Every finding on record at High Plains Post Acute LLC

Based on observations, record review and interviews, the facility failed to ensure three (#3, #8 and #11) of six residents reviewed for accidents out of 21 sample residents received adequate supervision to prevent accidents. Resident #3 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric (upper thigh bone - hip fracture) fracture, acute pain due to trauma and orthostatic hypotension. The resident was known to be a fall risk upon admission due to her fall at home which resulted in the resident's left hip fracture. However, the fall assessment completed on 3/12/25 documented the resident had not fallen and was a low risk for falls. The facility implemented a fall care plan upon admission which included ensuring items were within the resident's reach.On 4/18/25 Resident #3 turned her call light on after using the bedside commode in her room. When staff had not responded to the call light after 15 minutes, the resident stood up from the commode and attempted to reach the toilet wipes, which were not within easy reach. The resident sustained a fall which resulted in her transfer to the hospital where she was discovered to have a right wrist fracture and right hip fracture which required surgical repair. Specifically, the facility failed to:-Implement effective fall interventions in order to prevent a fall with major injury to Resident #3;-Ensure fall interventions were consistently implemented for Resident #8; and,-Ensure Resident #11's foot pedals were in place on her wheelchair when staff were transporting the resident.Findings include: I. Facility policy and procedure The Accidents and Supervision policy, dated 3/1/25, was provided by the nursing home administrator (NHA) on 8/7/25 at 2:41 p.m. It revealed in pertinent part, “The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. “Identification of hazards and risks: The process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. “Evaluation and Analysis: The process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Both the facility-centered and the resident-centered direct approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk and identifying or developing interventions based on the severity of the hazards and immediacy of risk. “Implementation of interventions: Using specific interventions to try to reduce a resident’s risks from hazards in the environment. The process includes communicating the interventions to all staff, providing training as needed and ensuring that the interventions are put into action. “Monitoring and modification: Monitoring is the process of evaluating the effectiveness of care plan interventions. Modifications is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. The monitoring and modification process includes ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of new interventions. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency and based on the individual resident’s assessed needs and identified hazards in the resident environment.” II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture, acute pain due to trauma and orthostatic hypotension. The 3/18/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She required full assistance of one person for bed mobility, transfers, locomotion, dressing, and toileting. The resident was incontinent of bladder and bowel. The assessment indicated the resident had a prior fall within the last month while at home, resulting in a fracture to her left hip. B. Resident and resident representative and resident representative interview Resident #3 and her representative were interviewed together via phone on 8/11/25 at 10:19 a.m. Resident #3 said she was on the commode in her room (on 4/18/25) when she pushed her call light for assistance off the toilet. She said she waited 15 minutes for staff to come and assist her but to come and assist her but no one answered her call light. She said the toilet wipes were not within reach and so she stood up from the commode to reach back behind her for the wipes and fell to the floor. Resident #3 said she laid on the floor Resident #3 said she laid on the floor until staff arrived to answer her call light. Cross reference F565 for grievances of a group related to call lights. Resident #3’s representative said the resident sustained a right wrist fracture and a right hip fracture as a result of her fall. She said the resident did not return to the facility and was discharged to another facility after her hospital stay. C. Record review The fall care plan, initiated 3/13/25, identified that Resident #3 had a potential for fall/injury related to decreased range of motion and a fall with fracture. Interventions included keeping frequently used items within reach (initiated 3/13/25), keeping the call light within reach (initiated 3/13/25), assisting with transfers as needed (initiated 3/13/25), the resident was to be supervised during toileting activities (initiated 4/18/25) and encouraging the resident to use a reacher device (initiated 4/21/25). -However, the interventions for supervision during toileting and encouraging the resident to use a reacher device were not implemented until after the resident’s fall and transfer to the hospital on 4/18/25. -Additionally, the toilet wipes were not within easy reach of the resident, which caused her to have to stand up and reach behind her to reach them (see resident interview above). The admission fall risk assessment, dated 3/12/25, revealed Resident #3 was a low risk for falls. -The fall risk assessment documented the resident had not fallen, however, the resident was admitted with a fractured hip related to a fall at home. The 4/17/25 physician’s follow-up progress note documented Resident #3 was still non weight bearing on her leg, still needed help with transfers and remained a fall risk. The 4/18/25 nurse progress note, documented at 9:35 p.m., revealed Resident #3 was sent to the hospital for Xrays. -The progress note did not document the reason the resident was sent to the hospital for Xrays or what time she was transported from the facility. The 4/18/25 nurse progress note, documented at 5:49 a.m., revealed the nurse called the hospital and was informed that Resident #3 had been admitted to the hospital. -The progress note did not indicate the reason the resident had been admitted to the hospital. The 4/19/25 nurse progress note, documented at 7:19 a.m., was documented as a late entry progress note (for the 4/18/25 fall). The progress note documented Resident #3 was assessed by the registered nurse (RN) for immediate trauma/injury. Resident #3 reported pain at her right hip with guarding (physical response to attempt to protect an injury) while being assessed. The resident was transferred to her bed with staff assistance. Once in bed, Resident #3 complained of right wrist pain with some deformity noted at the ulnar bone (long bone of the arm, on the outside of the wrist). A small amount of blood was noted from a skin tear at the ulnar side of her wrist. The physician and the resident’s representative were notified and the physician gave orders to send the resident to the hospital for evaluation and treatment. The resident was transported to the hospital via ambulance at approximately 7:30 p.m. The 4/21/25 fall/post fall progress note documented that Resident #3 stated she was reaching for the wipes and fell to the floor, extending her right hand as she was falling. The resident had turned her call light on and then reached for the wipes. The resident overreached and fell off the bedside commode. The note documented the certified nurse aide (CNA) who placed Resident #3 on the bedside commode placed items where the resident directed them to be placed. Review of Resident #3’s call light records for 4/18/25 revealed Resident #3 pushed her call light at 6:18 p.m. The duration for the 6:18 p.m. call light was 25 minutes and 19 seconds. D. Staff interview The director of nursing (DON) was interviewed on 8/11/25 at 2:40 p.m. The DON said Resident #3 initially admitted to the facility for a left hip fracture that occurred at home. The DON said Resident #3 was very careful about using the call light and waiting for staff. She said not waiting for staff to answer her call light to assist her before reaching for the wipes (on 4/18/25) was out of character for the resident. -However, Resident #3 said she turned her call light on and waited for 15 minutes for staff to come and assist her before attempting to get the wipes herself (see resident interview above). -Additionally, per Resident #3’s 4/18/25 call light log, the resident turned her call light on at 6:18 p.m. and the call light was not answered for over 25 minutes (see record review above). The DON said the facility changed nursing shifts at 6:00 p.m. and staff performed walking rounds at that time. She said the general goal for answering call lights was six minutes. She said Resident #3’s fall occurred during shift change, which was not an excuse, but justified the long wait time for the resident’s call light. The DON said staff found Resident #3 on the floor when they went in to answer her call light. She said Resident #3 did not vocalize her need for assistance. -However, Resident #3 requested assistance from staff by pushing her call light over 25 minutes before she was found on the floor when a staff member answered her call light. The DON said Resident #3 was sent out to the emergency room after the fall and was found to have a fracture to her right wrist and right hip. She said the resident did not return to the facility. The DON said a fall assessment was completed for residents at the time of admission. She said the assessment gathered information from the family in an attempt to mitigate potential issues at the time of admission. She said Resident #3 should have been documented as a high risk for falls due to her fall history at home. The DON said the facility implemented standard fall interventions for residents at admission. She said some interventions implemented were non-skid socks, fall mats, low bed position and a “call don’t fall” sign. III. Resident #8 A. Resident status Resident #8, age greater than 65 years, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, anxiety, subsequent encounter for fracture with routine healing, abnormalities of gait and mobility, generalized muscle weakness, and a history of falls. The 8/6/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. She was dependent on staff for partial to moderate assistance with most ADLs. Resident #8 has abnormalities of gait and mobility, is unsteady on her feet, and had a history of falls. The MDS assessment indicated the resident had a history of falls. B. Observations and staff interview On 8/6/25 at 9:10 p.m., Resident #8 was in her room, lying in bed. -The resident did not have the tactile wedge pillow (triangle-shaped pillow) in use. On 8/7/25 at 4:20 p.m. Resident #8 was in her bed in her room, without a tactile pillow in place. CNA #1 confirmed the tactile pillow was not in use. She said the pillow was put next to the wall, because she liked to roll on her right side. CNA #1 said the pillow was used to keep her arm on the bed, preventing her arm from falling between the bed and the wall. C. Record review The 7/5/25 fall risk assessment documented that Resident #8 was at a high risk for falls. Resident #8’s fall care plan, initiated 10/1/24, identified that the resident was at high risk for falls. Pertinent interventions included non-skid socks, a call light within reach, the bed in the lowest position, the fall mat in front of the bed and staff were to offer assistance with ADLs before and after meals. A progress note, dated 5/27/25, documented interventions for fall included a floor mat at bedside as the resident allows/tolerates when the resident was lying in bed, non-skid footwear when not in bed, when possible, non-skid socks when not wearing footwear, when possible or as tolerated by the resident, bed in a low position when in bed, positioning wedges for tactile boundaries, an anti-rollback device on the wheelchair, and check and change before and after meals and during rounds at night. Fall incident on 7/1/25 - unwitnessed On 7/1/25, the interdisciplinary team (IDT) progress note documented that Resident #8 was found on the floor, lying in front of the bed with her head towards the foot of the bed. The resident was lying on the floor with her head on a pillow and covered with a blanket. The resident declined to wear non-skid socks. A floor mat was in front of the bed. The plan is to replace the resident’s call light with a bump call light. Fall incident on 7/5/25 - unwitnessed A post-fall note, dated 7/5/25, documented the nurse went into Resident #8’s room as the roommates' call light was on and the resident was found lying on the floor on her right side. A fall mat was in place, the bed was in lowest position and the call light was within reach. The resident was found without non-skid socks on, as the resident wore non-skid slippers during the day, but had them off as she was in bed and positioning wedges for tactile boundaries were not in place. The fall assessment was completed and the resident was scored at high risk for falls. D. Additional staff interviews Registered nurse (RN) #1 was interviewed on 8/7/25 at 4:26 p.m. RN #1 said Resident #8 had a history of falls. She said Interventions used for the resident were the floor mat at bedside and the bed in the lowest position. She said she did not know about the use of the tactile pillow as an intervention for Resident #8. RN #1 was interviewed a second time on 8/7/25 at 4:39 p.m. RN #1 said she had inquired what the tactile pillow intervention was for Resident #8, and she said it was a pillow that was put at the edge of the resident’s bed so she could feel it and know where the bed boundary was. The DON and the nurse consultant were interviewed on 8/11/25 at 2:40 p.m. The DON said the facility used a fall assessment to determine the residents’ risk for falls. The DON reviewed Resident #8’s electronic medical record (EMR) and confirmed the resident was at high risk for falls. She said the resident had experienced falls. She said current interventions were to place the resident’s bed in the lowest position and ensure the resident’s call light was within reach. The DON said the interdisciplinary team (IDT), consisted of herself, the NHA, the SSD, the AD, and the physical/occupational therapist and the IDT was the staff involved with reviewing the fall evaluation post-fall incident. IV. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, history of transient ischemic attack (a brief and temporary interruption of blood flow to the brain) and history of falling. The 8/2/25 nursing admission assessment revealed the resident was confused and had short-term and long-term memory problems. She required assistance from staff for most ADLs and used a wheelchair. The nursing admission assessment indicated the resident had a history of frequent falls. B. Observations On 8/6/25 at 10:58 a.m. Resident #11 was attempting to self-propel in her wheelchair through the common area. CNA #1 transported the resident to the nurses’ station in her wheelchair. There were no foot pedals attached to the resident’s wheelchair, which caused the resident to hold her legs and feet up and off of the ground. -Other staff members were in the vicinity; however, no staff members intervened to ensure Resident #11 was not transported in her wheelchair without foot pedals. On 8/6/25 at 11:06 a.m. Resident #11 was again attempting to self-propel in her wheelchair near the nurses’ station. CNA #2 assisted the resident to her room and then to the television (TV) in the common area. There were no foot pedals attached to the resident’s wheelchair, which caused the resident to hold her legs and feet up and off of the ground. -Other staff members were in the vicinity; however, no staff members intervened to ensure Resident #11 was not transported in her wheelchair without foot pedals. On 8/6/25 at 11:37 a.m. Resident #11 was transported to the bathroom from the common area in her wheelchair. CNA #2 told the resident to lift her feet up. There were no foot pedals attached to the resident’s wheelchair, which caused the resident to hold her legs and feet up and off of the ground. C. Record review The fall assessment, dated 8/1/25, revealed Resident #11 was a high fall risk. Review of Resident #11’s care plan, initiated 8/4/25, identified Resident #11 was a fall risk. Interventions included utilizing a fall mat while the resident was in bed, keeping the bed in the low position and keeping the call light and frequently used items in reach. -However, the fall care plan failed to include an intervention to ensure Resident #11’s foot pedals were in place when she was being transported in her wheelchair in order to prevent potential falls. D. Staff interviews The director of rehabilitation (DOR) was interviewed on 8/11/25 at 1:05 p.m. The DOR said that not every resident utilized wheelchair foot pedals due to the facility’s goal to increase mobility. He said the residents’ feet should not dangle from the wheelchair or drag across the floor when staff were transporting the resident in order to prevent the wheelchair from tipping over. The DOR said each resident was fit to a wheelchair for proper fit and should have foot pedals in their room. The DON and the nurse consultant were interviewed on 8/11/25 at 2:40 p.m. The DON said a majority of the residents without wheelchair foot pedals had the ability to self-propel in their wheelchairs. She said there were foot pedals available for each wheelchair. The DON and the nurse consultant were unclear as to what was best practice for utilizing foot pedals during transport. The nurse consultant said the residents might fall trying to get out of their wheelchairs if foot pedals were attached to their wheelchairs. E. Facility follow-up On 8/12/25 at 4:52 p.m. (after the survey exit) the NHA provided an update regarding Resident #11’s care plan that documented the resident self-propelled safely without pedals and using them could hinder her mobility. -However, the care plan continued to fail to include an intervention for staff to ensure Resident #11’s foot pedals were in place when she was being transported by staff.

Based on observations, record review and interviews, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and quality of life in the facility that were important to the residents.Specifically, the facility failed to ensure resident council grievances were addressed to resolve resident concerns related to call light response times.Findings include:I. Facility policyThe Grievance policy, dated September 2016, was received from the nursing home administrator (NHA) on 8/11/25 at 4:14 p.m. The policy documented in pertinent part, Residents must be able to file complaints and [NAME] also be assisted to file complaints, if necessary. Confidentiality of the aggravated party will be maintained as much as possible and grievances may also be submitted anonymously. The social services director (SSD) is the staff designee and Grievance Official responsible for overseeing the grievance process. The process must include an investigation, action taken to resolve the complaint and information about the resolution shared with the resident. The facility must address grievances promptly, preventing further violations while investigations are taking place. A grievance decision will be issued in writing and where appropriate, an oral explanation shall accompany the written one.II. Resident group interview Residents #18, #19, #20, #21 and #22, who were identified by the facility and assessment as interviewable, were interviewed together as a group on 8/7/25 at 2:00 p.m. The residents said call lights were not being answered timely and sometimes they had to wait in excess of 30 minutes for the call light to be answered.The residents said certified nurse aides (CNA) and other staff members answered their call lights, would say they had to come back and then they would not come back to answer the call light.The residents said they had reported their call light concerns to the resident council, however, they had not heard of any resolutions and continued to have concerns with long call light times.III. Resident council meeting minutesOn 8/6/25 at 8:35 a.m. the NHA provided the resident council minutes for April 2025, May 2025, June 2025 and July 2025. The 4/10/25 resident council meeting minutes documented residents had said call lights were not answered timely.-However, there was no documentation to indicate how the facility planned to address the residents' concern. The 5/8/25 resident council meeting minutes documented residents had said call lights were not answered timely. -However, there was no documentation to indicate how the facility planned to address the residents' concern.The 7/10/25 resident council meeting minutes documented residents had said call lights were not answered timely. The minutes documented the director of nursing (DON) would pull the call light audit reports for the three residents who had voiced concerns and review the logs with the residents. -However, the resident group interview conducted during the survey revealed residents' continued to have call light concerns (see interview above). IV. Grievances The grievance forms generated from the resident council meetings were provided by the social service director (SSD) on 8/11/25 at approximately 4:00 p.m.The 4/10/25 grievance form documented Resident #9 expressed concern that call lights were not answered timely. The resolution result documented by the facility revealed the facility spoke with the resident and attempted to show the resident the call light log to go over the durations of wait times with an average of seven minutes. The form documented Resident #9 refused to talk or sign the grievance. The 7/10/25 grievance form documented Resident #9 expressed concern that the call lights were too long. The resolution result documented the facility reviewed the resident's call light times. The form further documented that the facility reviewed that a pager system was being implemented no later 8/1/25. The form documented the facility acknowledged there were some longer call light times.-However, the grievance form failed to indicate how the facility planned to address the long call lights until the new pager system was in place or if the resident was satisfied with the resolution. The 7/10/25 grievance form documented Resident #12 expressed concern that the call light times were too long. The resolution result documented the facility would have a new pager system implemented by 8/1/25.-However, the grievance form failed to indicate how the facility planned to address the long call lights until the new pager system was in place or if the resident was satisfied with the resolution.V. Staff interviewsThe DON was interviewed on 8/6/25 at 1:00 p.m. The DON said the call light system was hooked to a computer. She said the call lights would ring to pagers which the CNAs carried. She said the new system had been in place for a few weeks. The SSD, the activities director (AD) and the NHA were interviewed together on 8/11/25 at approximately 4:00 p.m. The AD said the resident council meeting was held once a month. The SSD said as the residents had concerns, the grievance forms were filled out and provided to the department responsible for addressing the concern. The NHA said the grievance forms needed to have a resolution within 72 hours. She said she wanted them to be as timely as possible. She said the grievance forms demonstrated that the facility was paying attention to the call lights. She said the interdisciplinary team talked about call lights everyday. She said she wanted to make sure call lights were within reach. She said the facility implemented walkie talkies and the pager system in August 2025 to address call lights. She said the facility additionally had each resident assigned to a staff member for weekly rounds.-However, residents continued to voice concerns regarding long call wait times (see interview above). The NHA said that the call light audits had shown call lights had been answered timely. She said she had not performed audits to watch call lights and to observe to see if the lights were answered and turned off without performing the task. The DON was interviewed again on 8/11/25 at 5:38 p.m. The DON said the staff had been instructed to not turn off the call lights until the task was completed (during the survey).

