gives PRN pain medications. S/he said the resident had complained of shoulder pain before; the complaint was not out of the ordinary. -S/he stated that s/he did try to obtain a pain score from the resident, but the resident mumbles and s/he (LPN) couldn't understand her response. Instead, s/he assessed the resident's arm by asking her if certain parts of her shoulder hurt when s/he pressed on it and looked for facial grimacing. Certified nurse aide (CNA) #1 was interviewed on 2/7/12 at 9:15 p.m. The CNA stated that s/he worked the evening shift on 11/12/11. S/he stated that when he/she came in on 11/12/11, s/he heard that an x-ray had been ordered for the resident. S/he stated that resident #15 was yelling, not like s/he normally did. The CNA said something was wrong and s/he saw that the resident's knee was swollen. CNA #2 was interviewed on 2/7/12 at 9:23 p.m. The CNA stated that s/he worked the evening shift on 11/12/11, but had not worked 11/11/12. S/he stated s/he had heard from another CNA that the resident, who required total care with all activities of daily living (ADLs) except for feeding, had fallen. S/he could not remember who had said that to her. -S/he stated that on 11/12/11 the resident was up for dinner and s/he stated the resident said in Spanish to him/her, "my leg (is) hurting" and it "hurts so much." S/he stated the resident kept saying this over and over. CNA #2 stated s/he reported the resident's complaints to LPN #1. -CNA #2 stated the resident used to scream; however, this scream was different. "Something was definitely wrong." Registered Nurse (RN) #1 was interviewed on 2/7/12 at 10:00 p.m. RN #1 stated that s/he worked the night shift and that s/he worked the night of 11/11/11 and early morning of 11/12/11. -S/he stated that at about 5:00 a.m. on 11/12/11, she was notified by a CNA that the resident was found with a bruise on her left leg. S/he stated that when s/he went to check on the resident, she found a bruise on her posterior (behind her) left knee. -S/he stated that the resident had not fallen as the resident was unable to walk. And, if the resident had fallen, staff would have known. -S/he stated that s/he did not know why the resident had a bruise on her knee. S/he said when s/he assessed the resident, the resident had "guarded" her leg and would not allow him/her to touch the leg; the resident grabbed the RN's hand. -S/he stated that she administered 650 mg of Tylenol to the resident and did not go back and check to see if the medication was effective as his/her shift was up. -S/he confirmed that s/he called the voice mail line of the physician and did not call the urgent line. CNA #3 was interviewed on 2/8/12 at approximately 11:00 a.m. S/he stated that on 11/12/11 during the day shift, s/he recalled the resident having pain. S/he stated when the resident was rolled from side to side, she was in pain. S/he stated the resident did not want her leg touched. S/he stated that the resident had a usual behavior of screaming, however, the screaming that day was a lot more; it seemed more than usual. CNA #5 was interviewed on 2/7/12 at approximately 2:30 p.m. The CNA stated that s/he came in between 5 to 6:00 a.m. on 11/12/11. S/he stated s/he was asked to assist with resident #15's personal care. S/he stated that when the resident was changed she "screamed" in pain. S/he stated the resident screamed with pain every time she was moved from side to side during incontinence care. CNA #4 was interviewed on 2/7/12 at 9:35 p.m. CNA #4 stated s/he worked the evening shift on 11/12/11 and the resident was crying out in pain. S/he stated that she reported it to the nurse. The director of nurses (DON) was interviewed on 2/9/12 at 2:15 p.m. -The DON stated that the expectation was the nurses were to call the urgent line to speak with a physician and not to leave a voice mail. -The DON stated the expectation was that PRN pain medications be documented on the resident's pain management sheet. She stated after reviewing the 11/11 MAR, the resident's PRN medications were not recorded correctly. She stated the resident's pain level should have been assessed using a number. She stated the 'faces' pain scale used numbers to express the severity of a resident's pain. -The DON stated that the expectation was if the resident continued to have pain the physician should be called. 2. Resident #92, age 66, was admitted to the facility on [DATE] with diagnoses, per the computerized physician's orders [REDACTED]. The 11/15/11 minimum data set (MDS) indicated resident #92 was able to understand simple, direct communication from others and was able to provide simple, direct communication to others. The last Brief Interview Mental Status exam completed for Resident #92 on 8/18/11 indicated that the resident was usually alert and oriented as evidenced by a score of 12 points out of 15 points possible. Resident #92 was at risk for pressure ulcers and had unhealed pressure ulcers. a. Diabetic Management Plan In pertinent part, the CPO for 1/12 read: - Call MD on non-urgent line if (blood sugars) <60 or >400. - If FSBS (fingerstick blood sugar) is >400 give 12 units regular insulin SQ (subcutaneous) and recheck in 2 hours. If still >400, don't give additional insulin. Leave message on non-urgent line for MD. An undated care plan read, in pertinent part, that Resident #92 is "...at risk for complications related to Diabetes Mellitus. He is not compliant with his diet as evidenced by eating snacks in his room." The goal for Resident #92 was to minimize risk for hypo/[MEDICAL CONDITION] signs and symptoms thru next 90 days." Approaches included: -Administer [MEDICATION NAME] (insulin) sub-q (subcutaneous) daily as ordered -Administer [MEDICATION NAME]per sliding scale as ordered -Provide regular mechanical soft diet as ordered -Provide hs (bedtime) snack -Obtain FSBS (finger stick blood sugar) three