Based on observations, interviews, and record review, the facility failed to ensure that four (#1, #14, #7 and #2 of seven residents reviewed for activities received an ongoing program of activities designed to meet needs and interests, and promote physical, medical, and psychosocial well-being out of 21 sample residents. Specifically, the facility failed to offer and provide a personalized activity program for four Residents (#1, #14, #7 and #2). Findings include: I. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the August 2025, diagnoses included neurogenetic disorder with Lewy bodies (type of dementia), chronic obstructive pulmonary disease (COPD) and dementia (gradual decline in mental abilities). The 6/12/25 minimum data set (MDS) assessment revealed the resident was rarely understood, had severe decision-making impairments and had both short-term and long-term memory impairments per staff assessment. She was dependent on staff for activities of daily living (ADLs). The 4/3/24 MDS revealed it was very important to the resident to listen to music she liked, to be around animals such as pets, t to do things with groups of people and to do her favorite activities, to go outside and get fresh air when the weather was good and to participate in religious spiritual practices. B. Observations On 8/6/25 at 9:45 a.m. Resident #1 was sitting in a wheelchair in the main television room. She was resting with her eyes closed. On 8/6/25 at 9:15 p.m. Resident #1 was sitting in her wheelchair in front of the television in the common area. On 8/7/25 at 9:40 a.m. Resident #1, at activities, was sleeping in a wheelchair, for coffee and conversation. On 8/7/25 at 10:00 a.m. Resident #1 was sitting in a wheelchair in the main television room and was asleep. On 8/11/25 at 9:41 a.m. Resident#1 was asleep in her wheelchair in the main television room. D. Record review The activities care plan, revised 3/19/25, revealed the resident enjoyed both independent and group activities. The care plan documented the resident enjoyed spiritual services, being in social areas, going outside (when weather permits), music, pets/animals, dancing in her wheelchair, visiting with family/friends, watching/listening to television and outings/van rides. The care plan documented the resident liked to be around people and enjoyed listening to music. Pertinent interventions included encouraging and assisting group activities and encouraging participation in the activities. The July 2025 and August 2025 (8/1/25 to 8/11/25) participation logs documented that the resident attended a variety of activities. -However, review of the participation logs did not reveal pet visits were provided per the residents preference. C. Resident #1’s representatives interview The resident’s representative was interviewed on 8/7/25 at 12:07 p.m. The resident’s representative said Resident #1 enjoyed being around people and listening to music. D. Staff interviews The activity director (AD) was interviewed on 8/11/25 at 4:00 p.m. The AD said Resident #1 enjoyed being involved in group activities. She said Resident #1’s interests included spiritual services, being in social areas, going outside, music, pet visits, dancing in her wheelchair, visiting with family,watching and listening to television and outings/van rides. The AD said she did not have any documentation that the resident was offered pet visits per her preference. II. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO diagnoses included polyneuropathy (nerve function causes numbness, burning pain, and muscle weakness in arms and legs), and stroke. According to the 4/25/25 MDS the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. She was dependent on staff for ADLs. The 10/23/24 MDS revealed it was very important to listen to music she liked, it was very important to be around animals such as pets, it was very important to do things with groups of people and to do her favorite activities. It was very important to go outside and get fresh air when the weather was good and to participate in religious spiritual practices. B. Observations On 8/6/25 at 2:26 p.m. the resident was sitting in the hallway with nothing to do. She was eating popcorn. On 8/6/25 at 3:06 p.m. the resident continued to sit in the hallway with no meaningful activities. The staff were passing her in the hallway but did not say anything to her as they passed her On 8/6/25 at 3:15 p.m. Resident #14 was in her wheelchair in the common area. The television was on, but the resident was not watching. On 8/6/25 at 3:24 p.m., the resin continued to sit in the common area. She was observed to use her feet to self propel herself slightly down the hallway. On 8/6/25 at 4:00 p.m. Resident #14 continued to sit in the hallway with no meaningful activities. The staff passed her, but did not acknowledge her as they passed her in the hallway. C. Record review The activity care plan, revised on 11/4/24, revealed the resident preferred to be involved in group and individual activities. Interests included activity cart, arts and crafts, being social areas, card and board games, going outside, self propelling around the facility and pets/animals. Pertinent interventions included providing supplies such as books, craft supplies and games, reminding and encouraging to assist and transport to activities as needed and encouraging participation in expressed individual group activities of interest. D. Staff interviews The AD was interviewed on 8/11/25 at 4:00 p.m. The AD said Resident #14 preferred to be involved in group and individual activities. The AD said the resident enjoyed the activity cart, arts/crafts, being in social areas, going outside, Bingo, self-propelling around the facility, word puzzles, music, physical activity, outings/trips, reading material, parties/socials, pets/animals, visiting with family and watching television. III. Resident #7 A. Resident status Resident #7, age greater than 65, admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic embolism and thrombosis of inferior vena cava (blood clot), dementia, glaucoma (disease that causes decreased vision) and hypertension (high blood pressure). The 7/25/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of four out of 10. The resident was dependent on staff for activities of daily living (ADL). The MDS assessment revealed it was very important for the resident to participate with groups of people, to listen to music, to go outside to get fresh air and participate in their favorite activities. B. Observations During a continuous observation on 8/6/25 beginning at approximately 10:07 a.m. and ending at 10:45 a.m. Resident #7 was sitting in her recliner in her room. She had nothing to do. There was no music was playing. The activities calendar posted in the hallway revealed there was coffee and chat at 10:30 a.m. The staff did not ask Resident #7 if she would like to participate in coffee and chat. On 8/6/25 at 2:45 p.m. Resident #7 was sitting in her wheelchair in her room. There was no music playing in her room and her television was off. The resident did not have any engaging activities. During a continuous observation on 8/6/25, beginning at 2:45 p.m. and ending at 3:24 p.m. the following was observed: At 3:05 p.m. Resident #7 yelled out, “Hey” at visitors walking past the room. No staff responded to Resident #7. At 3:08 p.m. Resident #7 yelled out, “Hey” at visitors walking past the room. No staff responded to Resident #7. At 3:10 p.m. Resident #7 yelled out, “Hey” at visitors walking past the room. No staff responded to Resident #7. At 3:13 p.m. the nurse consultant passed by the room of Resident #7 and the Resident yelled out, “hey.” The nurse consultant replied back with, “ hey” and never stopped to ask Resident #7 if she needed assistance. At 3:24 p.m. an unidentified CNA assisted Resident #7 from the bathroom placing her back in her wheelchair and leaving Resident #7 sitting alone in the middle of her room with nothing engaging in front of her. Staff did not offer an activity. On 8/6/25 at 3:50 p.m. Resident #7 was sitting in her wheelchair in the room alone with no activity, and no staff interacting with her. On 8/6/25 at 4:45 p.m. Resident #7 sitting in her wheelchair alone, still no meaningful activity or engagement. On 8/6/25 at 6:00 p.m. an unidentified staff member assisted Resident #7 back to her room leaving her alone in her wheelchair with no activity. On 8/7/25 at 11:37 a.m. Resident #7 was sitting in her wheelchair, with no meaningful activity in front of her. On 8/11/25 at 6:38 p.m. the courtesy activity cart was observed with coloring books, markers, outdated magazines, old books, and a container with random craft pieces. -The courtesy cart did not contain any materials for music, sensory or aromatherapy (see interview below). C. Resident #7’s representative interview The resident’s representative was interviewed on 8/7/25 at 12:04 p.m. The representative said activities were very important to Resident #7. The representative said the resident enjoyed being in a group activity or with other people. The representative said Resident #7 had told her that staff just wheeled her to her room and left her there. The representative said the resident had vision impairments, so she did not enjoy watching television. D. Record review The care plan, revised on 2/25/25, revealed the resident enjoyed many different activities. She preferred group activities and liked going outside, music, physical activities and visiting with family/friends. Pertinent interventions included encouraging the resident to participate and providing the resident supplies as needed. Review of the activity participation records from 7/1/25 to 8/11/25 did not reveal the resident was offered musical activities per her preference and showed no musical activity listed/offered. E. Staff interviews The AD was interviewed on 8/11/25 at 6:00 p.m. The AD said there were five activity staff available seven days a week. The AD said Resident #7’s participation was dependent on her roommate. The AD said if her roommate refused to participate in activities then Resident #7 would refuse. The AD said Resident #7 had vision impairments and was placed near the staff for assistance when she participated in the activities. The AD said Resident #7 was not currently on a one-to-one program but said that the resident would benefit from a one-to-one program three days a week The AD said the residents were offered a courtesy cart at all hours of the day. She said the cart included items like books, crafts, fidget toys, coloring supplies, radios for music and oils for aromatherapy. CNA #4 interviewed on 8/7/25 at 2:53 p.m. CNA #4 said Resident #7 enjoyed sitting in her recliner in the afternoons and people watching in the hallway. She also enjoyed going to meals early and would verbalize when she was done. IV. Resident #2 1.Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer’s disease, dementia and anxiety disorder. The 6/26/25 MDS assessment revealed the resident had both short term and long term memory impairments. The resident was severely cognitively impaired with a BIMS score of four out of 15. The resident was dependent on staff for ADLs. Resident #2 was unable to verbally communicate her needs. The 12/13/24 MDS assessment revealed it was somewhat important to be around animals and it was very important to go outside to get fresh air when the weather was good to listen to music she likes. B. Observations On 8/7/25 at 3:30 p.m. Resident #2 was in the restorative dining room for a manicure activity. She was in her wheelchair facing a wall, away from the other residents at the table. The staff did not interact with the resident or adjust the direction her wheelchair was facing. On 8/7/25 at 4:15 p.m. Resident #2 was in her wheelchair in front of the television in the common area. The resident was not engaged with the television. On 8/11/25 at 2:07 p.m. Resident #2 was in her wheelchair in the common area. Resident #2 was not engaged with the television. She appeared restless and fidgeting, folding herself in half at the waist while sitting in her wheelchair. C. Resident #2’s representatives interview Resident #2’s representative was interviewed on 8/11/25 at 2:25 p.m. She said she was under the impression that her mother spent most of her time in bed, unless it was time for lunch or dinner. She said her mother loves animals, but animals did not come to the facility. C. Record review Resident #2’s activity care plan, revised on 2/24/25, revealed Resident #2’s interests included arts/crafts, parties/socials, card/board games, going outside and pets/animals. Pertinent interventions included encouraging the resident to participate in expressed individual and/or group activities of interest. Review of Resident #2’s July 2025 and August 2025 (8/1/25 to 8/7/25) activity participation logs revealed activities including card/board games, pet visits and outdoor activities were not offered to the resident. Resident #2’s July 2025 and August 2025 (8/1/25 to 8/7/25) activity participation log revealed daily participation in independent TV time. D. Staff interview The AD was interviewed on 8/11 at 6:00 p.m. She said if a resident was non-interviewable, she would interview a family member to assess family structure, religion and preferred activities. The AD said Resident #2 had a sensory mat that should have been utilized when the resident appeared restless.

Based on observations, record review and interviews, the facility failed to ensure menus met the resident's nutritional needs.Specifically, the facility failed to ensure residents were provided adequate food to ensure they were not hungry after meals and in between meals. Findings include:I. Facility policy and procedure The Menu Planning and Requirements policy, dated 2020, was provided by the nursing home administrator (NHA) on 8/11/25 at 12:33 p.m. It revealed in pertinent part, Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served, (based on age, gender, physical activity, and state health), in accordance with the Dietary Reference Intakes/Recommended Dietary Allowances as issued by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, unless otherwise contraindicated by medical conditions and needs. Menus are planned in advanced and are varied for the same day of consecutive weeks. Cycle menus are to be planned for a minimum of one week or based upon specific state regulations.II. Resident group interviewA group interview was conducted on 8/7/25 at 2:00 p.m. with five residents (#18, #19, #20, #21 and #22) who were identified by the facility and assessment as interviewable. The residents said the following: -The meals did not always fill them up; and, -They were hungry when the meals were over, because they did not receive enough food at their meals. -Resident #19 said she was unable to eat any of the snacks which were provided because she did not have teeth. III. Menu extensionsThe menu extensions for the week of 8/6/25 to 8/13/25 were provided by the NHA on 8/7/25 at 1:40 p.m The extensions revealed the following:The 8/6/25 menu extensions revealed the following menu items and portion sizes for dinner:-One breast, lemon herb chicken;-One cup garden salad;-Fresh baked roll; and,-Peanut butter cookie.-The menu extensions did not indicate the size of the chicken breast to be served. The menu caloric needs for 8/6/25 revealed the menu provided 1537 calories for the day.The 8/7/25 menu extensions revealed the following menu items and portion sizes for dinner: showed the following:-Chicken strawberry salad; -A bread stick; and, -A slice of pie slice.-The menu extensions did not indicate how much chicken strawberry salad or pie to serve to each resident. IV. ObservationsOn 8/6/25 at 5:15 p.m. the evening tray line was observed. The residents were served a chicken breast which was approximately three ounces, a biscuit, eight ounce (oz) garden salad and a peanut butter cookie. -The menu extensions indicated the residents were to receive a dinner roll and not a biscuit (see extensions above).On 8/7/25 at 5:15 p.m., the evening meal was observed. The residents were served three oz of chicken strips, iceberg garden mix salad served with tongs, a two oz scoop of strawberries, a breadstick and a slice of pie which was approximately one inch thick.V. Staff interviewsThe registered dietitian (RD) was interviewed on 8/6/25 at 5:30 p.m. The RD said the facility had menu extensions which were to be followed. The RD said she has changed the menu and extensions when residents did not like an entree. She said she reviewed the menus to ensure they met the needs of the residents. She said that she kept their daily calorie intake for the meals between 1700 and 1800 with room for snacks. -However, the extensions revealed the total calories provided on 8/6/25 was 1537 calories, which was below what the RD recommended for daily caloric intake (see menu extensions above). She said if a resident was losing weight then the protein pudding was utilized and also the resident was assessed for health shakes. The RD said that snacks were always available if residents were hungry. She said there were rice crispies, cheese crackers and various other snack items.The cook was interviewed on 8/7/25 at 5:15 p.m. The cook said he was not aware how the pie was cut and into how many portions. The cook agreed the pieces were small.

Based on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#8) of two residents out of 21 sample residents. Specifically, the facility failed to ensure nursing staff followed the physician ordered pain parameters when administering as needed (PRN) pain medication to Resident #8.Findings include:I. Facility policy and procedureThe Pain Management policy, dated 2025, was provided by the nursing home administrator (NHA) on 8/11/25 at 4:14 p.m. It read in pertinent part, The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The facility, in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment.II. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia, anxiety, subsequent encounter for fracture with routine healing, abnormalities of gait and mobility, generalized muscle weakness and a history of falls.The 8/6/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She was dependent on staff for partial to moderate assistance for activities of daily living (ADL). B. Record reviewReview of Resident #8's August 2025 CPO revealed the following physician's orders:Pain Scale 1-10 or [NAME] pain scale, 1-3 mild pain, 4-6 moderate, and 7-10 severe. Tolerable pain level is 3 out of 10, ordered 10/1/24.Acetaminophen oral tablet, give 650 mg by mouth every eight hours as needed for mild and moderate pain, ordered 7/1/25;Tramadol HCI oral tablet 50 mg, give one tablet by mouth every eight hours as needed for severe pain, ordered 7/1/25. Review of Resident #8's August 2025 medication administration records (MAR) revealed the resident received Tramadol PRN on the following dates:-On 8/1/25 for a pain level of 5;-On 8/2/25 for a pain level of 5;-On 8/3/25 for a pain level of 5;-On 8/8/25 for a pain level of 5;-On 8/9/25 for a pain level of 5; and,-On 8/10/25 for a pain level of 6.-However, per the physician's orders for pain medication parameters, Resident #8 should have been administered acetaminophen, not tramadol, for a pain level of 5 or 6. III. Staff interviewsRegistered nurse (RN) #3 was interviewed on 8/11/25 at 10:45 a.m. RN #3 said Resident #8 had generalized pain from arthritis. She said after a PRN pain medication was administered she would return in an hour to check on the effectiveness. The director of nursing (DON) and the corporate nurse consultant were interviewed together on 8/11/25 at 2:40 p.m. The DON said the facility used the [NAME] pain scale and the faces pain scale for nonverbal residents. The DON reviewed Resident #8's electronic medical record (EMR) and confirmed the tramadol was not administered according to the physician's orders and parameters.

Based on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#9 and #16) of the three residents reviewed for oxygen use out of 21 sample residents.Specifically, the facility failed to:-Ensure Resident #9 and #16 did not run out of oxygen in their portable oxygen tanks; and,-Ensure staff used the appropriate personal protective equipment (PPE) when filling residents' portable oxygen tanks.Findings include: I. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - blocks air flow and makes it difficult to breathe), lower respiratory infection (infection in lower airways of the lungs) and chronic respiratory failure with hypoxia (lungs are unable to oxygenate the blood adequately). The 5/7/25 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. The resident required assistance with activities of daily living (ADL). The MDS assessment revealed the resident required oxygen use. B. Observations On 8/6/25 the following observations were made: At 11:00 a.m. Resident #9 was sitting in her wheelchair with oxygen on and engaged in an adult diamond art kit. At 12:08 p.m. Resident #9 called out for certified nurse aide (CNA) #1 and asked her to check her portable oxygen tank level. At 12:10 p.m. CNA#1 walked over to Resident #9 and pulled her oxygen tank out of its carrying case. CNA #1 checked the oxygen tank level and found the portable oxygen tank to be empty. Resident #9 said she did not feel oxygen coming out of the nasal cannula in her nose. CNA #1 went to fill the oxygen tank. C. Record review The oxygen care plan, initiated 3/10/25, identified that the Resident #9 was on supplemental oxygen related to the diagnosis of COPD. The resident was to receive oxygen via nasal cannula continuously at 2 liters per minute (LPM). Pertinent interventions included ensuring the resident received oxygen as ordered. -The care plan did not indicate how often staff were to check the resident’s portable oxygen tank to ensure that it was full. Review of Resident #9’s August 2025 CPO revealed a physician’s order for continuous oxygen at 2 LPM via nasal cannula. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2025 CPO, diagnoses included epilepsy (seizures), prior stroke, thyroid disease, anxiety, COPD and depression. According to the 7/16/25 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required substantial/maximal assistance to toilet transfer. The MDS assessment indicated the resident used oxygen. B. Observations and staff interview On 8/6/25 at approximately 1:15 p.m., CNA #3 checked Resident #16’s portable oxygen tank and found it to be empty, as indicated by a steady red light. CNA #3 appeared surprised and said the oxygen tank should not have been empty already, as she had refilled it earlier that morning and expected it to still be full. She said she suspected a possible malfunction with the tank. She said earlier that morning, immediately after refilling it, she observed the oxygen tank’s dial light spinning in circles, which was abnormal. She said the oxygen tank might be broken, which could explain both the spinning dial movement and the oxygen tank being empty that early. C. Record review The oxygen care plan, revised 5/6/25, identified Resident #16 used oxygen. The resident was dependent on oxygen therapy and received 2 LPM via nasal cannula at night. The resident’s goal was to have no signs or symptoms of poor oxygen absorption or sleeping issues with oxygen use at night. Interventions included ensuring the resident's oxygen tubing was long enough for the resident to move around, encouraging her to wear the oxygen and giving oxygen as ordered and reporting any issues to the nurse or physician if the resident had any issues with oxygen levels. Review of Resident #16’s August 2025 CPO revealed a physician’s order for continuous oxygen via nasal cannula at 2 LPM. III. Staff interview The DON was interviewed on 8/11/25 at 8:06 p.m. The DON said she expected residents’ portable oxygen tanks to be filled before meals and after meals. She said the night shift staff filled the oxygen tanks before residents went to bed and in the morning as well. The DON said after being notified that Resident #9 and Resident #16’s portable oxygen tanks were empty, she had put a plan in place (during the survey) to ensure the oxygen tanks were checked on a more frequent basis. The DON said Resident #16’s oxygen tank may have been broken as she had heard it was spinning and it may have not been reading correctly. The DON said she would talk with the respiratory equipment provider and provide Resident #16 with a new portable oxygen tank if the old one was faulty. The DON said when the portable oxygen tanks were filled, the staff were to wear the appropriate PPE, which included an apron, gloves and a face shield. IV. Facility follow-up The DON provided a notebook on 8/7/25 at approximately 11:00 a.m. with an audit log. The log included all residents who had oxygen orders. The log indicated the facility began oxygen audits to ensure oxygen tanks were checked at the start of the shift and every two hours. The audit log indicated if the oxygen tanks were less than a quarter full, the oxygen tank would be filled immediately. The new process indicated if the oxygen tanks were found empty, the charge nurse should be notified.

Based on observation, record review and interviews, the facility failed to ensure three (#13, #17 and #5) of four residents reviewed for accidents out of 24 sample residents remained free from accidents. Resident #13, who was identified with osteoporosis after a pathological (fracture caused by disease processes rather than trauma) right femur fracture (thigh bone above the knee) that required hospitalization and surgery on 6/22/24, sustained a non-displaced [NAME] fracture (an ankle injury that involves a fracture of the proximal fibula) on 1/12/25. The facility failed to ensure and document a root cause analysis and implement timely person-centered interventions after Resident #13 sustained a right femur fracture on 6/22/24. Additionally, the facility failed to schedule osteoporosis screening and treatment which was recommended after the resident had surgical repair to the fractured right femur. The facility failed to ensure and document a root cause analysis and implement timely person-centered interventions after Resident #13 sustained the right fibula fracture on 1/12/25. Additionally, Resident #17 was admitted to the facility on [DATE]. Upon admission the facility implemented fall interventions as the resident was determined to be a fall high risk. On 11/17/24 Resident #17 sustained an unwitnessed fall and sustained a concussion, a contusion (bruise) to the knee, a laceration of the forehead and cervical strain related to her fall. The facility updated the resident's fall care plan on 11/22/24 to include placing a floor mat at her bedside whenever she was in bed. However, observations revealed the facility did not consistently implement the fall mat while the resident was in bed (see observations below). On 1/11/25 Resident #17 sustained another unwitnessed fall when she attempted to self-transfer from her wheelchair to her bed. The fall care plan did not document any new interventions. The facility initiated 15-minute checks overnight for the resident on 1/16/25, however the facility did not update the resident's care plan to include the 15-minute checks. On 2/3/25 Resident #17 sustained another unwitnessed fall, the cause of which was not determined. Resident #17 sustained another unwitnessed fall on 2/4/25 when she attempted to self-transfer from her wheelchair to a sofa in the main living area. Upon evaluation, it was found Resident #17 sustained sacral insufficiency fractures (stress fracture). The facility failed to implement new person-centered fall interventions to prevent future falls. Also, the facility failed to complete a thorough root cause analysis to determine how Resident #5 obtained a skin tear. Findings include: I. Facility policy and procedure The Incidents/Accidents policy and procedure, revised September 2016, was provided by the nursing home administrator (NHA) on 2/27/25 at 3:11 p.m. It read in pertinent part, All incidents/accidents are to be documented. In the progress notes document the date time and location of the incident/accident; document any assistive devices in use; vital signs should be documented; document a full description of any injuries; any resident statement of the account of the incident; document only what was observed; indicate when the physician was notified and any orders; indicate when the legal representative was notified. II. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, type 2 diabetes mellitus (DM), displaced fracture of right lower femur and non-displaced [NAME] fracture of right fibula. The 1/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. She was dependent on staff for toileting, personal hygiene, required substantial/maximal assistance with bed mobility, transfers and required set up assistance with eating. The assessment did not document the diagnoses of osteoporosis (disease that weakens the bones). -However, review of Resident #13's electronic medical record (EMR) revealed the resident had a diagnosis of osteoporosis. B. Observations On 2/24/25 at 1:00 p.m. Resident #13 was sitting in her room in a wheelchair with her feet down and resting on the foot rests on her wheelchair. Her right leg was in a splint. Resident #13's call light was lying on the floor next to the resident's wheelchair. A foot board (a special padded board that attaches onto the wheelchair foot rests to keep feet from sliding off) was not on Resident #13's wheelchair. On 2/24/25 at 2:00 p.m. Resident #13 was sitting in her room in a wheelchair with her feet down and resting on the foot rests on her wheelchair. Her right leg was in a splint. Resident #13's call light was lying on the floor next to the resident's wheelchair. A foot board was not on Resident #13's wheelchair. C. Resident #13's representative interview Resident #13's representative was interviewed on 2/24/25 at 2:34 p.m. Resident #13's representative said she was told by a certified nurse aide (CNA), after Resident #13 returned from the hospital on 1/12/25, that she had transferred Resident #13 by herself and pivoted Resident #13 from the wheelchair to the bed. She said she had a care conference with the facility after the 1/12/25 fracture and told the facility because of Resident #13's fractures that two people needed to transfer her at all times for safety reasons. She said the facility told her that they would be using a hoyer lift with two people at all times. D. Record review 1. Care plan The activities of daily living (ADL) care plan, initiated 4/12/23, indicated Resident #13 had impaired physical mobility due to a right lower extremity fracture. Interventions included non-weight bearing on the right lower extremity (initiated 6/30/24 and revised 1/16/25) and required two people with the use of a hoyer lift (initiated 7/16/24 and revised 1/16/25). The osteoporosis care plan, initiated 1/14/25, indicated Resident #13 had bone loss. Interventions included staff to observe for complaints of pain, completing labs per orders and reporting to the physician. The fall/injury care plan, initiated 4/6/23, indicated Resident #13 was at risk for falls and injury. Interventions included assisting with transfers/ambulation as needed (initiated 4/6/23), completing fall risk assessment upon admission and quarterly (4/6/23), instructing and reinforcing safety awareness measures (4/6/23), keeping call light in reach (4/6/23), non skid socks/footwear (initiated 6/28/24 revised 6/28/24), encouraging bed to be in low position (initiated 6/28/24) and wheelchair with foot pedals and foot board at all times (initiated 1/15/25). -However, observations revealed the resident did not have a foot board in place on her wheelchair (see observations above). -A review of the comprehensive care plan revealed the osteoporosis care plan was not initiated until 1/14/25, the wheelchair foot boards was initiated on 1/15/25 and the use of the Hoyer lift with two people was re-initiated on 1/16/25, after Resident #13 experienced a second right lower extremity fracture. 2. Incident on 6/22/24 The 6/22/24 nursing progress note, documented at 12:30 p.m., revealed Resident #13's right knee was swollen and she was unable to bend her knee. The nurse practitioner was notified. Vital signs were taken. The resident was administered Tylenol for pain in her right knee. The resident was sent out to the hospital for evaluation and treatment. The 6/22/24 physical abuse investigation documented Resident #13 complained of pain in her right knee which was revealed to be a fracture above her knee. On 6/22/24, in the morning, Resident #13 was a stand pivot transfer by a CNA and had been up to the shower, up in her wheelchair for activities and laid down after lunch. Resident #13 denied anyone hurting her and there were no behavior changes. Staff were interviewed and did not witness any event that was a causative factor. Resident #13 was admitted to the hospital and required surgery to her right lower femur (thigh bone). The surgical report revealed specialized clips were used due to her brittle bones. The report of physical abuse was unsubstantiated. -However, there was no identification of a root cause analysis being completed after the resident sustained a right lower femur fracture and there were no person-centered interventions implemented after the resident sustained the fracture. The 6/22/24 hospital progress note documented Resident #13 had a displaced fracture of the right femur and was admitted for orthopedic consult and possible surgery. The 6/24/25 hospital physical therapy (PT) note documented Resident #13 was up with two person assistance using a stand-pivot transfer on the left. Right lower extremity precautions were weight-bearing as tolerated for transfers. The 6/25/24 hospital progress note documented Resident #13 had an open reduction internal fixation (ORIF) of the right femur (a surgical procedure to realign the bone and stabilize the fracture), done on 6/23/24. It recommended an outpatient osteoporosis screening and treatment. -However, the facility failed to schedule the osteoporosis screening until March 2025, nine months after it was recommended (see facility follow up below). -A review of the EMR failed to reveal an interdisciplinary team (IDT) risk management review note of the 6/22/24 incident and root cause analysis with any interventions that needed to be implemented to prevent any further fractures. Review of the July 2024 CPO revealed the following physician's orders related to transferring the resident: -Use a Hoyer lift for transfers, ordered 7/8/24 and discontinued 7/15/24. -Weight bearing as tolerated for transfers only to the right lower extremity, ordered 7/15/24 and discontinued 7/17/24. The 8/8/24 PT discharge summary notes documented Resident #13 was substantial/maximal assistance for transfers. Review of the August 2024 CPO revealed a physician's order for the resident to be weight-bearing as tolerated, ordered on 8/16/24 and discontinued 1/12/25. 3. Incident on 1/12/25 The 1/12/25 nursing progress note documented Resident #13 was calling out in pain and had swelling and heat in her right knee and ankle. The physician was notified and an x-ray was requested of the knee and ankle. The resident was given ibuprofen for pain per physician's order. The 1/12/25 nursing progress note documented the x-ray report identified a spiral fracture to the right lower extremity. Resident #13 was sent to the hospital emergency room for evaluation and treatment. The 1/12/25 nursing progress note documented the resident returned to the facility with a cast. The 1/12/25 physical abuse investigation documented Resident #13, before she got up in the morning, complained of pain to her right leg with swelling in her right knee and ankle. The right knee and ankle were warm to the touch. The physician was notified and an x-ray was obtained. The x-ray results indicated a spiral fracture to her right lower extremity. The resident was sent to the hospital for further evaluation and treatment. The resident had no recent history of falls or trauma. The activities director (AD) reported that on 1/11/25 the resident turned herself in her wheelchair which caused the affected leg to be twisted in front and outside the front of the wheel. CNA #4 reported on 1/11/25 she changed Resident #13 before getting her up for dinner and she grimaced and complained of leg pain. She asked the nurse to assess her and the nurse gave her medication for pain. CNA #4 said she was then able to transfer Resident #13 to the wheelchair with a gait belt. The report of physical abuse was unsubstantiated. -However, there was no summary of a root cause in the physical abuse investigation or identification and implementation of interventions to prevent future fractures. Review of the January 2025 CPO revealed a physician's order to use a Hoyer lift for transfers, ordered 1/12/25. The 1/15/25 quarterly care conference documented Resident #13's transfers were to be with a Hoyer lift with two people at all times. -A comprehensive review of the resident's EMR failed to reveal an IDT risk management review note of the 1/12/25 incident and root cause analysis with interventions that needed to be implemented to help prevent any further fractures. E. Staff interviews Registered nurse (RN) #1 was interviewed on 2/26/25 at 10:00 a.m. RN #1 said Resident #13 was totally dependent on staff for transfers and required two person assist with the use of a Hoyer lift. She said prior to the most recent fracture, she was a one person extensive assistance with pivot transfers. CNA #2 was interviewed on 2/26/25 at 11:10 a.m. CNA #2 said Resident #13 was full weight-bearing before she fractured her femur bone in June 2024. She said after Resident #13 returned from the hospital in June 2024, Resident #13 required the use of a Hoyer lift until PT cleared her to be a two person transfer assist. She said Resident #13 needed a Hoyer lift after she experienced a fracture in her right leg in January 2025 for safety reasons. The director of rehabilitation (DOR) was interviewed on 2/26/25 at 11:20 a.m. The DOR said that prior to her fracture in June 2024, Resident #13 was full weight-bearing. The DOR said after Resident #13 returned from the hospital, she was maximum assistance of two people for transfers. He said an order for a Hoyer lift was in place from 7/8/24 to 7/17/24 and then she was cleared to be weight-bearing as tolerated on her right lower extremity with one to two person assistance. He said after her second fracture, she was required to be a Hoyer lift. He said he did education with nursing staff at that time on transfers, Hoyer lift use and how to manage her splint/cast. The director of nursing (DON) and the NHA were interviewed together on 2/26/25 at 11:55 a.m. The DON said prior to Resident #13's fracture in June 2024, there were no precautions in place and she was a one person pivot transfer. She said prior to the fracture in June 2024, staff were assisting Resident #13 in the morning and she was complaining of right knee swelling and pain after they put her back to bed. She said the staff noticed at that point that her right knee was swollen. She said during the investigation and staff interviews, they were unable to identify any events that happened before that may have contributed to the fracture. The DON said it was not identified until after Resident #13 had surgery in June 2024 that she had a significant osteoporosis. The DON said after Resident #13 returned from the hospital she was a two person Hoyer lift for transfers and worked with therapy to build up her strength and endurance. She said in August 2024 PT felt she could stand and pivot with her lower extremities. The DON said during the physical abuse investigation for the fracture in January 2025, staff indicated that on 1/11/25 Resident #13 was observed by staff members to be moving her wheelchair herself and had caught her right leg in front of the wheel on her wheelchair and may have twisted it. She said they reviewed camera footage and Resident #13 moved herself around in her wheelchair with poor safety awareness and would catch her leg against the door. She said Resident #13 did complain of some increased pain in the evening of 1/11/25 that was medicated with Tylenol. She said when staff tried to get Resident #13 up in the morning for breakfast Resident #13 was complaining of extreme right knee pain. The DON said staff then noticed her knee was red and swollen. She said the physician was notified and an x-ray was ordered. She said when the results of the x-ray came back positive for a fracture, Resident #13 was sent to the hospital for further evaluation and treatment. She said after she returned from the hospital, the intervention that was implemented for Resident #13 was to make her a two person Hoyer lift for safety reasons. The NHA said the facility had incident reports and physical abuse investigations which summarized their findings. She said the facility did not have a formal IDT root cause analysis which documented the findings with interventions in the resident's EMR. She said their process was informal and verbal. CNA #4 was interviewed on 2/27/25 at 1:15 p.m. CNA #4 said Resident #13 was a one pivot transfer prior to her fracture in January 2025. She said on 1/11/25 Resident #13 was up for breakfast and went to activities. She said she laid Resident #13 back down after activities. She said she tried to get Resident #13 up and she was tearful and complaining of right knee pain. She said she contacted the nurse to assess and Resident #13 was medicated with Tylenol. She said she was contacted by the facility later that Resident #13 had experienced a leg fracture. She said the facility watched the cameras for the day and they saw Resident #13 had reached down after she had twisted her leg. She said she was not aware of any other additional interventions to help prevent fractures. She said Resident #13 had foot pedals but she would take her feet off the pedals to self propel herself in the wheelchair. E. Facility follow up The facility fractures root cause analysis and timeline was provided by the NHA on 2/28/25 at 5:10 p.m. (after the survey). It documented the undated root cause of the 6/22/24 femur fracture was due to Resident #13's bone demineralization that was identified during surgery. The exact cause of the fracture was unknown. Interventions included transfers with a Hoyer lift and working with PT. On 7/15/24 she had an order by orthopedics that she could be weight-bearing as tolerated for transfers only. She was discharged from PT on 8/19/24 with a substantial maximal assistance of one person for transfers and remained wheelchair bound for mobility. The 1/12/25 fracture root cause analysis, undated, identified Resident #13's osteoporosis as a contributing factor. The resident was participating in activities and the facility suspected the resident twisted her leg when independently moving her wheelchair. Resident #13 was identified to lock her wheelchair and then tried to move forward and dragged her leg. After returning from the hospital to the facility, she was a Hoyer lift transfer, a footboard was to be in place and two people assisted for care. PT services were involved for strengthening of the upper extremity, ADLs and wheelchair positioning. The medical director letter, undated, documented a nondispaced spiral fracture of the right tibia and closed fracture of the proximal right fibula which were due to demineralization of the bone, severe peripheral vascular calcification and advancement of her comorbidities. A DEXA scan (a scan that measures bone density) was scheduled for March 2025. -However, osteoporosis screening and treatment was ordered nine months after osteoporosis was identified during an ORIF to the right femur and two months after Resident #13 sustained a second fracture to her right lower extremity. 50219 III. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia, generalized muscle weakness, osteoarthritis, osteoporosis and a history of falling. The 2/13/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS assessment score of three out of 15. The resident was dependent on staff for most ADLs. B. Resident friend and representative interviews Resident #17's friend was interviewed on 2/26/25 at 1:30 p.m. The resident's friend said she felt Resident #17 was declining and wanted to sleep all the time. The resident's friend said Resident #17 had fallen several times at the facility, during which she had fractured her tailbone and had received seven stitches in her head. The resident's friend said the falls were serious. The resident's friend said there was someone sitting with Resident #17 for ten hours per day. The resident's representative was interviewed on 2/26/25 at 1:32 p.m. The resident's representative said Resident #17 had several falls within the months prior and sustained some injuries. The resident's representative said she thought some of Resident #17's falls had been the result of her trying to get out of bed without calling for help due to her dementia. She said she had asked the facility staff how they could prevent her falls, to which the facility said they were trying to monitor Resident #17 more closely. C. Resident observations On 2/25/25 at 1:11 p.m. Resident #17 was lying in her bed. The fall mat was folded up beside the one-on-one caregiver's chair. On 2/26/25 at 9:24 a.m. Resident #17 was lying in the fetal position in her bed. The fall mat was not in place and was folded up beside the one-on-one caregiver's chair. On 2/27/25 at 1:35 p.m. Resident #17 was lying in her bed. The fall mat was folded up beside the one-on-one caregiver's chair. D. Record review The fall care plan, initiated 10/7/24, revealed Resident #17 was at an increased risk of falls and/or serious injury related to falls due to a recent fall resulting in fractured vertebrae and antidepressant medication use. Pertinent interventions, initiated on 10/7/24, included encouraging Resident #17 to have the bed in lowest position, encouraging non-skid socks and footwear, keeping frequently used items within reach, assisting with transfers as needed and administering medications as ordered. An intervention for a floor mat at bedside while Resident #17 was in bed was initiated on 11/22/24. -However, Resident #17's care plan was not updated after her falls on 1/11/25, 2/3/25 and 2/4/25 (see below). A fall risk evaluation, dated 10/2/24, revealed Resident #17 was at a high risk for falling. A progress note, dated 11/8/24 at 2:33 p.m., revealed Resident #17 was discharged from skilled services with physical therapy. An order for an anti-rollback device for Resident #17's wheelchair was placed due to the resident transferring without asking for assistance because of her dementia. A progress note, dated 11/11/24 at 10:46 a.m. revealed the facility received orders to place an anti-rollback device on Resident #17's wheelchair. -However, review of Resident #17's care plan did not reveal documentation regarding the implementation of anti-rollbacks for Resident #17. 1. Fall incident on 11/17/24 - unwitnessed A fall risk evaluation, dated 11/17/24 at 12:34 p.m., revealed Resident #17 was at a high risk for falling. A progress note, dated 11/17/24 at 4:43 a.m., revealed Resident #17 was found on the floor at 3:45 a.m. by a CNA. Resident #17 had blood on her gown and was bleeding from her head. Resident #17's vital signs and neurological examination were within normal limits. The nurse performing the assessment alerted Resident #17's provider and received orders to send the resident out for evaluation. Resident #17 was transferred to the emergency room at 4:05 a.m. The facility fall report, dated 11/17/24 at 4:28 a.m., revealed Resident #17 was found on the floor with her head underneath her bed. The resident's bed was in the lowest position. The report documented it appeared Resident #17 had been trying to get up and had repeatedly hit her head against the bars underneath the bed as evidenced by blood on them. Resident #17's bed was moved away from her to avoid further injuries. An abrasion was noted to the top of Resident #17's scalp. The report documented the predisposing environmental factors included the furniture and poor lighting. The report documented predisposing physiological factors included incontinence, weakness, and gait imbalance. -The report did not identify a root cause of Resident #17's fall or include what interventions were put into place. Hospital notes, dated 11/17/24 at 9:46 a.m., revealed Resident #17 presented to the emergency room after a sudden fall at the facility. Resident #17 sustained a concussion, contusion of the knee, laceration of the forehead, requiring stitches, and cervical strain related to her fall. A progress note, dated 11/17/24 at 10:10 a.m., revealed Resident #17 had returned to the facility. Resident #17 had swelling and bruising to both eyebrows, both eyelids and both knees. Resident #17 had seven stitches in place over the left side of her forehead. An administrative note, dated 11/18/24, revealed Resident #17 was found on the floor next to her bed during the night. The facility staff determined Resident #17 had increased confusion. A floor mat was added for a fall intervention. -However, observations during the survey revealed the floor mat was not consistently utilized. 2. Fall incident on 1/11/25 - unwitnessed A fall risk evaluation, dated 1/11/25 at 4:00 p.m., revealed Resident #17 was at a high risk for falling. A progress note, dated 1/11/25 at 4:00 p.m., revealed Resident #17 had an unwitnessed fall in her room after she self-transferred from her wheelchair to her bed. Resident #17 was assessed by the nurse and her vital signs and neurological assessment were within normal limits. Resident #17 denied any pain and her skin was intact without evidence of injury. Resident #17 was encouraged to use the call light to request assistance from the staff. The provider and Resident #17's representatives were contacted. The facility fall report, dated 1/11/25 at 4:00 p.m., revealed Resident #17 was found on the floor next to her bed. Resident #17 was sitting on top of a blanket which was on top of her floor mat. Resident #17 was sitting on her buttocks with her legs out in front of her. Resident #17 was wearing regular (not non-skid) socks and her shoes were across the room. Resident #17's wheelchair was within her reach. Resident #17 had attempted to self-transfer without calling for assistance. Resident #17 was encouraged to call for help if she wanted to get into bed. The report documented physiological factors included gait imbalance, impaired memory and weakness. The report documented predisposing situational factors included ambulating without assistance and improper footwear. An administrative note, dated 1/15/25, revealed Resident #17 was transferring herself without non-skid socks. Resident #17 was given non-skid socks and given education to wear the socks at all times to help with transferring herself. Resident #17 was educated on calling for assistance when attempting to transfer herself and having staff assist her with transfers. -However, review of the resident's care plan revealed non-skid socks were implemented on 10/7/24 and a new person-centered intervention was not implemented after the fall on 1/11/25. 3. Fall incident on 2/3/25 - unwitnessed A fall risk evaluation, dated 2/3/25 at 3:44 a.m., revealed Resident #17 was at a high risk for falling. A progress note, dated 2/3/25 at 2:50 a.m., revealed Resident #17 was found lying on the floor next to her bed. Resident #17 said she did not know how she got on the floor, but said she hit everything on her body very hard on the floor and that her buttocks hurt. Resident #17 was assessed by the nurse and her vital signs and neurological assessment were within normal limits. Resident #17 did not have any obvious signs of injury. Resident #17 was assisted back into bed and repositioned for comfort with her call light within reach. The facility fall report, dated 2/3/25 at 2:50 a.m., revealed Resident #17 was found out of bed lying on the floor. Resident #17 said she did not know what she was doing. Resident #17 said she hit the floor hard and that her buttocks hurt. The report documented predisposing physiological factors included gait imbalance and impaired memory. The report documented predisposing situational factors included ambulating without assistance and improper footwear. Resident #17 was out of bed without assistance and was not wearing any footwear. Resident #17's call light was within reach. A progress note, dated 2/3/25 at 12:30 p.m., revealed the facility received new orders for x-rays of Resident #17's lumbar spine, sacrum and both hips. Resident #17's representative was notified of these new orders. A progress note, dated 2/3/25 at 5:47 p.m., revealed Resident #17 was being monitored for a witnessed fall (however, the fall was unwitnessed). Resident #17 said she had pain in her sacral area. Resident #17 was receiving acetaminophen every six hours as needed and had a new order for tramadol as needed, but the tramadol was not available at that time. Resident #17 did not have much of an appetite due to her pain. -The report did not identify a root cause of Resident #17's fall or include what person-centered interventions were implemented. A progress note, dated 2/4/25 at 8:40 a.m., revealed Resident #17's x-ray results revealed she did not have any acute fractures. 4. Fall incident on 2/4/25 - unwitnessed A progress note, dated 2/4/25 at 8:57 a.m., revealed Resident #17 was lying on the floor in the hallway after breakfast. Resident #17 said she fell out of her wheelchair. The nursing staff at were not able to determine if Resident #17 hit her head during the fall. Resident #17 was yelling out in pain when trying to move. Resident #17 was sent to the emergency room for evaluation. A hospital note, dated 2/4/25 at 1:33 p.m., revealed Resident #17 presented to the emergency room after a fall at the facility. Resident #17 had pain in her buttocks and left leg and hit her head. The hospital note documented the facility staff reviewed camera footage after the incident and saw Resident #17 fall forward onto the ground from her wheelchair. Resident #17 was found to have bilateral sacral insufficiency fractures. A progress note, dated 2/4/25 at 3:31 p.m., revealed Resident #17 returned to the facility. Resident #17 had a non-operable sacral insufficiency fracture and was ordered acetaminophen for her pain. A progress note, dated 2/4/25 at 6:02 p.m., revealed Resident #17 had been found in the common area after breakfast that morning and tried to lie down or transfer herself to the couch. Resident #17 was found on the floor on her side. Resident #17 was wearing shoes and the anti-rollback device was on her wheelchair. Resident #17 was assessed for injury but was unable to move her limbs related to her pain. Resident #17's practitioner and representative were contacted and the resident was sent to the emergency room for evaluation. An administrative note, dated 2/6/25, revealed Resident #17 was sitting in the common area waiting for breakfast. Resident #17 was uncomfortable and attempted to transfer herself to the couch. She was found on the floor in front of her wheelchair. Resident #17 had a fall the night prior. Resident #17 had fallen early in the morning for both falls. Resident #17 had a one-on-one companion at the time of the note while her pain management was addressed. -Review of the resident's care plan did not identify a new person-centered intervention that was implemented following the fall and did not include the one-to-one companion. A progress note, dated 2/12/25 at 1:40 p.m., revealed Resident #17 was moved to a new room. An interdisciplinary team progress note, dated 2/14/25 at 8:58 a.m., revealed Resident #17 had a recent fall. The team would continue to focus on pain management and positioning for Resident #17. Resident #17 was added to a one-on-one activity program. E. Staff interviews CNA #1 was interviewed on 2/26/25 at 2:43 p.m. CNA #1 said fall interventions were found in the resident's Kardex (staff directive tool). CNA #1 said the Kardex detailed if the resident needed a floor mat, how they needed to be transferred, and if they were a high fall risk. CNA #1 said Resident #17 wanted to