times a day before meals -Call (unspecified) if <60 or >400 -If BS (blood sugar) >400 give 12 units regular insulin and recheck per order. b. Failure to follow diabetic management plan A review of the 1/12 Medication Administration Record (MAR) showed 27 instances of FSBS that were >400. The physician, nurses' notes and the MAR demonstrated that the physician was notified one time of the elevated blood sugars. The MAR also revealed that the 12 units of regular insulin were not always given and rechecks of FSBS were not completed in accordance with physician's orders [REDACTED]. -1/3/12 7:00 a.m., - blood sugar was 406, 12 units of regular Insulin given. No FSBS recheck documented on MAR. -1/11/12 7:00 a.m., - blood sugar was 456, 12 units of regular Insulin given. No FSBS recheck documented on MAR. -1/11/12 11:00 a.m., - blood sugar was 526, 12 units of regular Insulin given. No FSBS recheck documented on MAR. -1/11/12 4:00 p.m., - blood sugar was 517, 12 units of regular insulin administration not documented on MAR. FSBS recheck was completed. -1/13/12 11:00 a.m., - blood sugar was 519, 12 units of regular insulin administration not documented on MAR and no FSBS recheck was present. -1/21/12 4:00 p.m., - blood sugar was 427, 12 units of regular insulin administration not documented on MAR. Recheck was documented as refused. Resident Interviews: On 2/6/12 at 3:40 p.m., resident #92 stated that he was "not sure" what symptoms are for high blood sugar. Resident said the nurses seem to tell him they are high "a lot." Staff Interviews: On 2/9/12 at 12:30 p.m., the Director of Nurses (DON) stated it was her expectation that staff follow the physician orders. The DON stated that nurses were to notify the physician via the non-urgent line of each instance when the resident's blood sugar exceeds 400. The DON said documentation of physician communication should be recorded on the back of the MAR. The DON was informed of the documentation above regarding the resident's high blood sugars.

Based on observation, record review, and resident/staff interviews, the facility failed to ensure the environment remained as free of accident hazards as possible, and that two of 18 sample residents (#4, and #15) and two supplemental sample residents (#23 and #29) received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to: -Ensure safe smoking interventions were in place for resident #15 and resident #23. On 4/4/10, resident #23, who was known to have some confusion and physical limitations, smoked independently with oxygen on causing a flash explosion. This resulted in facial burns and singed hair and nares. The resident required overnight hospitalization following the incident and subsequent treatment for [REDACTED]. -Implement fall precautions and interventions for resident #4. -Ensure wheelchairs were in a safe working condition for residents #15 and #29. -Ensure the shower rooms on halls one and three were safe. -A GFI (ground fault interrupter) outlet was not in place in a resident's room (room #218). An electric toothbrush plugged in above the sink created an electrical hazard. The findings include: I. SMOKING 1. Observations of Smoking Area The facility's smoking area was located off the main dining room outdoors. The patio was covered with an awning; the area was not secured as no code for entry was needed. Residents were allowed to smoke on the patio that was not covered by the awning, as long as they remained in staff's line of sight. There were several ashtrays sitting on top the tables of which were observed to have multiple cigarette burns. There were also many cigarette butts on the patio which had not been cleared from the previous scheduled smoking time. The staff to resident ratio varied, but during the survey 6/15/10 through 6/21/10, the average ratio observed was one staff member to ten residents smoking. 2. Smoking Schedule Review of the facility's smoking schedule, which was updated on 5/27/10, showed residents were allowed to smoke at the following times supervised by the following departments: -6:45 a.m. Housekeeping -9:15 a.m. Dietary -11:00 a.m. Station 1.5 -1:30 p.m. Restorative -4:15 p.m. Station 2 -7:30 p.m. Station 3 -10:30 p.m. Station 1 -2:30 a.m. Station 2 Further review of the smoking schedule revealed the following: -"Please start and end on time." -"Smokers are allowed 2 cigarettes or 15 minutes to smoke." -"Staff must observe smokers but do not have to be in the smoking room." 3. Facility Policy Review of the revised smoking policy, dated 5/21/10, titled, "SMOKING, CARE OF RESIDENTS WHO SMOKE," stated, "Purpose: To maintain a safe environment for residents who smoke. To protect the residents, employees and visitors of this nursing home from the dangers associated with accidental fires or other catastrophes associated with smoking. This policy applies to all employees, residents, family members, visitors, physicians, volunteers, suppliers and third-party contractors working in any capacity at this nursing facility." The procedure stated in pertinent part; "1. Smoking is allowed only during designated smoking times and in designated smoking areas ...3. Review facility smoking policy/consent HCM NUR 4213 with resident and legal representative ...4. Complete assessment for Supervision of smoking HCM NUR 4214 on any resident who smokes to determine whether or not the resident is capable of safely smoking without assistance or supervision ...5. Care plan individualized smoking safety precautions for each resident who smokes ...The care plan will address: whether or not the resident needs assistance in lighting cigarettes, whether the resident must wear a smoking apron, whether or not the resident needs supervision while smoking, and any other relevant precautions to ensure the safety of the resident and this facility community ...8. Residents will not be permitted to keep their own smoking materials ...15. Residents who are in violation of the Policy may be subject to discharge proceedings for non-compliance with the rules, and thereby endangering the safety of themselves and others... 