Based on observations, 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 (#30) of three residents reviewed for catheters out of 24 sample residents. Specifically, the facility failed to: -Obtain physician's orders for the use of Resident #30's catheter; and, -Maintain documentation for Resident #30's catheter care and maintenance. Findings include: I. Facility policy and procedure The Care of an Indwelling Catheter policy and procedure, undated, was received from the nursing home administrator (NHA) on 2/27/25 at 3:04 p.m. It read in pertinent part, Routine catheter care helps prevent infections and other complications, and is usually performed daily and as needed. Record/report the care performed, the condition of the perineum and urinary meatus, the character of the urine and/or any sediment build-up, and intake and output as ordered. II. Resident # 30 A. Resident status Resident #30, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included end-stage renal disease, dementia, retention of urine and obstructive and reflux uropathy (conditions that cause urine to go back up the ureters and potentially damage the kidneys). The 2/7/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident had an indwelling urinary catheter. B. Observations On 2/24/25 at 11:11 a.m. Resident #30 was lying in bed with his urinary catheter bag clipped to his bed. C. Record review Review of hospital notes, dated 1/28/25 at 8:38 a.m., revealed Resident #30 had a urinary catheter placed during his stay at the hospital on 1/25/25 and was to continue to use the foley catheter. A review of Resident #30's February 2025 CPO revealed the following physician's orders: Indwelling foley catheter. May flush foley catheter with normal saline and may change foley catheter when there is evidence of obstruction or catheter malfunction, suspected infection, or compromise to the closed system, ordered 2/27/25 (during the survey). 1.) With mild soap and water wash area by wiping away from, never toward, the urinary meatus. 2.) Clean catheter of feces to minimize bacterial migration into the urethra and bladder. 3.) Do not pull on the catheter while cleaning it. 4.) Gently pat dry. 5.) Place the collection bag below bladder level. 6.) Place a cover over the collection bag for resident dignity. 7.) Ensure foley stabilization device is in place to prevent dislodgement/pulls on the catheter line. Allow one inch of slack, ordered 2/26/25 (during the survey). -The facility failed to obtain physician's orders for the flushing and maintenance of Resident #30's indwelling urinary catheter prior to the survey). Review of Resident #30's indwelling catheter care plan, initiated 2/5/25, revealed Resident #30 had a foley catheter in place for his urinary retention. Pertinent interventions included providing care and changing the catheter per physician order and performing catheter care every shift. A document, dated 2/7/25, revealed Resident #30 had a chronic foley catheter. Resident #30's practitioner documented the resident had obstructive uropathy present on admission, urinary retention and benign prostatic hyperplasia. -Review of Resident #30's catheter care task documentation, reviewed from 1/29/25 through 2/27/25, did not reveal any documented catheter care for the resident. Review of Resident #30's foley catheter output task documentation, reviewed from 1/29/25 through 2/27/25, revealed Resident #30 had urinary output recorded at least once per day from 2/13/25 through 2/26/25. Foley catheter output was recorded once per day on 2/16/25, 2/21/25, 2/23/25 and 2/26/25. -Urinary output was not recorded from 1/29/25 through 2/12/25, despite Resident #30 having a foley catheter in place. -Urinary output was recorded only once per day, rather than during each shift, on several days during the timeframe reviewed. -Review of Resident #30's January 2025 treatment administration record (TAR), from 1/29/25 through 1/31/25, did not reveal any documentation of urinary catheter care or maintenance. Review of Resident #30's February 2025 TAR revealed the following: Urinary catheter cleaning instructions (see February 2025 CPO above), initiated 2/26/25 (during the survey), was marked as completed on the evening of 2/26/25. -There was no documentation of urinary catheter care or maintenance on the February 2025 TAR prior to 2/26/25. -Review of progress notes, from 1/29/25 through 2/27/25, did not reveal any documentation of Resident #30's indwelling urinary catheter or catheter maintenance. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/26/25 at 2:43 p.m. CNA #1 said Resident #30 had a urinary catheter in place. CNA #1 said she did routine catheter care for Resident #30, which included draining the urinary catheter bag and recording his urinary output. CNA #1 said the CNAs at the facility wiped and cleaned Resident #30's catheter line and recorded they had done so on the catheter care task. CNA #1 said catheter care was performed every day and recorded in the electronic medical record (EMR). -However, there was no documentation of catheter care in the resident's catheter care documentation (see record review above). CNA #3 was interviewed on 2/27/25 at 8:18 a.m. CNA #3 said she performed catheter care two to three times per shift for Resident #30. CNA #3 said she cleaned the catheter using a washcloth to wipe down the catheter tubing starting from the meatus and working to the catheter bag. CNA #3 said she documented in the EMR at the end of her shift that she performed catheter care and emptied the catheter bag and recorded Resident #30's urinary output. -However, there was no documentation of catheter care in the resident's catheter care documentation (see record review above). Registered nurse (RN) #2 was interviewed on 2/27/25 at 11:35 a.m. RN #2 said there were two methods of documenting catheter care in the EMR which included the TAR or in the progress notes. RN #2 said catheter care needed to be documented each time so the appearance of the meatus and any discharge could be recorded and tracked. -RN #2 reviewed Resident #30's EMR but was unable to find any documentation regarding catheter care in the resident's progress notes or TARs. The infection preventionist (IP) was interviewed on 2/27/25 at 12:26 p.m. The IP said Resident #30 had had an indwelling urinary catheter since he returned from the hospital (on 1/29/25). The IP said catheter care should be performed at least once per shift. The IP said residents with urinary catheters usually had a physician's order in their EMR for the catheter itself. The IP said catheter care should be recorded in the TAR and the CNAs should document any catheter care they performed in the tasks section of the EMR. The IP said catheter care was performed to keep the catheter clean and prevent infection. The director of nursing (DON) and the IP were interviewed together on 2/27/25 at 1:00 p.m. The DON said catheter care should be performed during any peri-care and at least three to four times per shift. The DON said catheter care was recorded in the resident's EMR under the catheter care task. The DON said catheter care was performed to prevent infection. The DON said physician's orders for a urinary catheter were usually identified on the discharge instructions from the hospital and signed by the resident's practitioner on admission. -The DON and the IP both verified there was not an order for a urinary catheter in Resident #30's February 2025 CPO. The DON said the facility added a physician's order for a catheter (during the survey) for Resident #30, as it was missed during his readmission from the hospital. The DON said the physician's order for a urinary catheter did not get transferred to the facility's order system from Resident #30's hospital admission orders. The DON said the nursing staff should document catheter care each time it was performed.

Based on observations, record review and interviews, the facility failed to ensure one (#22) of six residents reviewed for unnecessary medications out of 24 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure staff monitored and documented Resident #22's behaviors consistently to justify the use of the resident's psychotropic medications; and, -Ensure the interdisciplinary team (IDT) reviewed Resident #22's use of antidepressant and antipsychotic medications, on at least a quarterly basis, to determine if the continued use of the medications was justified or if a gradual dose reduction (GDR) was indicated. Findings include: I. Facility policy and procedure The Behavior Psychotropic Drug policy, revised May 2011, was received from the nursing home administrator (NHA) on 2/27/25 at 3:45 p.m. It read in pertinent part, Psychotropic drugs are used only to treat a specific condition and then at the lowest effective dose with gradual dose reductions. The interdisciplinary team assesses and monitors the appropriateness, effectiveness and side effects associated with psychotropic medication for each resident. The behavior and mood assessment committee will review each resident on psychotropic medications at least quarterly and as needed. II. Resident #22 A. Resident status Resident #22, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included transient ischemic attack (a stroke that lasts only a few minutes), cerebral infarction (stroke), traumatic brain injury, psychotic disorder with delusions, depression and anxiety. The 1/29/25 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. The assessment revealed the resident took antipsychotic and antidepressant medications. The assessment revealed a GDR had not been attempted. The assessment revealed the resident did not have hallucinations or delusions. B. Resident's representative interview Resident #22's representative was interviewed on 2/24/25 at 2:06 p.m. The representative said Resident #22 had been on psychotropic medications for the past six months. She said she was not sure psychotropic medications were the best option for treating the resident's behavior. The resident's representative said the resident's spouse died in 2023 and ever since then, she would mention she saw or talked to her spouse. The representative said she wished the facility would treat the resident's delusions, not just with medications, but with other tools. She said when she visited Resident #22 and the resident mentioned she saw or talked with her spouse, she would ask the resident how her spouse was or what she did with her spouse. She said the resident was easily redirectable. C. Record review Review of Resident #22's anxiety care plan, revised 12/13/24, revealed the resident had anxiety. She had expressions of worry not easily redirected and restlessness. Interventions included behavioral health consult as needed, monitoring and recording mood to determine if problems seemed to be related to external causes, offering non-pharmacological interventions, such as one-on-one support, offering reassurance, offering validation and offering to contact family. Resident #22's hallucination care plan, revised 12/13/24, revealed the resident had hallucinations. She had hallucinations, such as there was a cat in the room or her spouse was coming or near. Interventions included offering environmental changes as needed, offering mental health services as needed and offering non-pharmacological interventions, such as one-on-one support, offering reassurance, offering validation and offering to contact family. Resident #22's anti-psychotic medication care plan, revised 10/28/24, revealed the resident took anti-psychotic medications and had the potential for adverse reactions. Interventions included assessing drug use on a quarterly and as needed basis, consulting with pharmacy and psychiatrists as needed, laboratory work (labs) per orders, observing and documenting behaviors and mood and observing for potential side effects of medication. Review of Resident #22's February 2025 CPO revealed the following physician's orders: Aripiprazole (an antipsychotic medication) 5 milligrams (mg). Take one tablet by mouth one time a day for anxiety and depression, ordered 11/13/24. Venlafaxine (medication used to treat depression) 150 mg. Take one capsule by mouth one time a day for depression, ordered 11/12/24. Antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling and extrapyramidal symptoms (medication induced movement disorder). Monitor every 12 hours for medication side effects, ordered 11/12/24. Antipsychotic observation. Monitor for spitting, biting, pinching, kicking, slapping, scratching, throwing objects, self-inflicted injuries, extreme fear, hallucinations, delusions, paranoia, continuous yelling, screaming. Interventions include one-on-one, activity, adjusting room temperature, offering a backrub, changing position, giving fluids, giving food, redirecting, referring to behavior notes, removing resident from the environment and toileting. Write a behavior progress note explaining what behavior happened and who was notified if needed, ordered 11/12/24. Review of Resident #22's medication administration records (MAR) revealed the following: The November 2024 MAR, reviewed from 11/12/24 to 11/30/24, revealed there were no behaviors documented for the resident on 18 of 18 days. The December 2024 MAR, reviewed from12/1/24 to 12/31/24, revealed there were no behaviors documented for the resident on 31 of 31 days. The January 2025 MAR, reviewed from 1/1/25 to 1/31/25, revealed there were no behaviors documented for the resident on 31 of 31 days. The February 2025 MAR, reviewed from 2/1/25 to 2/26/25, revealed there were no behaviors documented for the resident on 25 of 25 days. -A review of Resident #22's electronic medical record (EMR) from 11/12/24 through 2/26/25 revealed there were no progress notes documented related to any behaviors exhibited by the resident. -A review of the resident's EMR revealed there was no documentation to indicate IDT reviewed the resident's psychotropic medication use, on at least a quarterly basis, to determine if the continued use of the medications was justified or if a GDR of the medications was indicated. D. Staff interviews Certified nurse assistant with medication aide authority (CNA-Med) #1 was interviewed on 2/27/25 at 8:59 a.m. CNA-Med #1 said she did not offer non-pharmacological interventions for Resident #22. She said Resident #22's behavior included hollering in the afternoon/evening when she exhibited sundowning behavior. She said she documented behaviors as a progress note. Registered nurse (RN) #1 was interviewed on 2/27/25 at 10:18 a.m. RN #1 said she tried non-pharmacological interventions when medications did not work. She said interventions included talking to the resident, offering activities, and finding out why the resident exhibited the behavior. She said she documented behaviors in the resident's MAR and treatment administration record (TAR). RN #1 said Resident #22's behaviors included yelling for help and anxiety. She said Resident #22's behavior was mostly in the afternoon/evening when she exhibited sundowning behavior. She said Resident #22 said she saw her husband once and she said had anxiety and yelled for help because she wanted to go home. The social services director (SSD) was interviewed on 2/27/25 at 11:26 a.m. The SSD said nursing and social services determined what behaviors needed to be monitored for residents. The SSD said the interventions were determined by asking the resident, asking the family and asking the staff what helped when the resident exhibited a behavior. The SSD said the IDT reviewed residents who took a psychotropic medication at admission, quarterly and as needed. She said the IDT reviewed the resident's cognitive status, medical history, social history, behaviors noted in the resident's EMR, labs and recommendations from the pharmacist in order to determine if a GDR should be attempted for a psychotropic medication or if the medication was justified. She said the IDT documented the review meeting and any GDRs on a paper form. The SSD said Resident #22 was on psychotropic medications. She said she had anxiety. The SSD said Resident #22 struggled when she was first admitted to the facility because she wanted to be near her daughter. The SSD said she did not know nursing was not documenting when the resident exhibited behaviors. The SSD said it was important to document when the resident exhibited a behavior to know if the medication was helping the resident's behavior. The SSD said there should have been an IDT meeting in January 2025 and Resident #22's psychotropic medications should have been reviewed during that meeting. She said was not sure why this did not occur. The director of nursing (DON) was interviewed on 2/27/25 at 12:09 p.m. The DON said the IDT determined what behaviors needed to be monitored for residents and what non-pharmacological interventions should be offered. The DON said the assistant director of nursing (ADON) and the SSD entered what behaviors to monitor and what non-pharmacological interventions to offer in the resident's TAR. The DON said nurses documented what behaviors were observed and what non-pharmacological interventions were offered in the resident's EMR. The DON said the IDT reviewed residents who took a psychotropic medication at admission, quarterly and as needed. The DON said the IDT reviewed the resident's behaviors, recommendations, labs and determined if a GDR was indicated or if the medication was justified. The DON said the IDT meeting was documented on a paper form. The DON said Resident #22 was on a psychotropic medication. She said she had anxiety, which caused her to be nervous and squirmy. The DON said she did not know the nursing staff was not documenting the behaviors observed and the interventions offered for Resident #22. The DON said she did not know the IDT did not meet to review Resident #22's psychotropic medications in January 2025.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure facility staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP). Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 3/4/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. II. Facility policy and procedure The Enhanced Barrier Precautions policy and procedure, dated 3/1/24, was received from the nursing home administrator (NHA) on 2/27/25 at 1:53 p.m. It read in pertinent part, All staff receive training on high-risk activities and common organisms that require EBP. High-contact resident care activities include changing briefs or assisting with toileting and device care or use for urinary catheters. III. Observations On 2/24/25 at 11:11 a.m. Resident #30 was lying in bed with his urinary catheter bag clipped to his bed. A sign indicating that Resident #30 was on EBP was on his door and drawers containing PPE were positioned outside of his room. On 2/26/25 during a continuous observation of peri-care from 2:21 p.m. to 2:38 p.m. the following was observed: At 2:21 p.m. Resident #30 was lying in bed with his urinary catheter bag clipped to his bed. The director of rehabilitation (DOR) performed hand hygiene, donned gloves and pulled Resident #30 by his shoulders to reposition him in bed. At 2:24 p.m. the DOR repositioned Resident #30 and adjusted the resident's sheets on his bed. At 2:29 p.m. certified nurse aide (CNA) #1 performed hand hygiene and donned a gown and gloves before entering Resident #30's room. The DOR told Resident #30 that CNA #1 was downing a gown so she could perform peri-care but the DOR was just going to help the resident turn. At 2:33 p.m. the DOR helped Resident #30 turn over in his bed while CNA #1 performed incontinence care. The DOR pulled the sheet resting under Resident #30 to roll him and reposition him. The DOR then placed a pillow between Resident #30's legs. At 2:38 p.m. the DOR adjusted the fitted sheet on Resident #30's mattress and helped CNA #1 place a new blanket over the resident. The DOR then adjusted Resident #30's pillow under his head. -The DOR failed to don a gown to provide direct care to Resident #30, who had a catheter. IV. Staff interviews CNA #1 was interviewed on 2/26/25 at 2:43 p.m. CNA #1 said Resident #30 had an indwelling urinary catheter. CNA #1 said she wore a gown and gloves when performing catheter care and emptying the catheter bag. CNA #3 was interviewed on 2/27/25 at 8:18 a.m. CNA #3 said she performed catheter care for Resident #30 two to three times per shift. CNA #3 said she wore two pairs of gloves while performing catheter care. CNA #3 said she did not wear a gown while performing catheter care. The infection preventionist (IP) was interviewed on 2/27/25 at 9:00 a.m. The IP said education on EBP was ongoing with the staff. The IP said she had given the CNAs pocket guides on what EBP was and when to use it, initiated EBP care plans for residents that required it and had a binder at the nurses' station detailing which residents needed what precautions. The IP was interviewed again on 2/27/25 at 12:26 p.m. The IP said Resident #30 had an indwelling catheter. The IP said the staff needed to wear a gown and gloves whenever they transferred Resident #30, provided catheter care, and changed his sheets or clothing. The IP said both staff members need to wear a gown and gloves during incontinence care if one staff member was helping Resident #30 turn and the other was providing incontinence care. The IP said when staff had any contact with Resident #30 the staff needed to wear a gown and gloves. The IP said it was important to use EBP because any of Resident #30's clothing or sheets could have his urine on it and the facility did not want to risk transferring his urine to other residents. The IP said she did reeducation with the staff about what EBP was and when to use it a few days prior to the interview. The DOR was interviewed on 2/27/25 at 10:59 a.m. The DOR said the nursing staff needed to wear a gown and gloves whenever they were doing catheter care or dealing with urine. The DOR said if a resident had contact precautions they needed to wear a gown and gloves during transfers or other high-contact care. The DOR said when he was assisting with Resident #30 (see observation above) he was providing basic care and only needed to wear gloves. The DOR said the staff needed to don a gown whenever they were dealing with Resident #30's catheter or urine. Certified nurse aide with medication aide authority (CNA-Med) #1 was interviewed on 2/27/25 at 11:09 a.m. CMA-Med #1 said Resident #30 had an indwelling urinary catheter and required EBP. CNA-Med #1 said EBP needed to be followed any time the staff were going to be in contact with any bodily fluids. CNA-Med #1 said the nursing staff needed to wear PPE any time they performed incontinence care, emptied catheter bags, or provided other care in which they would be in direct contact with bodily fluids. CNA-Med #1 said PPE for EBP included wearing a gown and gloves. CNA-Med #1 said EBP was to prevent cross-contamination of the staff or the resident with any pathogens. Registered nurse (RN) #2 was interviewed on 2/27/25 at 11:35 a.m. RN #2 said EBP meant the staff needed to wear a gown and gloves when providing catheter care, transfers or other high-contact activities. RN #2 said EBP was used to prevent the transfer or contamination of drug-resistant bacteria. The director of nursing (DON) was interviewed on 2/27/25 at 1:00 p.m. The DON said when a resident was on EBP, the staff needed to wear a gown and gloves when providing any personal care, repositioning, changing linens and other care activities. The DON said PPE needed to be worn when doing any personal care for Resident #30, not just when dealing directly with his urinary catheter. The DON said EBP was used to protect residents from the transmission of MDROs.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#22 and #37) of six residents reviewed for antibiotic use out of 24 sample residents. Specifically, the facility failed to effectively track and monitor the use of long-term antibiotics for Resident #22 and Resident #37. Findings include: I. Professional reference According to The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 3/4/25 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html. To track how and why antibiotics are prescribed, (providers perform reviews on resident medical records for new antibiotics started to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. II. Facility policy and procedure The Antibiotic Stewardship policy and procedure, undated, was received from the nursing home administrator (NHA) on 2/24/25 at 11:58. It read in pertinent part, The goal of antibiotic stewardship is to prevent unnecessary side effects and adverse symptoms or illness as a result of antibiotic use and to limit their use to only true infections as determined by the McGreer criteria. Antibiotics should be prescribed in the least harmful way by being organism-specific, ordered in the shortest amount of time, and in the lowest dose to treat the infection. The McGreer criteria is used to evaluate documented symptoms. III. Resident #22 A. Resident status Resident #22, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician order (CPO), diagnoses included transient ischemic attack (a stroke that lasts only a few minutes), cerebral infarction (stroke), traumatic brain injury, overactive bladder, elevated white blood cell count, psychotic disorder with delusions, depression and anxiety. The 1/29/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview (BIMS) score of seven out of 15. The assessment revealed the resident was not on an antibiotic. -However, review of Resident #22's electronic medical record (EMR) revealed the resident was currently receiving an antibiotic (see record review below). B. Resident #22's representative interview The resident's representative was interviewed on 2/24/25 at 2:06 p.m. She said Resident #33 was prone to urinary tract infections (UTI) and she did not think the facility was monitoring for signs and symptoms of UTIs. C. Record review Review of Resident #22's February 2025 CPO revealed the following physician's order: Nitrofurantoin 50 milligrams (mg), give one capsule by mouth one time a day prophylaxis (prevention), ordered 11/13/24. -The physician's order for the Nitrofurantin failed to indicate the duration for the use of the antibiotic and the diagnosis. The antibiotic therapy care plan, revised 10/31/24, revealed the resident was on antibiotic therapy related to UTI prevention. Interventions included administering the antibiotic medication as ordered, encouraging fluids, observing for side effects of medication use and reporting any changes to the physician. -Review of the resident's EMR did not reveal a risk versus benefit statement or a physician's justification for the long-term use of an antibiotic. -Review of Resident #60's EMR revealed no documentation to indicate the facility's infection preventionist (IP) completed an antibiotic use assessment or documented the McGeer's criteria met to justify the physician's order for Nitrofurantin. -Review of the IP infection surveillance documents from December 2024 to 2/26/25 revealed the facility identified residents with active infections. -However, the IP infection surveillance documents failed to include Resident #22's long-term use of Nitrofurantin. D. Staff interviews The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 2/27/25 at 1:53 p.m. The IP said the facility's process for monitoring and tracking infections and antibiotic use included making sure the McGeer's criteria were met when there was a new antibiotic started or a resident admitted to the facility on an antibiotic. The IP said she discussed antibiotic usage with the medical director when an antibiotic was first ordered, when labs were needed and as needed. The IP said the medical director reviewed antibiotic use as needed if the resident was not improving, to monitor for efficacy and if sensitivity was obtained. The IP said the process for prophylactic antibiotic use was to monitor for side effects indefinitely. The IP said Resident #22 admitted to the facility on nitrofurantoin to prevent UTIs because she had frequent UTIs. The IP said the resident came from the hospital and the resident was on nitrofurantoin before the hospitalization . The IP said there was not a process for a physician to review the risk versus benefit when a resident was on an antibiotic for a prophylactic reason. The IP said she did not know what physician prescribed the antibiotic and followed the resident for prophylactic usage. The IP said there should be a duration and a reason Resident #22 was on nitrofurantoin. 47350 III. Resident #37 A. Resident status Resident #37, age 70, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 CPO, the diagnoses included cirrhosis of the liver and non infective gastroenteritis and colitis (inflammation of the stomach and colon). The 1/24/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. She required partial/moderate assistance with eating, toileting personal hygiene, transfers and was independent with bed mobility. The assessment did not indicate Resident #37 was on antibiotics. -However, review of Resident #37's EMR revealed the resident was currently receiving an antibiotic (see record review below). B. Record review The February 2025 CPO documented the following physician's order: Cipro (an antibiotic) tablet 500 mg) once a day for abdominal infection, ordered 10/19/24 to be discontinued 10/19/25, one year after the initial order date. The 10/13/24 hospital progress noted documented spontaneous bacterial peritonitis (inflammation of the lining of the abdomen) and a left lower abdomen cellulitis (bacterial infection of the skin) with recommendations that Resident #37 would likely need long term prophylactic antibiotics after discharge. -There was no documentation in Resident #37's EMR to indicate side effects were being monitored while the resident was on the antibiotic. -There was no documentation in Resident #37's EMR to indicate an antibiotic checklist for Cipro had been completed (see IP interview below). -There was no infection surveillance line listing report provided for February 2025 for the Resident #37's prophylactic use of Cipro, signs/symptoms of infection, laboratory work and if McGeer's criteria were met. C. Staff interview The IP was interviewed on 2/27/25 at 9:00 a.m. The IP said the facility followed the McGeer's criteria for antibiotic stewardship. She said when an antibiotic was ordered or when the resident was admitted to the facility with an antibiotic, an antibiotic checklist was filled out and turned in the IP. She said she checked the dashboard every morning to see if any new antibiotics were ordered, the staff would fill out the antibiotic checklist and she would review the antibiotic stewardship to see if it met criteria. She said she would also review the supporting documentation and laboratory results. She said she would then map those infections and place them on her line list. She said she was not aware that Resident #37 was on an antibiotic when she was readmitted to the facility. She said Resident #37 had been hospitalized in October 2024 for liver disease. She said she reviewed Resident #37's medical record, during the survey, and it appeared she was being treated for an infection that was visible on her hospital CT (computed tomography) scan results. She said this should have been captured when she was readmitted , tracked and monitored for side effects and symptoms. She said she was not sure why this was not captured but would add Resident #3 so that the antibiotic was monitored and tracked.

Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents/hazards. Resident #1 had a diagnosis of advanced Huntington's disease (inherited disease that causes degeneration of the nerve cells in the brain) and was identified as a fall risk. Interventions for Resident #1 included a low bed and a fall mat. Resident #1 needed the assistance of two staff for transfers. On the morning of [DATE], certified nurse aide (CNA) #1 was assisting Resident #1 to get ready for the day. CNA #1 had lifted the bed from a low position to a higher position and had removed the fall mat to prepare to transfer Resident #1. CNA #1 stepped away from Resident #1 with the bed in a high position and left the room to find assistance for the transfer. While CNA #1 was away from Resident #1, she fell out of bed and was found on the floor lying on her right arm with the right side of her face against the floor. Blood was visible around Resident #1's head. Resident #1 was sent out to the hospital and received sutures to her right temple and was noted to have a sacral fracture. Resident #1 passed away on [DATE]. According to the death certificate the cause of death was decomposition following a mechanical fall. Findings include: I. Resident status Resident #1, age 67, was admitted on [DATE], readmitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician's order (CPO), diagnoses included Huntington's disease and abnormal involuntary movements. The [DATE] minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) of zero out of 15. The assessment identified a diagnosis of a progressive neurological condition. Resident #1 was identified as receiving hospice care. II. Fall on [DATE] The facility investigation dated [DATE] at 7:53 a.m. described the incident as, The CNA was providing care to the resident. The CNA stepped out of the room to ask for assistance to transfer the resident. the resident rolled out of the bed sustaining injury. The resident plan of care included an air mattress with winged overlay for sensory perception. The conclusion to the investigation documented, The staff member did not have a history of this type of incident. Staff member was providing care services to the resident and left the room to get a second staff member to assist with the transfer- the resident had a recent medication change causing her to be more alert. This is an educational opportunity to press the call light when extra assistance is needed and not to step out of the room. The fall investigation and progress note, dated [DATE] at 8:00 a.m., noted CNA #1 notified the nurse that the resident had fallen out of bed. The nurse immediately entered the room finding the resident lying on her right arm with the right side of her face against the floor. Upon examination, the nurse and the charge registered nurse (RN) found Resident #1 had a large hematoma to the right temple area which was bleeding. Her entire head was examined but no other injury was noted due to the blood and her hair. Her vital signs and neurological assessment were completed immediately. The area was cleaned immediately and pressure was applied to her right temple until the ambulance arrived. Her family and medical doctor (MD) were notified by the assistant director of nursing (ADON). III. Record review The care plan, initiated [DATE] and revised [DATE], identified the resident required assistance with self-care deficits including dressing and impaired physical mobility secondary to Huntington's disease. Interventions included transfers with a Hoyer lift with two or more staff as she allowed. The anticoagulant care plan, initiated [DATE] and revised [DATE], identified a risk for bleeding related to the use of an antiplatelet. Interventions included to notify physician of any problems or concerns. The fall care plan, initiated on [DATE], identified the resident had an active history of falls related to weakness. Interventions included: -Assist with transfers/ambulation as needed. -Call light within reach when possible. Another fall care plan, initiated [DATE] and revised on [DATE], identified a history of falls. Interventions included: -Assist with transfers/ambulation as needed. -Keep call light in reach. -Notify physician of any changes in condition. -Resident to have a soft helmet on at all times while in bed and hard helmet on while out of bed. -Helmet for safety related to unsteady gait/balance related to Huntington's disease. -Winged mattress for sensory perception. Fall intervention related to overestimating when transferring in and out of bed. -Encourage floor mat next to bedside when the resident is laying in bed. The care plan, initiated [DATE] and revised [DATE], identified limited physical mobility related to Hintington's disease. Interventions included the resident was totally dependent on staff for locomotion. The care plan, initiated [DATE] and revised [DATE], identified a communication related to impaired cognition. Interventions included to ensure/provide a safe environment, call light in reach, adequate low glare light, bed in lowest position and wheels locked and to avoid isolation. She was admitted to hospice care on [DATE] for Huntington's Disease. The provider follow-up note dated [DATE] included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The progress note dated, [DATE] at 8:05 a.m., identified the facility called and notified the hospice provider of the fall with a hematoma on the right side of the head with difficulty controlling the bleeding. An order to send the resident to the emergency room (ER) for evaluation. The progress note dated, [DATE] at 8:22 a.m., included a message was left with the resident's daughter. The facility explained the resident had a fall with a head laceration to the right temple with bleeding. The progress note dated, [DATE] at 2:16 p.m., included the report from the hospital that the resident received six sutures to the head laceration and would need to keep pressure bandage on for at least the next 24 hours. The resident was found to have a sacral fracture. The hospice provider was notified about the update. The provider progress note dated, [DATE] at 1:53 a.m., included Patient found resting comfortably in bed. She has head wrapped with pressure bandage due to a recent fall with head laceration. Was treated in emergency room and returned to the facility. Continues under hospice care. The provider follow-up note dated [DATE] included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The provider progress note, dated [DATE] at 4:15 a.m., included in part, appears comfortable. Patient with sutured area on forehead. The interdisciplinary team (IDT) fall risk note, dated [DATE] at 8:31 a.m., included Related to resident rolling out of bed on [DATE]. Soft helmet while in bed and hard helmet when out of bed for safety related to weakness of body movements from disease process of Huntington's disease. The hospice note dated, [DATE] at 1:10 a.m., included the patient was in her bed in the low position. The note included discussion of status with risk of a brain bleed was possible. Interventions provided included fall precautions to include a low bed and call light in place. The hospice note, dated [DATE] (time unknown), included the nurse left the patient's room with the patient lying supine and helmet on, call light in reach, and fall mat in place on the floor next to the bed. The facility investigation, dated [DATE] at 11:30 p.m., described the incident, resident passed away peacefully with family at bedside under hospice care. The conclusion to the investigation documented, the resident passed away peacefully. Resident was without brain injury from fall 8 (eight) days prior. Facility concluded resident expired due to Huntington's disease process. The death certificate for Resident #1 identified the date of death as [DATE]. The cause of death was identified as decompensation following a mechanical fall, hypovolemia (low blood volume), and cephalohematoma (blood under the scalp from an injury). The death certificate was signed on [DATE]. IV. Interviews CNA #1 was interviewed on [DATE] at 1:05 p.m. CNA #1 said staff would check with their supervisor when they arrived to see which residents were fall risks and on fall precautions/interventions. He said if the resident had a fall mat they automatically knew there were fall interventions for the resident. He said every resident on fall precautions had a fall mat and repositioning pillows. He said if someone had a fall they were to notify the nurse immediately after making sure the resident was safe. He said if a resident required the assistance of two people, staff were to use the call light and wait for assistance and never to leave the resident unattended. He said if a resident had a fall after the nursing assessment they were to be monitored every 15 minutes. CNA #2 was interviewed on [DATE] at 1:10 p.m. CNA #2 said she would know who was a fall risk from the medical record on kiosks and the fall mats next to the bed. She said there were checklists that identified specific needs of the resident. She said the information in the kiosk had the resident specific fall interventions. She said if a resident were to fall she was to make sure the resident was safe and call for a nurse to assess. She said if she needed assistance from another staff member she was not to leave the resident alone but she was supposed to use the call light and wait for assistance. RN #1 was interviewed [DATE] on 1:15 p.m. RN #1 said the fall interventions for each resident were in the physician's orders. She said if a resident fell , the CNAs were to call her or any nurse and the nurse who completed the initial assessment would complete an assessment, fill out a fall risk assessment and notify the director of nursing (DON). She said if the injury was severe, she would send out the resident. The DON was interviewed on [DATE] at 1:35 p.m. The DON said the Resident #1 had fallen from the bed that was not in the low position and the fall mat was not in place when CNA #1 had stepped out to get assistance with the transfer. She said the resident had fallen and hit her head on the floor and sustained a laceration to the right temple. She said the facility sent her out to the ER and made notifications to the hospice provider, the family and the physician. She said the hospital reported to the facility the laceration needed six sutures and to keep the pressure dressing on for 24 hours. The DON said CNA #1 acknowledged she failed to follow facility protocol and left a resident identified as a fall risk unattended which resulted in the resident falling out of bed. She said the resident passed away eight days after her fall. She said after the fall, the facility provided education on assistance with transfers. She said the CNAs had access to the fall interventions on the Kardex (a tool utilized by staff for providing consistent care for residents) that could be accessed by the kiosk. The nursing home administrator (NHA) was interviewed on [DATE] at 2:45 p.m. The NHA said CNA #1 was terminated after the incident. The hospice executive director ([NAME]) was interviewed on [DATE] at 4:45 p.m. The [NAME] said hospice assessed the resident after notification of the fall and when the resident returned to the facility. She said the facility called hospice about the fall and bleeding and the ER transfer on [DATE]. She said the resident had trauma to the right temple which required six sutures. She said the coroner's death certificate identified the cause of death as decomposition following a mechanical fall.