17. If a resident's family or visitors are in violation of the Policy, the resident may be subject to discharge proceedings in order to protect the safety of this facility community." 4. Resident #23 Supplemental sample resident #23, [AGE] years old, was readmitted to the facility 4/5/10. The admission face sheet showed the following Diagnoses: [REDACTED]. According to the most recent admission MDS, dated [DATE], supplemental sample resident #23 was alert and oriented had short-term memory problems. He was understood by others and able to understand. The resident was coded with modified independence in regard to daily decision-making and demonstrated difficulty making decisions in new situations only. Resident #23 did not have any mood or behavioral symptoms. He required extensive assistance for bed mobility, transfers, dressing, toilet use, and bathing. Resident #23 had partial loss of voluntary movement and limitation of movement in one leg. Resident #23 was on oxygen therapy. Review of the physicians note, dated 4/2/10, stated in pertinent part, "...Confusion, short-term and long-term deficits..." a. Incident Report According to an incident report, dated 4/4/10 at 8:00 p.m., the resident was involved in an incident, which occurred at 7:30 p.m. The incident report stated that resident #23 went to the smoking room unassisted/unaccompanied to smoke; he was an independent smoker. According to the report, resident #23 acquired cigarettes and attempted to light the cigarette while his oxygen (via nasal canula) was still on and running. This caused a flash explosion resulting in facial burns and singed hair and nares. The fire was quickly extinguished by the resident due to insufficient fuel to continue the fire, but the nasal canula was still burning, which was removed by the Registered Nurse (RN) who was in an adjacent room. The RN documented that the resident received burns to the face, nares and palmer aspect of the hands bilaterally, no third degree/full thickness burns. Resident's airway revealed some soot in the nose and larynx, but the airway was not compromised. The resident was transported to the hospital for evaluation. b. Hospital Assessment On 6/28/10, a review of the hospital admission paperwork for the resident's 4/4/10 visit was reviewed. The "Initial Trauma Evaluation and Management Form," dated 4/4/10 at 9:00 p.m., under Chief Complaint and History of Traumatic event, stated in pertinent part..."(NH) Nursing home on oxygen time being diagnosed with [REDACTED]. c. Record Review Review of the physician's note, dated 4/5/10, stated in pertinent part, "...1. Second degree flash burns to face...eyes: singed right eyelashes with lid swelling, lips/pharynx: swollen and red with burn markings, no oral swelling, skin: singed mustache and nasal hairs, second degree burns around nose and bilateral cheeks. Mild pain and burning sensation, positive for serous drainage. ,Assessment and Plan: 1. second degree burns to face-keep face clean with saline daily, neomycin, Polytrim, Lidocomb apply to face lesion/burns four times daily until healed, monitor for any signs or symptoms of infection..." Review of the physician's note, dated 4/9/10, stated in pertinent part, "...1. Patient having increased scabbing, serous drainage from facial/nasal burns...facial burns and nasal occlusion...eyes: eyes swelling, singed eyelashes/brow right side...lips/pharynx: second burns with serous bloody drainage, severe scabs in nasal creases, bilateral nostril and upper lip and central lower lip...Plan and Assessment: 1. facial burn-needs strict, aggressive wound care, saline soaks to moisten and loosen drainage, debris soak every shift times 30 minutes. Remove moisten drainage, then apply thin layer polysporin. Please swab internal bilateral nares with polysporin...4. Dementia-needs assistance and reorientation early stage and decline expected-safety measure..." Review of the physician's note, dated 4/16/10, stated in pertinent part, "...Facial burns after lightening cigarette with oxygen nasal canula on, burned moustache...all wounds look second degree-no evidence of third degree, clean...second degree facial burns-no evidence third degree on several exams (previously worried about left nasal and upper lip but these are looking much better)..." Review of the physician's note, dated 4/26/10, stated in pertinent part, "...few scabbed areas cheeks/upper lip/ right nostril...second degree burns to face-healing very well. Expect minimal to no scarring..." Review of the TAR, dated 4/9/10, documented the following physicians treatment order, "Strict, aggressive wound care to facial burns, saline soak dressing applied to all burns for 30 minutes every shift and clean all drainage/scabbing. Using a Q-tip apply polysporin and lubricate the internal nostrils." Review of the weekly skin assessment, dated 4/9/10, identified facial burns. The skin assessment for the week of 4/13/10 identified burns to the cheek, nose tip, and lips with no signs/symptoms of infection or drainage. The note, dated 4/20/10, identified, "burned face, healing well. Scab on nose side, no signs or symptoms infection and no drainage." The final skin assessment note, dated 4/27/10, identified that the facial burns were healing well, the right side of the nose remained scabbed with no signs or symptoms of infection or drainage. The "Social Services Progress Notes," dated 4/4/10, documented the smoking incident which involved resident #23. It was noted that resident #23 had superficial burns to the face, was transported to the emergency room , and his smoking assessment was updated. Review of the updated form, dated 4/4/10, titled, "Assessment for