Based on record review, observations, and interviews, the facility failed to ensure two (#7 and #25) of five residents out of 23 sample residents were free of significant medication errors. Resident #7 had several medications prescribed to treat a significant mental health condition (bipolar), a progressive chronic pain condition (fibromyalgia), and a blood clotting condition (deep vein thrombosis). Between 6/1/23 to 7/25/23, the facility repeatedly failed to ensure the resident received these medications on schedule and as ordered to prevent complications and worsening symptoms. Resident #25 had several medications prescribed to treat a progressive neurodegenerative brain disorder (Huntington's disease). Between 6/1/23 to 7/25/23, the facility repeatedly failed to ensure the resident received these medications on schedule and as ordered to prevent complications and worsening symptoms. The facility's failure to ensure Residents #7 and #25 received their medications as ordered contributed to Resident #7 experiencing increasing distress (fear, anxiety, behavioral symptoms) and Resident #25 experiencing signs of distress (agitation, behavioral symptoms). The facility's failure to develop, implement, and monitor medication administration processes to prevent repeated, significant medication errors contributed actual decline in Resident #7 and #25's quality of life and created the potential for serious physical and psychosocial harm if the situation was not immediately corrected. I. Immediate jeopardy A. Findings of immediate jeopardy Resident #7 had several medications prescribed to treat a significant mental health condition (bipolar), a progressive chronic pain condition (fibromyalgia), and a blood clotting condition (deep vein thrombosis). Between 6/1/23 to 7/25/23, the facility repeatedly failed to ensure the resident received her medications on schedule and as ordered to prevent complications and worsening symptoms. The facility also failed to notify the physician and psychiatrist consistently of the missed doses. The facility failures contributed to Resident #7 experiencing increasing distress - fear, anxiety, and behavioral symptoms. Resident #25 had several medications prescribed to treat a progressive neurodegenerative brain disorder (Huntington's disease). Between 6/1/23 to 7/25/23, the facility repeatedly failed to ensure the resident received her medications on schedule and as ordered to prevent complications and worsening symptoms. The facility also failed to notify the physician and psychiatrist consistently of the missed doses. The facility failures contributed to Resident #25 experiencing signs of distress - agitation and behaviors, and other signs of distress. Until the survey was conducted, 7/19/23 to 8/14/23, there was insufficient evidence potential adverse consequences of the medication errors were considered and the errors were discussed with pertinent providers. The facility's failure to develop, implement and monitor medication administration processes to prevent repeated significant medication errors contributed actual decline in Residents #7 and #25's quality of life and created the potential for serious physical and psychosocial harm if the situation was not immediately corrected. On 8/10/23 at 1:13 p.m., the nursing home administrator (NHA) was notified that the facility's failure created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 8/10/23 at 5:34 p.m., the facility submitted a plan for immediate jeopardy. The plan read: Immediate Action: On 8/10/23, the facility contacted the primary care physician for Resident #7 and Resident #25. The physician ordered labs and ultrasound for all extremities for Resident #7. No new orders for Resident #25. An audit of all residents was completed on 8/10/23 and no other residents were identified with missing medications. On 7/27/23, licensed nursing staff received education related to access of the facility's controlled substance dispenser from the pharmacy, pharmacy notification, and physician education when a medication is not available or is not given. On 8/10/23, the facility contacted the pharmacy to initiate medication autofill for eligible residents. The social services director (SSD) provided follow up psychosocial support to Resident #7 related to feelings of sadness expressed during the survey process. Systemic Changes: The DON or designee will collaborate with the medical director, pain clinic, and the hospice entity related to medication availability. The licensed nurse will document attempts to contact the pharmacy for medications in the residents' progress notes. The DON or designee will follow up with the pharmacy if medications are not received. The agency orientation education will be updated to include the procedure for unavailable medications or medications not given. The agency orientation checklist will have education related to missing medications procedures, physician notifications of missed medications and steps on how to reorder medication. The auto fill, if possible, would apply to existing medications with no changes. If there is a change in medication, it would be set up in the system accordingly to autofill parameters. New admissions would continue with the current process of faxing and calling orders and set up with autofill parameters. The DON or designee would ensure that anytime there is a missed medication that a physician is notified and a progress note is entered. If a resident experiences a behavior change, the DON or designee in conjunction with the social services director (SSD) will review the medication administration record to ensure the medications were administered as ordered and acute clinical conditions have been ruled out. The SSD will follow up as indicated. When a medication is missed, the DON or designee will conduct a missed medication incident to include a root cause analysis to determine the cause of the missed medication and identify preventative measures that can be implemented to reduce further incidents. Monitoring: The director of nursing (DON) would begin weekly audits to ensure residents' medications are available for the next 7 days. The DON or designee will complete a daily review of missed medications and ensure that notifications occur. The DON or designee will run a report to identify missed medications and ensure that physician notifications and follow up action (are) documented in the residents' progress notes. Medication administration will be added to the QAPI agenda and will be reviewed monthly and ongoing. C. Removal of immediate jeopardy On 8/10/23 at 5:34 p.m. the NHA was notified, based on a review of the plan, that the immediate jeopardy was removed. However, the deficient practice remained at a G scope at severity, isolated, actual harm. II. Facility policy The Medication Administration policy, dated March 2019, was received from the NHA on 7/27/23 at 1:26 p.m. It read, in pertinent part: The licensed nurse or qualified person will administer medications according to the physician's order. For missed doses- if two consecutive doses of a vital medication or a vital one-time order are withheld or refused, the physician is notified. For residents unavailable for medications- for residents not in their rooms or otherwise unavailable to receive medication on the pass, the medication administration record is flagged. After medications are passed, the nurse returns to the missed resident to administer the medication. A review of the facility policy revealed it addressed notification and missed medications due to resident unavailability, refusal, and withholding, but did not address measures to ensure medication availability in order to prevent repeated significant medication errors. III. Record review and interviews revealed the facility failed to develop, implement, and monitor medication administration processes to prevent repeated, significant medication errors affecting Resident #7 and Resident #25. A. Resident #7 1. Resident status Resident #7, age 71, was admitted to the facility on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnosis included insulin-dependent diabetes, fibromyalgia, bipolar disorder, chronic embolism and thrombosis of deep veins, and chronic pain syndrome. The 5/10/23 minimum data set (MDS) assessment showed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. The resident had behaviors of delusions and signs of depression within the 14-day look-back period. The comprehensive care plan, revised on 2/22/22, revealed: -The resident was at risk for blood clotting and had to take an anticoagulant (blood thinner). Interventions were to draw labs as ordered and notify the physician of any concerns or problems. -The resident had chronic pain, fibromyalgia, and diabetic neuropathy. Interventions were to administer pain medications as ordered and contact the pain clinic for refills. -The resident had a diagnosis of bipolar disorder with behaviors and major depressive disorder. Interventions were to document behavior changes, administer medications as ordered and notify the physician of behavior changes. Physician orders dated 2/1/23 to 7/6/23 included: -Enoxaparin (Lovenox) 80 milligram (MG)/ 0.8 milliliter (ML)- injected subcutaneously two times a day for deep vein thrombosis (deep vein blood clots)- ordered on 2/1/23. -Latuda 20 MG- give one time a day for bipolar disorder in the morning- ordered on 5/27/23 and discontinued 6/2/23. -Latuda 20 MG- give 40 MG one time a day for bipolar disorder in the evening- ordered on 5/27/23 and discontinued 6/28/23. -Latuda 60 MG- give one time a day for bipolar disorder- ordered on 6/29/23. -Trazodone 50 MG- give 1.5 tablets one time a day for depression associated with chronic insomnia- ordered on 6/20/23 and discontinued 6/28/23. -Trazodone 50 MG- give one time a day for depression associated with chronic insomnia- ordered on 6/28/23. -Milnacipran (Savella) 50 MG- give 100 MG two times a day for fibromyalgia- ordered on 2/10/23. -Hydrocodone acetaminophen 10-325 MG- give one tablet every four hours for chronic pain in multiple sites- ordered on 3/13/23. 2. Resident interview and observation Resident #7 was interviewed on 7/26/23 at 9:30 a.m. She was aware of what medications she took and what the medications were for. She stated her Lovenox (anticoagulant) was necessary for her life and she did not feel the facility understood how important it was. She said it made her feel fearful and anxious when the facility would run out of her Lovenox because she did not know what the negative effect would be. She had almost contacted the doctor herself because she felt the facility was not trying hard enough to get her medications refilled. She stated that when she did not receive her Latuda (antipsychotic), she felt more depressed and irritable and when she did not receive her pain medications, it made her chronic pain syndrome and fibromyalgia harder to manage. During the interview, the resident showed signs of distress (shaking, crying) when talking about not receiving her medications as prescribed. 3. Record review a. Review of Resident #7 medication administration records (MARs) for June and July 2023 and progress notes from 6/1/23 to 7/26/23, revealed the facility failed to ensure medications were administered as ordered to treat the resident's mental health condition, progressive, chronic pain condition, and blood clotting condition. MAR and progress note review revealed documentation of significant medication errors - missed doses of the medications to treat the resident's mental health condition, progressive, chronic pain condition, and blood clotting condition. (1) The June 2023 MAR revealed: -The resident did not receive her Latuda 8 times during the month due to the facility being out of medication. -The resident did not receive her Lovenox injection 7 times during the month due to the facility being out of medication. -The resident did not receive her Hydrocodone acetaminophen 19 times during the month due to the resident being asleep. (2) The July 2023 MAR revealed: -The resident did not receive her Lovenox 3 times during the month due to the facility being out of medication. -The resident did not receive her Savella 5 times during the month due to the facility being out of medication. -The resident did not receive her Hydrocodone acetaminophen 9 times during the month due to the facility being out of medication. (2) Progress notes from 6/1/23 to 7/26/23 confirmed missed doses of Latuda, Lovenox, Hydrocodone acetaminophen, and Savella, as well as the resident's reports of distress and behavioral symptoms. -Health status note dated 6/1/23 revealed the resident had recent psychotropic medication changes, discontinuation of Abilify and Trazodone, with no adverse effects or behaviors noted. She was to continue on her Latuda 20 MG in the morning and 40 MG in the evening. -Nursing note dated 6/2/23 revealed the resident reported being more tired than usual and feeling lightheaded. It was difficult for her to focus and answer questions. A call was placed to the psychiatrist's office and a message was left in regard to the recent changes to the resident's Latuda on 5/27/23. -Order note dated 6/2/23 revealed a new order for the resident's Latuda. Discontinue the 20 MG a day dosage to be given in the morning and instead give only the 40 MG dosage one time a day. -Order administration note dated 6/7/23 at 3:39 p.m. revealed the resident did not receive her Latuda 40 MG dosage due to the facility waiting on an order from the pharmacy. -Order administration note dated 6/7/23 add 10:17 p.m. revealed the resident reported to nursing she had missed her bipolar medication (Latuda) and was not feeling well. -Order administration note 6/8/23 revealed the resident did not receive her Latuda 40 MG dosage due to the medication being unavailable from the pharmacy. -Order administration note 6/9/23 revealed the resident did not receive her Latuda 40 MG dosage due to the medication being unavailable from the pharmacy. -Nursing note dated 6/10/23 revealed the resident's Latuda 40 MG was still on order. -Order administration note 6/10/23 at 4:58 p.m. revealed the resident did not receive her Latuda 40 MG dosage due to the medication being unavailable from the pharmacy. -Order administration note dated 6/11/23 revealed the resident did not receive her Latuda 40 MG dosage due to the medication still being on order. -Order administration note dated 6/12/23 revealed the resident did not receive her Latuda 40 milligram dosage due to the medication still being on order. -Order administration note dated 6/13/23 revealed the resident did not receive her Latuda 40 MG dosage due to the medication still being on order. -Order administration note dated 6/14/23 revealed the resident did not receive her Latuda 40 MG dosage due to the medication still being on order. -Order administration note dated 6/15/23 revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG dosage due to the facility needing a new order. -Restorative therapy note dated 6/15/23 revealed the resident was not compliant with the therapy program as ordered -Pharmacy consultant progress note dated 6/15/23 failed to reveal the pharmacist had made any recommendations or drug reviews regarding possible adverse outcomes to the resident for not being administered her Latuda on 6/7, 6/8, 6/9, 6/10, 6/11, 6/12, 6/13, and 6/14/23. -Order administration note dated 6/16/23 at 9:00 a.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG dosage due to the facility needing a new order. -Order administration note dated 6/16/23 at 11:16 a.m. revealed the resident was not compliant with antibiotic ointment treatment as ordered. -Order administration note dated 6/16/23 at 4:38 p.m. revealed the resident did not receive her Latuda 40 MG dosage due to the medication not being available. The physician was notified. -Order administration note dated 6/17/23 at 4:16 p.m. revealed the resident did not receive her Lovenox injection 80 MG/0.8 ML due to the medication being on order. -Order administration note dated 6/17/23 at 5:34 p.m. revealed the resident did not receive her Latuda 40 MG dosage due to the medication being on order. -Order administration note dated 6/18/23 at 6:36 a.m. revealed the resident did not receive her Lovenox injection 80 MG/0.8 ML due to the medication being on order. The medication was to be delivered that day. -Order administration note dated 6/18/23 at 12:56 p.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG dosage due to the facility needing a new order. -Order administration note dated 6/18/23 at 4:57 p.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG dose due to the facility needing a new order. -Order administration note dated 6/18/23 at 5:55 p.m. revealed the resident did not receive her Latuda 40 MG dosage due to the medication still being on order. -A physician's long-term care follow-up note dated 6/20/23 revealed the resident had requested a visit as she was having increased problems initiating and maintaining sleep related to her depression. There was no reference in the note regarding missed doses of her antipsychotic Latuda (see above). -Order note dated 6/20/23 revealed a new prescription for the resident to receive Trazodone 1.5 MG tablet by mouth at bedtime for depression associated with chronic insomnia. -Order administration note dated 6/21/23 revealed the resident was not compliant with her oral inhaler treatment as ordered. -Order administration note dated 6/23/23 revealed the resident did not receive her Lovenox injection 80 MG/0.8 ML due to the medication not being available. -Order administration note dated 6/24/23 at 12:24 p.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing a new order. -Order administration note dated 6/24/23 at 4:12 p.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing a new order. -Order administration note dated 6/24/23 at 9:05 p.m. revealed the resident did not receive her Lovenox injection 80 MG/ 0.8 ML due to the medication being on order and not available. -Order administration note dated 6/25/23 at 1:22 a.m revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing a new order. -Order administration note dated 6/25/23 at 8:08 a.m. revealed the resident did not receive her Lovenox injection 80 MG/ 0.8 ML. The doctor was notified the resident needed a prescription refill. -Order administration note dated 6/25/23 at 5:01 p.m. revealed the resident did not receive her Lovenox injection 80 MG/ 0.8 ML due to the medication still being on order. -Order administration note dated 6/26/23 revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing a new order. -Nursing note dated 6/28/23 revealed the psychiatrist gave new orders to increase the resident's Latuda from 40 MG to 60 MG and to decrease the Trazodone to 50 MG. The note did not reveal the facility had notified the psychiatrist of the number of times she missed her Latuda dosage (see above). -Order administration note dated 6/29/23 revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing a new order. -Order administration note dated 7/1/23 revealed the resident did not receive her Lovenox injection 80 MG/ 0.8 ML due to the medication being on order and was not available. -Order administration note dated 7/2/23 at 5:01 p.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing a new order. -Order administration note dated 7/2/23 at 10:22 p.m. revealed the resident did not receive her Lovenox injection 80 MG/ 0.8 ML due to the medication not being available. -Order administration note dated 7/3/23 at 7:02 a.m. revealed the resident did not receive her Lovenox injection 80 MG/ 0.8 ML due to the medication not being available. -Nursing note dated 7/3/23 at 12:53 PM revealed the facility re-faxed a prescription for the Lovenox to the pharmacy and called the pharmacy to verify. Medication was to be delivered on the next shipment. -Order administration note dated 7/6/23 at 12:26 p.m. revealed the resident did not receive her Savella 100 MG dose due to the medication not being available. The pharmacy was contacted. -Order administration note dated 7/6/23 at 10:08 p.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing new orders. -Order administration note dated 7/7/23 at 3:35 a.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility needing new orders. -Order administration note dated 7/7/23 at 8:30 a.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the medication being unavailable and the facility awaiting a pharmacy delivery. -Order administration note dated 7/7/23 at 8:45 a.m. revealed the resident did not receive her Savella 100 MG due to the medication being unavailable and the facility awaiting pharmacy delivery. -Order administration note dated 7/7/23 at 11:07 a.m. revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the medication being unavailable in the facility awaiting refills. The physician was notified. However, the note did not indicate the physician was notified the resident had also not been receiving her Savella (see above). -Order administration note dated 7/22/23 revealed the resident did not receive her Savella 100 MG due to the medication not being available and awaiting pharmacy delivery. -Order administration note dated 7/24/23 at 8:59 a.m. (during survey) revealed the resident did not receive her Savella 100 MG due to the medication not being available. -Order administration note dated 7/24/23 at 1:13 p.m. (during survey) revealed the resident did not receive her Hydrocodone acetaminophen 10-325 MG due to the facility awaiting new orders. -Order administration note dated 7/25/23 at 8:50 a.m. (during survey) revealed the resident did not receive her Savella 100 MG due to the medication not being available. A call was made to the pharmacy for an update. -Nursing note dated 7/25/23 at 11:15 a.m. (during survey) revealed a call was placed to the pharmacy to find out the status of the Savella. The pharmacy relayed the medication would arrive in the afternoon and nursing made a call to the provider to notify. -Nursing note dated 7/25/23 at 11:29 a.m. (during survey) revealed the provider contacted back the nurse and gave an order to skip the morning dose of the Savella and resume regular dosing when medication arrived. -Nursing note dated 7/25/23 at 5:14 p.m. (during survey) revealed nursing made a call to the pharmacy as the Savella medication was still not delivered. The pharmacy said the medication was not due to arrive until 7/26/23. Nursing contacted another pharmacy but was unable to coordinate delivery from another pharmacy. b. Record review revealed the facility lacked a process to ensure pertinent providers were notified of missed medications. (1) See the facility's Medication Administration policy above; the policy revealed it addressed provider notification and missed medications due to resident unavailability, refusal, and withholding, but did not address notification when medication was unavailable from the pharmacy, or it was still on order, or needed a new order. (2) Out of the 41 incidents of missed medications in the progress notes between 6/1/23 and 7/25/23, the facility contacted the physician four times (see above). (3) A psychiatric visit note dated 6/28/23 revealed the psychiatrist visited with the resident. She told him she had missed a few doses of her Latuda but did not tell him how many doses she had missed. The note failed to reveal the psychiatrist was notified by the facility the resident had missed 8 doses of Latuda out of the 31 days in the month of June 2023. c. Record review also revealed insufficient evidence that the potential consequences of the missed medications were considered. Laboratory results for 6/1/23 to 8/11/23 revealed the sole laboratory test completed during this timeframe was a complete blood count dated 8/11/23 (during survey). There was no evidence either a prothrombin time (PT) test (measuring how long it took for a clot to form) or an international normalized ratio (INR) (based on PT test results) were conducted for the resident despite her diagnoses (chronic embolism and thrombosis of deep veins) and missed doses of Lovenox (see above) in June and July 2023. B. Resident #25 1. Resident status Resident # 25 aged under 70, was admitted to the facility on [DATE]. The July 2023 CPO diagnoses included Huntington's disease, psychiatric disorder, mood disorder, and dysphagia (difficulty swallowing). The 5/8/23 MDS assessment revealed the resident was unable to complete the BIMS assessment due to rarely or never being understood. The staff assessment indicated the resident had severely impaired cognitive and decision-making skills. The comprehensive care plan, revised 2/16/23, revealed the resident had a diagnosis of Huntington's disease with depression and the potential for mood disturbances. The resident took psychotropic medications for behavior management. Interventions were to administer medications as ordered by the physician, review behaviors and interventions, and monitor for any adverse reactions. Physician orders dated 9/1/22 to 7/6/23 revealed: -Depakote 125 MG -give one capsule three times a day for behaviors -ordered on 9/21/22. -Olanzapine (Zyprexa) 15 MG- give one tablet two times a day related to Huntington's disease -ordered on 5/10/23 -Namenda 5 MG tablet- give one tablet one time a day for cognitive impairment-ordered on 5/31/23. -Lorazepam (Ativan) 1 MG tablet- give one tablet every six hours for anxiety related to Huntington's disease -ordered on 6/20/23 and discontinued 6/27/23. -Seroquel 25 MG tablet- give one tablet two times a day related to Huntington's disease -ordered on 6/27/23. 2. Resident observation The resident was observed on 7/24/23 at 12:28 a.m. in a tilted-back wheelchair at the nurse's medication cart. She was agitated, trying to throw her legs out of the wheelchair and moaning. The resident had not received her morning dose of Depakote. 3. Record review a. Review of Resident #25's MARs for June and July 2023, and progress notes from 6/1/23 to 7/26/23, revealed the facility failed to ensure medications were administered as ordered to treat the resident's behaviors, cognitive impairment, and anxiety associated with her progressive neurodegenerative brain disorder. (1) MAR and progress note review revealed documentation of significant medication errors - missed doses of the medications to treat the resident's neurodegenerative brain disorder. The June 2023 MAR revealed: -The resident did not receive her Namenda 4 times out of the month due to the resident being asleep. -The resident did not receive her Zyprexa 4 times out of the month due to the resident being asleep. -The resident did not receive her Seroquel 2 times out of the month due to the resident being asleep. -The resident did not receive her Depakote 9 times out of the month due to the resident being asleep. -The resident did not receive her Ativan 7 times out of the month due to the resident being asleep. The July 2023 MAR revealed: -The resident did not receive her Namenda 7 times out of the month due to the facility being out of medication. -The resident did not receive her Depakote 4 times out of the month due to the facility being out of medication. -The resident did not receive her Ativan 14 times out of the month due to the resident being asleep. (2) Progress notes from 6/1/23 to 7/26/23 confirmed missed doses of Depakote, Zyprexa, and Namenda, as well as documented the resident's distress and behavioral symptoms (anxiety, crying out, agitation, combativeness) at times when she had not received her medications. -Order administration note dated 6/11/23 at 8:31 p.m. revealed the resident was having anxiety and crying out. She had not received her evening dosage of Zyprexa due to being asleep. -Nursing note dated 6/23/23 at 1:28 p.m. revealed the resident was displaying behaviors of restlessness and agitation. She had not received her morning dosage of Zyprexa or Depakote due to sleeping. -Order administration note dated 6/24/23 at 9:00 a.m. revealed the resident had behaviors of yelling out. -Behavior note dated 6/25/23 revealed the resident displayed behaviors of crawling out of her bed, yelling out, and crying, requiring staff assistance. -Nursing note dated 6/26/23 at 9:16 a.m. revealed nursing received a report from the certified nursing aide (CNA) that the resident had been found on the fall mat next to her bed with no injuries. -Nursing note dated 6/26/23 at 2:16 p.m. revealed while an attempt was being made to collect urine for a sample, the resident became combative with staff. -Order administration note dated 6/26/23 at 2:24 p.m. revealed the resident attempted to hit the nurse and yelled obscenities. -Order administration note dated 6/27/23 at 9:18 a.m. revealed the resident was calling out and staff were unable to console her. -Order administration note dated 6/27/23 at 11:22 a.m. revealed the resident missed her Depakote 125 MG due to sleeping. -Behavior note dated 6/27/23 at 11:32 a.m. revealed nursing placed a call to hospice regarding the resident's behaviors when she was awake. The resident cried, used obscenities, and had loud vocalizations. A request for a new order of Seroquel 25 MG twice a day was received. The note failed to reveal the facility notified hospice the resident had missed several doses of psychiatric medications (see above). -Order administration note dated 7/15/23 at 8:54 a.m. revealed the resident did not receive her Namenda 5 MG due to the medication being on order. -Order administration note dated 7/16/23 at 10:56 a.m. revealed the resident did not receive her Namenda 5 MG due to the medication not being available. The provider was notified. -Order administration note dated 7/17/23 at 1:22 p.m. revealed the resident did not receive her Namenda 5 MG due to the medication not being available and the provider was notified. -Order administration note dated 7/18/23 at 8:37 a.m. revealed the resident did not receive her Namenda 5 MG due to the medication being unavailable and the facility awaiting pharmacy delivery. -Order administration note dated 7/23/23 at 1:38 p.m. revealed the resident did not receive her Namenda 5 MG due to the medication not being available. -Order administration note dated 7/24/23 at 7:03 a.m. revealed the resident did not receive her Depakote 125 MG due to the medication not being available. -Order administration note dated 7/24/23 at 5:04 p.m. revealed the resident received her Depakote 125 MG, however, according to her MAR, she did not receive her dosage at that time due to being asleep. -Order administration note dated 7/25/23 at