Supervision of Smoking," revealed that resident #23 was not a safe smoker, and he required direct supervision during smoking. The assessment identified that resident #23 had impaired decision making and judgment and was not able to demonstrate the ability/willingness to leave an unsafe smoking situation. d. Incident Outcome: On 6/21/10, the "Notes on (name) incident" were reviewed. The note, dated 4/4/10, identified that the facility had notified the administrator and social services regarding the incident that involved resident #23 smoking with oxygen on, which resulted in resident #23 being transported to the emergency room for facial burns. The facility verified that resident #23 was assessed to be an independent smoker and that he had been educated on the dangers of smoking with oxygen. A second note, dated 4/5/10, revealed that the emergency room did not find extensive burns that meet the criteria for reporting to the occurrence hotline. An interdisciplinary team meeting was conducted and the following process/procedures were completed and implemented; all resident files were audited to ensure each had a smoking assessment which identified whether the resident would be an independent or supervised smoker. The files were also audited to identify if a smoking contract was in place and care planned. The team decided that all smoking would be supervised with no exceptions, a new smoking schedule would be posted and an in-service would be conducted by social services for staff regarding smoking with oxygen and the facilities new guidelines. The following note was documented, "Discussed incident with corporate nurse and Regional Vice President (RVP) and determined it was not reportable to the occurrence hotline as it did not meet the guidelines of percentage of surface burned or ER report of severity of burns." 5. Resident #15 Resident #15, [AGE] years old, was admitted to the facility 12/17/09. The monthly Computerized Physicians Orders (CPOs) showed the following Diagnoses: [REDACTED]. According to the most recent quarterly Minimum Data Set (MDS), dated [DATE], resident #15 had no cognitive impairments, understood others and was able to be understood. The resident was coded with modified independence in regard to daily decision-making and demonstrated difficulty making decisions in new situations only. Resident #15 did not have any mood or behavioral symptoms. a. Observations During observation of the resident smoking on 6/17/10 at approximately 2:15 p.m., employee D was speaking with resident #15. Employee D informed resident #15 that his cigarette was very short and he needed to put it out. Resident #15 responded, "Oh let me take one more hit off it," and immediately smoked the cigarette down to his fingers before dropping the butt; there was no smoking extender used. During an interview with the resident on 6/17/10 at approximately 2:35 p.m., resident #15 was observed to have a raised red area with a light brown scab on his middle finger as well as a fluid filled blister on his right index finger. When asked about the blister resident #15 stated the blisters were old. b. Record review Care Plan Review of the care plan revealed that on 2/22/10, resident #15 was designated a supervised smoker due to a burn on his finger and giving cigarettes away. The approaches were for staff to listen to his concerns, remind him of the policy, allow him time to process and to contact social services. Under approaches a notation dated 6/21/10 stated, "need smoker extender for cigarettes." Review of the form titled, "Care Plan Update," revealed that on 4/5/10 under the problems section showed, "Right 2nd and 3rd finger and left middle finger burn." The goal was to have the burns heal with no signs or symptoms of infection, and the approach was to "tx (treat) as ordered, monitor every shift placement of band-aid." Review of the form titled, "Care Plan Update," revealed that on 6/17/10 under the problems section showed, "blister on" right "second finger." The goal was for the blister to heal and the approach was cleanse with normal saline and apply bandage or non-adherent pad at night. Review of the form titled, "Care Plan Update," revealed that on 2/20/10, under the problems section showed, "burns on" right "middle finger," and "Pt (patient) attest to burning finger with cigarette 10.5x0.5 open no tissue damage." The goal was for the resident to be free of any discomfort. The approaches were cleanse with saline or wound cleaner, cover with a band-aid or non-adherent pad and wrap around the finger, and "Assessed for supervised smoking." Minimum Data Set (MDS) Review of the MDS, dated [DATE], showed resident #15 was free of any functional limitations for range of motion (ROM); he had a rash, but no other skin problems or lesions. Resident #15 required extensive assistance with dressing, personal hygiene, and bathing. Review of the facilities Incident Reports on 6/21/10: No documentation was found in the resident's record or in the facility records which showed that an investigation had been completed regarding the burns to resident #15's fingers due to unsafe smoking practices for the months of 2/10, 4/10, or 6/10. Assessments Review of resident #15's "Assessment for Supervision of Smoking," dated 12/19/09, 2/22/10 and 4/4/10, identified that on the initial assessment date of 12/19/09, resident #15 was a safe smoker. The re-assessment dates of 2/22/10 and 4/4/10 showed that resident #15 was not a safe smoker and required direct supervision during smoking secondary to burns, and selling/borrowing cigarettes from other residents. The assessment on 4/4/10, listed cognition as a "disease/diagnosis/medication impacting ability to smoke." Review of resident #15's weekly skin assessment, dated 6/8/10, 6/10/10 and 6/15/10, showed that resident #15 had no new skin issues. Review of the 6/10 treatment administration record (TAR) revealed a physician's orders [REDACTED]. Review of the 6/10 treatment administration record (TAR) revealed an additional treatment, which was ordered on [DATE] to cleanse the right second finger with saline or wound cleanser, cover it with a band-aid or non-adherent pad at bedtime until healed. Nursing Notes Review of the nursing note, dated 6/4/10 at 6:45 a.m., a late entry for 5/27/10 at 5:30 p.m. The documentation revealed that resident #15 was found attempting to smoke cigarette butts during non-smoking times. Review of the nursing note on 6/6/10 at 3:50 a.m. revealed the following documentation, "Resident found smoking cigar outside in courtyard at 0130 (1:30 a.m.) Patient complaint with handing over cigar and returning inside. Social services notified. Will continue to monitor." Review of the nursing note for resident #15, dated 6/12/10 during the 10-6 shift, revealed the following note, "He was compulsive about smoking time & keep bothering staff to go to smoke before scheduled smoke break time. Reminded he needed to wait for scheduled time. Also, CNA (name) found five cigarettes from his pocket." Social Services Notes Review of the social services note, dated 4/10/10, showed the following documentation, "(Resident's name) signed (changes) to smoking policy on 4/5/10, currently smoking appropriately." Review of the social service note, dated 6/7/10 at 8:30 a.m., revealed the following notation, "(Name) smoking few times this last few days without supervision-varies in where he says smoke materials received." c. Staff Interviews During an interview on 6/17/10 at approximately 3:00 p.m., the station #4 nurse looked at resident #15's fingers. The nurse stated the blister was old and that she had completed resident #15's treatment on 6/16/10. The nurse was not sure where the burns came from as the wounds were present when she started working at the facility a few months ago. The nurse was shown the weekly skin report, which failed to show the wounds on resident #15's fingers. The nurse stated, she was not sure why this was not documented, but thought maybe it was because they knew about the wounds. The nurse then stated they must have forgotten to document it. During an interview on 6/17/10 at approximately 3:30 p.m. with corporate nursing consultant, she stated the record showed the injury was first documented in February and last discussed in April. The corporate staff member asked the director of nursing (DON) for the weekly skin report. The DON stated resident #15 was not included on the weekly skin report. During an interview with social services Director on 6/17/10 at approximately 4:38 p.m., the social services Director stated there was a safe smoker assessment and a smoking policy. The residents were observed smoking and based on those observations; social services determined whether the resident was a safe smoker. Social services was asked if procedures were implemented regarding resident #15's unsafe smoking practices as evidenced by repeatedly burning his fingers. The social services Director stated she did not complete resident #15's smoking assessment; however, one of the safety precautions implemented for resident #15 was to give resident #15 a smoking extender, which was applied to the cigarette by staff. During the interview, social services was informed that resident #15 had been observed smoking without having the extender on. II. Falls a. Resident #4 Resident #4, [AGE] years old, was admitted to the facility 1/27/07. The 6/10 Computerized Physicians Orders (CPO) showed the following Diagnoses: [REDACTED]. The resident's current Minimum Data Set (MDS) of 3/8/10 revealed the resident had difficulties with long and short-term memory and for cognitive skills for daily decision-making resident #4 was coded as moderately impaired. Resident #4 was rarely/never able to understand others or able to make self understood. The resident required extensive physical assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, eating and required total assistance for bathing. The MDS did not code the resident as experiencing a fall in the past 31-180 days, although the resident did experience a fall on 1/8/10. Observations: -On 6/15/10 at 4:58 p.m., the resident's call light was on above the door. The resident's door was open partially. The resident was observed laying across the bed toward the foot of the bed with his legs on the floor. The alarm was not sounding. The business office manager (BOM) was observed to answer the call light and summoned assistance, as the resident was laying across the bed. Although, there was a floor pad on the floor; it was not alarmed. -On 6/16/10 at approximately 4:00 p.m., the resident's call light was on above the door. The resident's door was open partially, the resident was lying across the bed near the foot of the bed, with his legs on the floor. The surveyor looked for staff, however, there was no visible staff on the hallway. The surveyor did alert a nurse that the resident was lying across the bed with feet on the floor. Although, there was a floor pad on the floor; it was not alarmed. The pressure bed alarm was not sounding. -On 6/17/10 at 10:39 a.m., the resident was observed to be lying in bed. The nurse was observed to assist the resident into the wheel chair. The resident's alarm was on the bed, although it was not sounding, as the nurse was assisting him into the sitting position. The nurse stated the resident was to have the pressure alarm on the bed to alert the staff he was attempting to get up. The nurse stated she would have the alarm checked. The floor pad did not have any alarm. Record review: -Review of the 6/10 CPO documented, "...apply pressure alarm while in bed..." -The care plan, last updated 3/22/10, identified the resident as being at risk for falls related to resident not having any safety awareness. The goal was for the resident to be free from falls and to be assessed for risks and interventions initiated. The pertinent approaches were, low bed and also floor pad alarm at bedside. -The fall risk assessment, dated 6/9/10 identified the resident as being a high risk for falls, related to intermittent confusion, decreased muscular coordination, assisted devices and not able to walk. -According to the incident report on 4/7/10, the resident was found on the floor by the roommate. The resident's call light was on. The new interventions documented the CNAs were inserviced regarding answering call lights in a timely manner. Interviews: -The business office manager (BOM) was interviewed on 6/17/10 at 1:39 p.m. The BOM stated when she answered the call light for resident #4 on 6/15/10, the resident was laying across the bed toward the foot of the bed with legs on the floor. The alarm was not sounding. -The charge nurse (LPN) was interviewed on 6/17/10 at approximately 2:00 p.m. The LPN stated the resident was at risk for falls, as he did not have any safety awareness. She stated he had a history of [REDACTED]. She stated the resident had a self release alarming seat belt while up in the wheel chair and a pressure alarm while in bed. The LPN stated she had a new pressure alarm placed on the bed. III. UNSAFE SHOWER ROOMS Observations were made of the shower rooms on the initial tour of the facility, on 6/15/10 starting at 9:15 a.m. Safety issues were identified as follows: 100 HALL SHOWER ROOM: There was no sharps container in place for the disposal of razors, etc. The Scale room had an old century tub chair lift sitting in the middle of the room. There was a large (6 ft X 3 ft) section of floor tile missing from where the tub had set. Additionally, a Merry Walker, a wheelchair and housekeeping cart were stored in the scale room. A third room in the shower area, was also used for storage. The floor was sunken with no threshold. An old shower chair and a table covered with parts from a baseboard heater were visible. 200 HALL SHOWER ROOM: The linoleum at the entrance of the shower stall was sunken, and allowed water to collect in a puddle. The tile in the shower stall was chipped and buckled so that water from the linoleum area could not go flow to the drain. 300 HALL (Medicare) SHOWER ROOM No sharps disposal containers in either stall. The first or larger stall had two uncapped disposable razors on the ledge/wall of the shower. There was a third razor on the floor. 400 HALL SHOWER ROOM: The first stall had a warped, rusty baseboard heater. There was a grey vinyl chair stored in the shower stall. The chair had cracks in the vinyl on the seat and front edge of the chair. The padded armrests were gone leaving bare metal on the armrests. On 6/15/10 at approximately 9:00 a.m., the MD said someone failed to install sharps containers in the shower rooms noted above. (Cross-reference to F244 and F253 regarding resident complaints of the shower rooms and housekeeping/maintenance issues.) IV. WHEELCHAIRS IN NEED OF REPAIR 1. Resident #29 During the Group Interview that took place on 6/15/10 at 2:00 p.m., it was observed that the arm rests on supplemental resident # 29's wheelchair, had multiple cracks, and were in need of being replaced. The resident was at risk for skin tears/injuries due to the condition of the arm rests. Supplemental resident #29, age 72, was re-admitted to the facility on [DATE]. According to the most recent Minimum Data Set, dated dated [DATE], his cognition was assessed as being moderately impaired. The resident had problems with both his short and long term memory. The resident required extensive assistance with bathing, and limited assistance with ambulation, hygiene, and dressing. He was independent with transfer and eating. 2. Resident #15 Resident #15, [AGE] years old, was admitted to the facility 12/17/09. The monthly Computerized Physicians Orders (CPOs) showed the following Diagnoses: [REDACTED]. According to the most recent quarterly Minimum Data Set (MDS), dated [DATE], resident #15 had no cognitive impairments, understood others and was able to be understood. The resident was coded with modified independence in regard to daily decision-making and demonstrated difficulty making decisions in new situations only. Resident #15 did not have any mood or behavioral symptoms. On 6/16/10 at 9:05 a.m., resident #15 was observed wheeling himself out of the dining room. He stopped the surveyor and stated that he wanted new wheels for his wheelchair because they were worn out. The rubber on the back wheels was observed to be thin and close to the rim, with frayed areas. It was also observed that his arm rests were cracked and in need of replacement. The resident was at risk for skin tears/injuries due to the condition of the arm rests. 3. Interviews During a meeting with the NHA and DON, on 6/21/10 at 9:35 a.m., the concerns were shared regarding residents' wheelchairs. The DON stated the evening CNAs were scheduled to clean the wheelchairs and should notice any repair issues and then report them. At 11:15 a.m., the Maintenance Director was asked who was responsible for repairing wheelchairs. He stated that if the wheelchair was owned by the resident, the need for repairs should be communicated to the Social Worker. The Maintenance Director then said if the wheelchair belonged to the facility, that he would repair it. V. NO GROUND FAULT INTERRUPTER IN PLACE The initial tour of the facility was conducted on 6/16/10 at approximately 10:30 a.m. with the Maintenance Director (MD) and Housekeeping Director (HD) in attendance. During the tour of the facility, room #218 was observed with a resident's electric toothbrush/charger plugged into the electrical outlet directly above the sink. The electrical outlet was not a GFI (ground fault interrupter) outlet creating the potential for electric shock in the event the plugged in device fell into the sink with water. The MD offered no comment regarding the potential electrical hazard in room #218.