Based on record review, observations, and interviews, the facility failed to ensure two (#1 and #7) of five residents received services and assistance to prevent a reduction in range of motion out of 23 sample residents. According to diagnoses on admission, Resident #1 did not admit to the facility with a contracture to her left hand but based on observations and interviews on 7/24-7/26/23, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her left hand. Further, the facility failed to provide the resident occupational therapy (OT) as ordered after the identification of a possible ligament injury to the left wrist on 1/16/23. The facility's failure to provide services to maintain the resident's mobility contributed to a decline in the mobility of the resident's left wrist and hand. Resident #7 was ordered assistance with hand splinting from the facility staff post surgical revision of her left hand. Interview and record review revealed the facility failed to ensure the resident was receiving assistance as ordered 3/14/23, 3/16/23, 3/25/23, 4/4/23, and 5/4/23, to maintain mobility or decrease further loss of range of motion of the resident's left hand. Findings include: I. Resident #1 A. Resident status Resident #1, age 88, was admitted to the facility on [DATE]. According to the July 2023 computerized physician's orders (CPO), diagnoses included diabetes type II, dementia with agitation and disorders of bone density and bone structure. The 6/23/23 minimum data set (MDS) assessment showed the resident had significant cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive one-two person physical assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. The resident had no functional limitations in range of motion of her upper or lower extremities. She was enrolled in hospice and had not received any therapy or restorative services during the MDS look back period. -No diagnosis of arthritis or cellulitis (bacterial infection to the skin) was indicated. B. Resident observations The resident was observed on 7/24/23 at 10:48 a.m. inside the activity room. The fingers on resident's left hand were curled and while participating in a balloon catch activity, the resident was unable to open her left hand at all. Resident #1 was observed on 7/25/23 at 12:15 p.m. in the lunchroom. The resident was attempting to adjust the front of her shirt with her left hand but she was only able to pinch the material with her thumb. Her left hand remained curled into a fist. Resident #1 was observed on 7/26/23 at 12:16 p.m. in the lunchroom. She was able to feed herself using her right hand but was not able to use her left hand. Her left hand rested on her lap, fingers curled in a fist position. C. Record review The comprehensive care plan initiated on 7/21/21 revealed the resident had a history of cellulitis in her left hand. Interventions were to assist the resident to the bathroom as needed, offer non medicinal means of pain relief, encourage the resident to comply with recommended interventions to help prevent skin breakdown, and notify the medical director or hospice of any skin breakdown. The resident had decreased range of motion with interventions to keep the call light within reach and keep frequently used items in reach. -The care plan did not indicate the reason, the location of, or the extent of the resident's decreased range of motion. The CPO reviewed from 7/17/22-7/26/23 revealed: -X-ray of left wrist due to red, swollen and warm-ordered on 7/17/22. -Keflex 500 milligram (MG])- give one tablet by mouth four times a day for cellulitis for five days-ordered on 7/18/22. -Voltaren gel 1%- apply to left wrist topically two times a day for joint pain and swelling for two weeks-ordered on 9/6/22. -Keflex 500 MG- give one tablet by mouth four times a day for cellulitis in the left hand for five days-ordered on 9/3/22. -Voltaren gel 1%- apply to left wrist topically two times a day for arthritic pain for two months-ordered on 9/27/22. -Aspercreme lotion 10%- apply to left wrist topically every eight hours as needed for pain- ordered on 10/28/22. -Occupational therapy (OT) to evaluate and treat for decreased range of motion and use of left upper extremities-ordered on 10/24/22 and discontinued 12/5/22. -OT to continue with therapy three times a week for thirty days related to wheelchair management, self-care training, therapeutic activities, therapeutic exercises and manual techniques due to lack of coordination and muscle weakness dated 10/26/22 and discontinued 2/6/23. -Restorative therapy for active assistive range of motion with rod; shoulder and elbow flex extension three times weekly or as tolerated- ordered 1/4/23 and discontinued 3/15/23. -X-ray of left hand and fingers for swelling and pain-ordered on 1/11/23. -Voltaren gel 1%- apply to left hand and knuckles topically two times a day for pain- ordered on 1/11/23. -OT to evaluate and treat diagnosis of left wrist scapholunate (small bones in the wrist) ligament injury- ordered on 1/16/23. -Voltaren gel 1%- apply to left hand and knuckles topically every six hours as needed for pain- ordered on 1/20/23. -No further orders were located pertaining to the resident's left wrist or hand. Physician visit notes dated from 9/27/22 to 1/17/23 revealed: -Physician visit note dated 9/27/22 revealed the reason for the appointment was for a swollen left wrist and left hand. The resident was able to hold objects in her left hand and still maintained range of motion. Voltaren gel was continued daily for joint arthropathy (disease of the joint). -Physician visit note dated 10/21/22 revealed the reason for the appointment was due to an abnormal reduction of circulating white blood cells. During the visit, the physician noted the nurses reported the resident was displaying signs of pain and discomfort with no recent falls or specific areas of concern identified. The resident was unable to describe the pain. The resident was still able to move all four extremities however, chronic arthritic changes were noted by the physician. -Physician visit note dated 1/11/23 revealed the reason for the appointment was left hand pain and swelling. The resident presented with acute pain, redness and swelling to her left hand and knuckles. She had a history of arthritis in her left wrist. An x-ray of the left hand was ordered to rule out any possible injuries and a topical gel was provided for relief of pain and swelling. -Physician visit note dated 1/12/23 revealed the reason for the appointment was left hand pain and swelling. The swelling had improved but the joints remained tender to the touch. At this time, the note documented the resident was l able to open her left hand and perform a range of motion activities but with discomfort. -Physician visit note dated 1/16/23 revealed the reason for the appointment was left hand pain and x-ray results. The x-rays revealed soft tissue swelling and arthritic changes of the hand with a suspected injury to the ligaments in the small bones of the resident's left wrist. The swelling had resolved but the resident was still displaying discomfort with her range of motion in the left wrist. A referral was recommended for OT to treat and evaluate the ligament injury. Review of therapy notes revealed: An OT therapist plan of care notes dated 11/23/22 revealed the resident was being seen for cellulitis of the left upper limb. The resident's level of functioning was bilateral upper extremity functional activity tolerance with moderate cues for left upper extremity use, no reported pain. The goal was for the resident to be able to feed herself with finger foods and use a cup to drink with stand by assistance from a therapist. The underlying impairments documented were decreased strength and range of motion in the left upper extremity requiring moderate assistance from staff. The OT therapist discharge notes dated 12/22/2 revealed the resident was able to feed herself with finger foods and use a cup to drink with verbal cues provided by staff. The goal of increasing strength and range of motion in the left upper extremity was not met due to resident pain. Record review failed to reveal a comprehensive assessment of the resident's range of motion by physical or occupational therapy since the resident's admission in July 2021, since resolution of her left wrist cellulitis in the fall of 2022, or since x-rays revealed ligament damage in 1/16/23. Further, record review revealed no evaluation or treatment recommendations from OT following the physician order on 1/16/23 for a referral to OT to treat and evaluate the ligament injury. Progress notes dated from 1/17/23 to 7/27/23 revealed the resident received restorative services to maintain mobility; however, there was no documentation regarding exercises for or the resident's mobility of her left wrist and hand. -Restorative therapy note dated 1/19/23 revealed the restorative therapist was working with the resident three times a week on upper body exercises to build up strength. -Restorative therapy note dated 1/26/23 revealed the resident was stable with restorative. She did refuse to participate at times but the restorative therapist would continue to encourage her to participate. -Restorative program note dated 2/2/23 revealed the resident remained stable with the restorative therapist's encouragement. -Restorative therapy note dated 2/10/23 revealed the resident continued with the restorative program and was totally physically dependent on the restorative therapist to perform all exercises. -Restorative therapy note dated 2/14/23 revealed the resident continued with the restorative program to work on upper body range of motion to prevent decline. -Restorative therapy note dated to 2/16/23 revealed the resident continued to refuse to participate at times and required restorative therapist encouragement. -Restorative therapy note dated 2/23/23 revealed the resident continued to work with the restorative therapist three times a week. She continued to receive encouragement to participate. -Restorative therapy note dated 3/2/23 revealed no changes to the resident's exercise program and she required total physical assistance from the restorative therapist to participate. -Nursing note dated 3/30/23 revealed the resident had been newly admitted to hospice services for a diagnosis of Alzheimer's disease. -There were no notes located after 3/22/23 referring to the status or treatment of the resident's left wrist and hand arthritis. D. Interviews and observation CNA #9 was interviewed on 7/26/23 at 9:45 a.m. She stated Resident #1 had a contracture to her left hand and she did not have a brace or hand splint. CNA #9 stated she did not know if occupational therapy or restorative therapy were working with Resident #1. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He said occupational therapy had worked with Resident #1 from 10/25/22 to 12/22/22. One of the goals was to strengthen the left upper extremity. Resident #1 had an incomplete range of motion in the left hand but it was not contractured at that time. He was not aware of the recommended referral from the physician on1/16/23. (See above) The minimum data set coordinator (MDS) was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said she had not worked with Resident #1 since she enrolled in hospice services on 3/30/23. Restorative had worked with her on upper extremity strength and range of motion. She could not recall if Resident #1 had a contracture in her left hand when she was discharged from restorative therapy services in March. The hospice aide (HA) was interviewed on 7/27/23 at 12:30 p.m. She was taking Resident #1 down the hallway and attempted to open the resident's left hand during the interview. The resident was unable to open any of her fingers without the HA's assistance and without grimacing and showing signs of pain. The HA stated it was very painful for the resident to try to open the left hand when she tried to clean the inside of the hand during showers. She said the hand was always closed when she came to see the resident and she had not seen any intervention in place to manage the contracture. The director of nursing (DON) was interviewed on 7/27/23 at 1:40 p.m. The DON was unaware Resident #1 had a contraction to her left hand, did not know what treatment the resident was receiving and did not know the status of her range of motion. The hospice clinical director (HCD) was interviewed via phone on 7/27/23 at 1:21 p.m. She stated she did not see anything in the resident's hospice records regarding her left hand. If there was a decline related condition, like a hand contracture, it would be documented in the hospice records if it occurred while the resident was on hospice services. II. Resident #7 A. Resident status Resident #7, age 71,was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included diabetes type II, contracture of the left hand (dated 4/2/23), fibromyalgia, bipolar disorder, chronic pain syndrome and injury of extensor muscle, fascia and tendon of left ring finger (dated 2/21/23). The 5/10/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive two person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She required total assistance for bathing and locomotion. The resident had not received any orthopedic surgery to repair bones, tendons, or ligaments in hand. The resident had an upper extremity impairment on one side limiting range of motion. The resident received occupational and physical therapy three times in the seven day lookback period. B. Resident observation and interview Resident #7 was interviewed on 7/26/23 at 9:30 a.m. She stated she had surgery on her left hand in January 2023 and was supposed to be doing therapy but therapy did not help her learn how to put a hand splint on and off on her own. She said she needed the staff's help but they did not do it for her except for maybe one time a week. Her splint was observed on her table next to her TV. Resident #7 was observed on 7/26/23 at 9:30 a.m. Two of the fingers on her left hand appeared bent over and the resident, when asked, was not able to open them. C. Record review The comprehensive care plan revised on 6/21/23 revealed the resident had a surgical repair of the left ring finger related to trigger finger type stiffening. Interventions included applying topical treatments as ordered and administering medication as ordered. The resident required assistance with self-care deficits related to a trigger finger surgical procedure due to tendon pain and to help decrease contracture like range of motion. Interventions were for staff to provide a level of assistance as required and to set up items needed within the residence reach. -The care plan did not include the use of a hand splint. The CPO reviewed from 12/1/22 to 7/26/23 revealed: -Surgical revision appointment for left hand on 12/7/22 at joint clinic- ordered on 12/1/22. -Post operative instructions from the surgical center to keep the operative hand elevated and watch for signs of infection- ordered 12/7/22. -X-ray to left wrist for pain- ordered on 1/30/23. -Physical and occupational therapy to evaluate and treat with no directions specified for order- ordered on 2/4/23 and discontinued 3/6/23. -Order from physician requesting occupational therapy (OT) for hand activities of daily living needs-ordered on 3/10/23 and discontinued on 7/3/23. -Physical therapy (PT) to evaluate and treat five times a week for twelve weeks for therapeutic activities, therapeutic exercises, neuromuscular reeducation related to muscle wasting- ordered on 2/8/23 and discontinued 6/15/23. -Order for OT for hand activities of daily living needs- ordered on 3/10/23 and discontinued on 7/3/23. -Order for splint replacement: remove to let resident move finger and retape each shift- ordered on 3/16/23 and discontinued 3/25/23. -Order for splint replacement: remove to let resident move finger and retape tape each shift- ordered on 3/25/23 and discontinued 5/4/23. -Occupational therapy for the resident to continue with occupational therapy services for 12 visits in 30 days for self-care, wheelchair management, and splinting- ordered on 4/4/23 and discontinued 5/4/23. -Physician order to use left hand brace (splint) 2 hours a day- ordered on 5/4/23 with no end date. -Occupational therapy order to evaluate and treat for left hand trigger finger ordered on 7/24/23. -Occupational therapy for the resident to be seen three times a week for four weeks for diagnosis of self-care, wheelchair assessment, and short arm splint- ordered on 7/24/23. Physician records reviewed from 3/14/23 to 7/26/23 revealed: -Physicians order dated 3/14/23 from the bone and joint clinic for physical therapy two to three times per week for four to six weeks. Finger splint to be applied to the left ring finger to aid in extension related to deformity of left ring finger. -Physician follow-up note dated 3/14/23 revealed the resident had seen the hand surgeon that day and was placed on a finger splint with instructions to tighten with tape daily to help with contracture of 4th digit. -The certified nurse aide (CNA) facility tasks for July 2023 did not reveal instructions to assist the resident with putting on or removing a hand splint. Further, review of the resident's treatment records did not document the implementation of current splint orders. Restorative progress notes revealed one note, dated 6/30/23, that read the restorative CNA washed the resident's left hand and was able to put her hand splint on for one to two hours. D. Staff interviews Registered nurse (RN) #1 was interviewed on 7/26/23 at 9:10 a.m. She said Resident #7 had a contracture to her left hand and had a hand splint staff were to assist her with. CNA #9 was interviewed on 7/26/23 at 9:45 a.m. CNA #9 did know if Resident #7 had a hand brace or splint. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He stated the therapy department had just met with Resident #7 to initiate occupational therapy for her left hand at her request. He stated she had a hand brace but she was incapable of using it without staff assistance. The minimum data set coordinator (MDS) was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said Resident #7 was receiving restorative therapy services from 5/25/23 until 7/3/23. Restorative was working with the resident on range of motion to promote extension of fingers on the left hand. She was working with Resident #7 on putting on a hand splint. The DON was interviewed on 7/27/23 at 1:40 p.m. She said was aware Resident #7 had a contracture in her left hand but did not know if there was a splint ordered for the resident to wear.