Based on observations, record review and resident and staff interviews, the facility failed to ensure that one of 18 sample residents (#2) maintained acceptable parameters of nutritional status. Resident #2 experienced a significant unplanned weight loss. --The facility failed to establish the resident's baseline nutritional needs and to determine an appropriate weight range for the resident. --The facility failed to provide adequate meal assistance and offer alternates when intake was poor. --The facility failed to implement planned nutritional interventions and to provide snacks. --The facility failed to revise the care plan with the occurrence of continued weight loss. Findings include: Sample resident #2 was re-admitted to the facility on [DATE]. According to the 6/10 Computerized Physician order [REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], the resident had cognitive impairments. The resident was coded as having severely impaired decision making skills. The resident required extensive assistance with all activities of daily living including eating. The MDS coded the resident as being 4'9" tall and weighing 107 pounds. a. History of significant weight loss Review of the resident's weights showed the resident experienced a significant weight loss (7.1% weight loss in one month from 4/4/10 to 5/2/10; significant weight loss defined as 5% or more in one month). The weights were as follows according to the weight change report: 1/4/10 - 109 2/1/10 - 108 3/23/10 - 105 4/4/10 - 107 5/2/10 - 99.4 5/7/10 - 100.2 5/11/10 - 94.8 (last entry for the weight change report). b. Record review revealed the facility was aware that resident #2 was at nutritional risk. --A physician telephone order dated 5/10/10, documented a recommendation from the registered dietitian (RD) to discontinue the 90 ml health shake two times a day on 5/10/10, and to start to administer 120 ml (4 oz) three times a day related to weight loss. --Review of the 5/10 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. --The 5/10 CPO, documented the resident was to be offered a tortilla at every meal per family request. Review of the Nutritional Risk assessment dated [DATE], failed to show the resident's baseline nutritional needs were established by the facility. Height, ideal body weight range, usual body weight range, body mass index (BMI a measure of the adequacy of weight for height), nutritional requirements such as daily calorie needs, daily protein needs, and daily fluids needs were incomplete/blank. --The initial diet history/assessment completed on 2/23/10, (a note documented the admit assessment was missing). The assessment also did not show the resident's baseline of nutritional needs were established. --The 5/17/10 NAR (Nutritional Risk Assessment), documented the resident had experienced greater than ten percent weight loss. --The 6/6/10 weight note, completed by the registered dietitian documented, - "5/30 wt (weight) 102 pounds- 6/6 wt: 99.6 # - wt loss is significant 5/30 (30 day -4.67%). Now wt loss times 30 days has slowed-not significant ...med pass inc (increased) 5/10, no recent labs. Continue interventions in place." --The physician progress notes [REDACTED]. Review of the laboratory results dated [DATE], showed the resident had a low [MEDICATION NAME] at 2.8 (normal range 3.5-5.0), a low total protein at 6.2 (normal range 6.3-8.2). c. Facility response to resident's weight loss --The 4/7/10 physician progress notes [REDACTED]. The note indicated Magic Cup and Prostat supplements would be initiated. --Review of the 6/10 CPO, documented an order for [REDACTED]. --5/13/10, change of condition form documented the physician was notified of the 7.9% weight loss. No new orders. d. Care plan The care plan with an open date of 8/24/09, identified the resident as having exhibited weight loss for the past 30, 90 and 180 days. The goal was for the resident to not have any further weight loss through the next 90 days. The approaches included: --Monitor weights; --Monitor in NAR meetings weekly; --Provide alternative choices at meals; --Provide snacks; --House supplement increased to two times a day; --Assisted dining room at all meals. There were no care plan updates after 8/25/09, even as the resident continued to lose weight. There was no evidence the interventions (see above) were re-evaluated to ensure they were being implemented (see observations above) and were the most effective means to promote meal intake. e. Observations 1) Meals The resident was observed at three meals. The resident was thin in stature, her face was gaunt and she spent her spare time when not lying down propelling herself throughout the facility. During observations of the resident's tray card, there was no documentation to indicate the resident was to be served tortillas at each meal as ordered by the physician. 6/16/10 --At 7:45 a.m., the resident was observe to receive her meal. The resident was not sitting at the assisted table, however, she was in the restorative dining room. The resident did not have a tortilla served with her meal. The resident began to eat the hot cereal. --At 8:00 a.m., the resident had finished the hot cereal. She was not eating the eggs or the meat. The resident sat with her hands folded on the table. --At 8:06 a.m., the resident continued to sit with her hands folded. She was not eating and did not receive any assistance. The resident was not offered any alternatives. --At 8:13 a.m., the resident had her hands on her wheels and was wheeling back and forth, she was sitting by a wall which kept her from being able to move. --At 8:18 a.m., the certified nurse aide was observed to be recording what the resident had consumed. The CNA did not offer any cueing/encouragement to the resident prior to recording the amount consumed. The resident was observed to eat only the hot cereal, which would be less than 25% of her meal. Although, review of the meal intake detail report documented two different entries for breakfast for 6/16/10. The first entry documented at 8:40 a.m., 50% consumed, the second entry completed at 10:01 a.m. documented 100%. --At 8:23 a.m., the CNA #N asked the resident in Spanish if she wanted to go to the door. The CNA assisted the resident out from behind the table. She did not offer the resident an alternate, or encouragement to eat or drink her fluids. 6/17/10 --At 11:56 a.m., the resident was sitting in the restorative dining room. She was sitting at one of the back tables. She had 240 of milk, 240 cc of lemonade and a cup of coffee. --At 12:03 p.m., the resident received her meal. The meal was a submarine sandwich. Although the meat was mechanical soft, the bread was thick. The resident was not served a tortilla with her meal. --At 12:06 p.m., the resident was picking at her food with her fingers. She ate a small amount of the cut fruit. --At 12:10 p.m. a CNA sat across from the resident and assisted another resident to eat her meal. She did not provide any encouragement or cuing to resident #2. --At 12:16 p.m., the resident continued to pick at her meal with her fingers. --At 12: 28 p.m. the resident was observed to eat the cut fruit with her fingers. The CNA at the same table did not cue the resident to use the fork. --At 12:30 p.m., the resident was not eating. --At 12:36 p.m., the CNA sat next to the resident and gave her a bite of food. The resident accepted. --At 12:39 p.m., the CNA left the table and the resident. --At 12:42 p.m., the resident drank the lemonade. --At 12:44 p.m., the CNA came back to the table, and handed her the juice to finish. The resident was then assisted out of the dining room. The resident was not encouraged to eat the rest of her meal. The resident left the table. The resident ate some strawberries off of the desert (strawberry shortcake), the cut fruit and picked at the bread. Although, review of the meal intake detail report documented two different entries for lunch for 6/17/10. The first entry documented at 1:04 p.m., 25% consumed, the second entry completed at 1:17 p.m., documented 75%. 2) The resident's activity level was high. She was active and expended calories per observations: 6/15/10 --At 9:55 a.m., the resident was observed propelling herself around the halls. --At 4:00 p.m., the resident was up in her wheel chair and was propelling herself around the facility. --At 4:45 p.m., the resident continued to propel herself throughout the facility. 6/16/10 --At 8:37 a.m., the resident was propelling herself around the facility. --At 8:59 a.m., the resident was observed wheeling herself around the hallways of the facility. 6/17/10 --At 4:00 p.m., the resident was observed to propel herself up and down the hall, talking in Spanish. Through translation, she was looking for her clothes. --At 4:45 p.m., the resident continued to propel herself throughout the facility. 6/21/10 --At 10:00 a.m., the resident was observed to be propelling her wheel chair down the hall. --At 10:30 a.m., the resident continued to propel her wheel chair around the facility. --At 11:00 a.m., the resident continued to propel herself in her wheel chair throughout the facility. f. Failure to offer snacks Although the 6/10 MARs, documented the resident received a magic cup or fortified cookie, it was documented it was administered, however, if she consumed it and how much was not documented. Review of the meal intake detail report beginning 3/25/10 through 6/20/10, showed the resident was offered and accepted a morning snack three times out of 90 opportunities. The report indicated "snack not offered" on the 87 opportunities. For the afternoon snack from 4/4/10 through 6/20/10, the resident was offered and accepted a snack four times out of 89 opportunities. The report indicated "snack not offered" on the other 85 opportunities. g. Interviews: --On 6/21/10, at 9:30 a.m., the acting director of nurses (DON), the nursing home administrator and the regional nurse consultant were interviewed. The request to speak with the registered dietitian (RD) was requested. However, by completion of the survey the RD did not come and talk to the surveyor. --The dietary manager (DM) was interviewed on 6/21/10, at 11:15 a.m. The DM stated that she was certified and that she attended the care conferences and she completed quarterly documentation. The DM stated the resident was followed in nutrition at risk, however, at present she was not being followed by the NAR. She stated the resident received fortified cookies and the family came to the kitchen to get different snacks for her. She stated the resident ate in the restorative dining room due to her needing assistance with eating. She stated when a resident was on the NAR then the RD followed the resident monthly. --A certified nurse aide was interviewed on 6/17/10, at approximately 10:30 a.m. The CNA stated the resident was continually propelling herself around the facility. --The charge nurse (LPN) was interviewed on 6/21/10, at 10:25 a.m. The LPN stated the resident had a history of [REDACTED]. She stated the resident required cueing and assistance to eat, as she could not eat independently. She stated it was typical for her to wheel herself around the facility when she was not lying down. h. In summary: The resident was not offered encouragement or cueing to consume her meals. The resident spent a significant amount of time expending energy by propelling herself around the facility. The resident was not offered morning or afternoon snacks. The resident was not offered alternates when she did not eat the food served. The resident was not provided the tortillas as directed by physician's orders [REDACTED].