Based on record review and interviews, the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to unavailable and missed medications that rose to the scope and severity of immediate jeopardy during the survey on 7/24/23 to 8/14/23. Due to the missed medications, it caused distress and decline to Resident #7 and Resident #25. Findings include: I. Facility policy The Quality Assessment Performance Improvement Plan, dated 4/3/23, was provided by the nursing home administrator (NHA) on 7/24/23 at 1:00 p.m. It revealed in pertinent part, Our facility's QAPI plan serves as guide for our overall quality improvement program and initiatives. The decision making within the facility will be driven by quality assurance performance improvement principles. These decisions will assist in promoting quality of care and quality of life of residents. In addition, these principles will lead to an emphasis on resident choice, person directed care and resident transitions. Any system that affects the satisfaction of residents, families and associates will be considered an area of opportunity. This will include systems affecting the quality of care, quality of life and safety of residents. Our QAPI efforts and activities across departments in order to better work together in assuring that areas of concern are being addressed and services are continually improved. The facility provides care and services to residents across the continuum of care. Because these services have an impact on the clinical care of the resident, all departments will be involved in QAPI efforts to continuously improve the clinical care provided. QAPI efforts will also incorporate healthcare partners in order to provide safe, effective care transitions to the residents we serve. These efforts are established in order to continuously improve our services. The QAPI program at this facility is comprehensive, data-driven and involves the full range of care and services offered, including the full range of departments. QAPI principles are utilized in order to align business and clinical care decisions within the facility in order to provide residents with individualized care to meet their specific goals. II. Cross-reference citation Cross-reference F760: The facility failed to ensure Resident #7 had medication available to include vital medications and Resident #25 received all medications as ordered by the medical provider. The facility failed to ensure medications were available for Resident #7 on several occasions including during the recertification process. The facility failed to administer medications to Resident #25, citing the resident was sleeping but failed to notify the providers of the several missed doses. The facility's failure to ensure Residents #7 and #25 received their medications as ordered contributed to Resident #7 experiencing increasing distress (fear, anxiety, behavioral symptoms) and Resident #25 experiencing signs of distress (agitation, behavioral symptoms). The facility's failure to develop, implement, and monitor medication administration processes to prevent repeated, significant medication errors contributed actual decline in Resident #7 and #25's quality of life and created the potential for serious physical and psychosocial harm if the situation was not immediately corrected. III. Interviews The director of nursing (DON) and the NHA were interviewed on 8/14/23 at 11:40 a.m. The DON said the missed medications for Resident #7 due to unavailability was investigated and narrowed down to one nurse. She said education was provided by the facility to include the DON and the facility reaching out to the pharmacy consultant to help with education as well. When the facility discovered the medication was still not being administered due to unavailability for Resident #7, they terminated the nurse on 7/11/23. She said she was aware the issue was still occurring during the recertification survey. The DON said the facility knew of non-compliance with the medication pass and educated the nurses on the importance of the medication and the process of ordering medications to prevent running out of the medication. The DON said she did not consider the medications for Resident #25 missed doses. She said the resident had the right to sleep. She said when the nurse documented sleeping it was considered acceptable documentation. She said the doses not given when the resident was sleeping were not communicated with the provider. The DON said as of 8/14/23, the facility was current on notification to providers of missed medications. The DON said the plan going forward was she would implement ordering medications that qualified for auto-refill and until it happened she or a designee would check the medication carts weekly to ensure a minimum of a seven day supply to help prevent future missed doses due to unavailability. She said there would be a review of residents who sleep during medication administration times and contact providers to discuss the medication orders.

Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure appropriate hand hygiene by food service staff. Findings include: I. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. II. Observations Observation of the meal service was conducted on 7/26/23 at 10:15 a.m. Cook (CK) #1 was preparing pureed and mechanical meals for the lunch meal. The CK was cutting whole pork loin for the lunch meal. The CK cut the whole pork loin into two inch slices. She placed the pan which the pork loin were in and placed it on the stove top. The CK left two end pieces of pork and grabbed them with her gloved hand and placed them on the pan which was on the stove top. She would wipe her gloved hands on the side of her apron. She walked into the dish room and returned with the blender. She proceeded to place six slices of the pork loin into the food processor and poured some broth into the processor to get the right consistency. She again poured the broth into the food processor and placed the plastic container on the counter. She wiped her hand on the side of her apron. She proceeded to stir the pureed pork loin until the right consistency was reached. She then grabbed several more slices of pork loin with her gloved hand and placed them into the food processor. She added more broth until she got the right consistency. She then walked over to the dish rack and grabbed two small metal containers. She poured the pureed pork into both metal containers and then reached into the food processor and scooped the rest of the pureed pork out with her gloved hand, scraping all pureed out of the food processor and placing it into the metal containers. She opened a sanitizing wipe and cleaned the thermometer and took the temperature. She then wrapped the pureed pork with aluminum foil and then placed it into the heating oven. She wiped her hands on the side of her apron and returned to the food processing area and removed the food processor and took it into the dirty dish area and returned to the serving line. The CK completed the same process for mechanically altered pork. The CK did not perform hand hygiene during this process. CK #1 was observed preparing the pureed bread for the lunch meal. The CK walked into the dirty dish room and retrieved the food processor. She placed it in the food preparation area. She was walking to the other side of the kitchen to retrieve rolls when she grabbed her apron and sneezed several times into her apron holding it with her hand. She proceeded to grab bread rolls and returned to the food preparation area. She then walked into the walk-in refrigerator and grabbed a gallon of milk and proceeded to puree the rolls. She walked over to the dish rack and proceeded to grab a metal container and poured the pureed roll into the container. She wrapped the container with plastic wrap. The CK did not perform hand hygiene during this process. DA #2 was observed preparing the service ware for the meals. DA #2 placed the utensil into a napkin. DA #2 was observed getting up and leaving the kitchen area several times. DA #2 was observed swatting away flies in the area. She would rub her forearm and then continued to wrap the service ware. DA #2 placed the service ware onto a tray. DA #2 did not perform hand hygiene during this process. DA #1 was observed preparing ham sandwiches for the lunch meals. DA #1 put on a pair of gloves. DA #1 was observed touching her nose and adjusting her glasses. She walked over to the bread rack and grabbed a loaf of bread. She walked into the walk-in refrigerator and retrieved a bag of cheese and placed them on the counter. DA #1 opened the bread and proceeded to grab eight slices of bread, placing them on the side of the green cutting board. DA #1 wiped her forehead and touched her nose. DA #1 then went into the walking refrigerator grabbing the door handle with her gloved hand. She retrieved a bag of cooked ham. DA #1 then reached into the bag of ham, grabbing a slice of ham and cutting each slice in half on the green cutting board. DA #1 then placed the bread on the green cutting board and proceeded to reach into the bag of cheese and would place a slice of cheese on the bread. DA #1 then grabbed a slice of ham and placed it on the bread making a total of four sandwiches. DA #1 would wipe her hand on the side of the apron and continue to touch her face. DA #1 would place her hand on the top of the sandwich and proceed to cut it in half. DA #1 reached above the counter and grabbed small sandwich bags. DA #1 grabbed each sandwich into the bag and then reached into her pocket and retrieved a pen writing the date on the bag. DA #1 completed the same process for four more sandwiches. DA #1 did not perform hand hygiene during this process. III. Staff interview The dietary manager (DM) was interviewed on 7/27/23 at 9:30 a.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. She said staff should never touch ready to eat foods with their hands. She said they should use serving tongs even if they have gloves on and they should use a spatula when taking food out of a container. Staff should wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash their hands between tasks to avoid cross contamination.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on all hand held showers in four of four showers rooms, increasing the risk of contamination to the facility's main water supply. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Cross-Connection Control, 11/2/22 https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection, which can result in a potentially serious public health hazard. A cross-connection control and backflow prevention program helps prevent contaminants from entering a drinking water distribution system. This fact sheet is part of EPA's (Environmental Protection Agency) Distribution System Toolbox developed to summarize best management practices that public water systems (PWSs), particularly small systems, can use to maintain distribution system water quality and protect public health. B. Observation Observations of the resident living environment conducted on 7/26/23 at 9:11 a.m. revealed: The east, north and west shower rooms did not have backflow valves installed on the hand held showers in all shower rooms. The hand held shower in the west shower room was positioned on the floor of the shower pan. The hand held shower was long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pan. II. Staff interview The maintenance supervisor (MTCE) was interviewed on 7/27/23 at 10:34 a.m. The MTCE observed the hand held shower in all shower rooms. He said the hand held showers on the west, east and north shower rooms should have had functioning backflow prevention valves on them. He said he would place the backflow valves on all of the shower room immediately.

Based on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen was free from flies. Findings include: I. Professional references A. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) page 186, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. B. According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019, pp. 95-96: -Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects should be kept out of all areas of a health-care facility. -From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Excluding pests from entering the indoor environment and -Applying pesticides as needed. II. Main kitchen observations and interviews On 7/24/23 at 8:56 a.m., during the initial tour of the main kitchen, two staff members were observed working in the kitchen preparing food and were observed swatting away flies. Flies were observed in all food preparation areas. Two staff members were observed utilizing their hands to clear flies from the area. Several flies were observed on walls, clean dishes, scoops and tongs and the dishwashing machine. The kitchen had four trash cans with all trash cans uncovered. On 7/25/23 at 8:24 a.m., during the morning kitchen tour three staff members were working in the kitchen preparing food, while swatting flies away from the tables, food and themselves. The kitchen had four trash cans with all trash cans uncovered. Observations during lunch preparation on 7/26/23 at 10:30 a.m., revealed flies were around the food racks, counters, service ware and on food which was being prepared for the lunch menu. The flies were observed in the dishwashing area with flies on clean plates and pans stored on the dish racks. A cook was observed swatting flies away with her hand. She said, These flies are terrible and they are getting worse. The dietary manager was interviewed on 7/27/23 at 9:30 a.m. She said the flies in the kitchen just seem to be getting worse and I don ' t really know where they are coming from. She said a negative outcome with the flies was the flies could be carriers of bacteria and just a plain nuisance. The maintenance director (MTCE) and pest control technician (PCT) was interviewed on 7/27/23 at 2:59 p.m. The MTCE said he had not heard of any problems with flies in the kitchen. The MTCE said they have two blue lights in the kitchen and may need to add more blue lights to help get rid of the flies. The PCT was told of the observations above of the trash cans not having trash lids. The PCT said that could be the problem of the increase of flies in the kitchen. The MTCE said he would speak with the DM and get some orders.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to: -Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the assisted dining room; and, -Ensure staff knocked before entering resident rooms. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, dated September 2016, provided by the nursing home administrator (NHA) on 7/26/23 at 5:53 p.m., it read in pertinent part: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, the right to receive adequate and appropriate health care consistent with established and recognized practice standards within the facility and within Health Department regulations, and the facility will protect and promote the exercise of rights for each resident. II. Meals served timely A. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:30 a.m., lunch at 11:30 a.m. and dinner at 4:30 p.m. B. Resident observations/interviews On 7/26/23 at 12:16 p.m., Resident #30 was observed self-propelling out of the dining room. Resident #30 was approached by the activity director and asked where she was going. Resident #30 said, I am tired of waiting and I am going back to my room. The AD asked Resident #30 if she wanted to some ice-cream and placed her back at her table and provided Resident #30 with a small bowl of ice cream. Resident #30's meal was served to her at 12:23 p.m. Resident #2 was interviewed on 7/26/23 at 2:40 p.m. Resident #2 said she was legally blind and she had difficulty eating her meals. She said, I need help with my meals but there was not enough staff in the dining room to help me with my meals and she said it takes a long time to get my meal. C. Additional observations 7/25/23 -At 11:10 a.m. There were 14 residents sitting in the assisted dining room. All of the residents' were seated in wheelchairs. -At 11:12 a.m. Resident #23 and Resident #38 were sitting in their wheelchairs sleeping. -At 11:39 a.m. A resident's daughter entered the assisted dining room and sat next to her mother. -At 11:45 a.m. Two female residents were observed sleeping. -At 11:47 a.m. A female resident removed her clothing protector. -At 11:52 a.m. Resident #23 and Resident #38 were sleeping in their wheelchairs. -At 11:53 a.m. The daughter was served her mother's meal and proceeded to assist her with eating the meal. -At 12:07 p.m. Resident #23 was served her meal. -At 12:13 p.m. Resident #38 was served her meal. A certified nurse aide (CNA) was observed trying to wake up Resident #38 so she could assist her. -At 12:20 p.m. The last meal was served to residents in the assisted dining room. 7/26/23 -At 11:13 a.m. There were eight residents observed sitting in the assisted dining room. -At 11:20 a.m. One resident was assisted into the dining room and placed at the table. -At 11:15 a.m. Two more residents were assisted into the dining room and their wheelchairs and placed at their table. -At 11:38 a.m. A total of 13 residents were seated in their wheelchairs in the assisted dining room. -At 11:40 a.m. One more resident was assisted into the dining room. -At 11:50 a.m. Four residents were served their meals. -At 11:55 a.m. 10 residents were still waiting for their meals. -At 12:06 p.m. The fifth tray was served in the assisted dining room. -At 12:09 p.m. The sixth tray was served in the assisted dining room. -At 12:13 p.m. There were eight residents still waiting for their meals. -At 12:22 p.m. A female resident was served her meal and a CNA asked if she wanted pepper and salt on her meal. The resident replied, I just want to eat. -At 12:24 p.m. The last meal was served. C. Staff interview The nursing home administrator (NHA) was interviewed on 7/27/23 at 10:40 a.m. She was told of the observations above. She said residents should not have to wait longer than 20 minutes for their meals. She said the resident's room trays were served first and then the assisted residents were served their meals and then residents in the main dining room. She said the residents should have been served in a timely manner. Cook (CK) #2 was interviewed on 7/27/23 at 11:30 a.m. She said staff would serve the room trays first and then the assisted dining room would be served next and then the main dining room last. She said most of the time it went well but if there was a problem it would delay the serving process. II. Failure to knock on doors before entering A. Observations On 7/24/23 at 10:00 a.m., the housekeeper (HSK) entered room [ROOM NUMBER] without knocking or waiting to be invited in. The resident was seated in her recliner next to the window and her roommate was sleeping in the bed next to the door entrance. The HSK proceeded to clean the room. The HSK repeated the same process for room [ROOM NUMBER], #3 and #4. -At 10:05 a.m., licensed practical nurse (LPN) #1 entered room [ROOM NUMBER] without knocking or waiting to be invited in. The resident was in the restroom when LPN #1 walked in. LPN #1 then turned and left the room. -At 10:15 a.m., LPN #1 entered room [ROOM NUMBER] without knocking or waiting to be invited in, walked across the room and appeared to be standing next to the resident's bed. The resident was lying in bed in her room and was awake looking forward. LPN #1 did not speak to the resident or acknowledge her in any way, then turned and exited the room. -At 11:23 a.m., certified nurse aide (CNA) #3 entered room [ROOM NUMBER] without knocking or waiting to be invited in. CNA #3 exited the resident's room. -At 1:54 p.m. LPN #1 walked into room [ROOM NUMBER]. She was sleeping in her bed across the room next to the window. LPN #1 then turned and left the room. B. Resident interview Resident #13 was interviewed on 7/24/23 at 11:18 a.m. He said he preferred that staff knock on the door to her room before they entered and stated, It's the rule. She said the housekeeping and nursing staff never knocked upon entering his room. Resident #145 was interviewed on 7/24/23 at 3:18 p.m. She said staff never knock prior to entering her room. She said they just walked right in. C. Staff interviews LPN #1 was interviewed on 7/25/23 at 2:21 p.m. LPN #1 was told of observations above. She said, I don't have to knock if I am in line of sight of the resident. CNA #8 was interviewed on 7/25/23 at 4:50 p.m. She said staff should always knock and announce themselves and wait for them to answer before going into a resident's room. The director of nurses (DON) was interviewed on 7/26/23 at 1:39 p.m. She said all staff should knock prior to entering residents' rooms in order to maintain their dignity. She said staff were provided this education upon hire during their general orientation and it was reviewed annually during their in-service training. She said, The staff know better.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 15 of 30 resident rooms in three hallways. Specifically, the facility failed to ensure walls, ceilings and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 7/26/23 at 9:11 a.m. revealed: room [ROOM NUMBER]: The restroom wall had deep scratches and gouges approximately seven inches long by one inch wide. The baseboard cove underneath the sink had an area approximately 12 inches long which was peeling away from the wall. The shower across from room [ROOM NUMBER] had six pea sized holes on the wall next to the shower. room [ROOM NUMBER]: The wall next to the door in the restroom had an area approximately six feet high by half inch wide of cracked plaster. There were three nickel sized holes next to the door frame. room [ROOM NUMBER]: The entrance door had chipped and splintering wood on the bottom approximately seven inches long by four inches wide. The bathroom wall had deep gouges from the wheelchair hitting the wall approximately five feet long. room [ROOM NUMBER]: The entrance door had chipped and splintering wood on the bottom approximately six inches long by four inches wide. The vinyl flooring was missing a section approximately 12 inches long by three inches wide next to the restroom door. room [ROOM NUMBER]: The wall behind the recliner had two damaged areas from the recliner hitting the wall. The damage was approximately six inches long by three inches wide and seven long by two inches wide. room [ROOM NUMBER]: The transition strip leading into the resident's room had a missing transition strip approximately 36 inches long by three inches wide. The wall above the toilet had a hole approximately two inches in diameter. The wall in front of the toilet had an area approximately five feet long two inches wide which was damaged from the wheelchair hitting the wall. The entrance door had chipped and splintering wood on the bottom approximately five inches long by four inches wide. room [ROOM NUMBER]: The baseboard cove was missing a section approximately five inches long by four inches wide. The telephone junction box next to the resident's bed was missing a cover. The privacy curtain rail had been removed with the outline still visible on the ceiling. room [ROOM NUMBER]: The door frame had deep chipped and splintering wood approximately four inches wide by 14 inches high from the wheel chair hitting the door frame. The wall paper outside of room [ROOM NUMBER] had a section approximately 10 inches long by two inches wide which was cut. The shower room on the north hall had sheetrock damage approximately four feet wide by three feet high. room [ROOM NUMBER]: The corner section next to the restroom had an area approximately four feet high by one inch wide of chipped and peeling sheetrock. room [ROOM NUMBER]: The wall above the resident's bed had chipped and peeling sheet rock approximately 16 inches long by six inches wide. The corner piece next to the restroom had chipped and cracking sheetrock approximately four feet long by inches wide Room # 26: The wall next to the restroom had a section approximately four feet high by three inches wide from the wheelchair hitting the corner. The metal corner piece was visible. The wall paper next to the resident's window was damaged from the chair hitting the wall. room [ROOM NUMBER]: The wall paper behind the resident's recliner had an area approximately eight inches long by three inches wide which was damaged from the recliner hitting the wall. room [ROOM NUMBER]: The wall paper was peeling next to the resident's shelf and the shelf was falling off the wall. The corner piece next to the resident restroom had chipped and peeling sheetrock approximately 18 inch high by three inches wide. The metal corner piece was exposed. room [ROOM NUMBER]: Had a missing piece of baseboard cove approximately six inches long by four inches wide. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance director (MTCE) and the nursing home administrator (NHA) on 7/27/23 at 10:05 a.m. The above detailed observations were reviewed. The MTCE documented the environmental concerns. The MTCE said the facility utilized a computer system to identify environmental issues. The MTCE said he did have work orders for the damage identified during the environmental tour. The MTCE said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on interviews and record review, the facility failed to ensure care and services to meet the highest practicable wellbeing was provided for one of three residents reviewed for skin care, of six sample residents. Specifically, the facility failed to ensure monitoring and treatment for [REDACTED].#3 ' s hand. The hematoma worsened over the course of five days, leading to [DIAGNOSES REDACTED], infection, and ultimately necrosis. The resident required hospitalization and multiple surgical interventions to debride the necrotic tissue. The findings include: A. Professional Reference: The Lippincott Manual of Nursing Practice, tenth edition, indicated the following in pertinent part: An examination should involve the following techniques as appropriate for eliciting findings: inspecting the area visually, palpating (touching) the observed parts to note whether they are tender to touch and what various structures feel like to distinguish the normal from the abnormal, percussion to observe the density of the underlying tissue and determine whether they are fluid filled, air filled, or solid. Individuals on anticoagulants should be observed carefully for symptoms of bleeding, which should be reported immediately. These symptoms included bruising/hematoma, and a note indicated the skin should be inspected carefully. Adult Physical Assessment and Care of the Older Adult. (2014). In S. Nettina (Ed.), Lippincott Manual of Nursing Practice (10th ed., pp. 181-182). Ambler, Pennsylvania: Wolters Kluwer Health Lippincott Williams & Wilkins. B. Facility Policy: The facility ' s policy for temporary/acute conditions, indicated the following in pertinent part: Assessments and care plans had been developed for a number of temporary/acute changes in condition, including bruises. The assessment and care plan should be completed whenever one of the mentioned changes in condition was identified, and should include a description of the resident ' s problem and the nurse ' s findings, as well as interventions put in place. Assessment and documentation around the concern should occur for a minimum of 72 hours, and until the problem was resolved or the condition stabilized. C. Resident Status and Care Plan: Resident #3, age 77, was admitted to the facility on [DATE]. According to the July 2016 computerized physician orders, [DIAGNOSES REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident was able to understand others sometimes, and was rarely or never understood. She was not able to complete a brief interview for mental status, but staff assessments indicated impairment in her short term and long term memory. She was unable to recall the current season, the location of her room, staff names and faces, or that she was in a nursing home. She displayed continuous inattention. She was unable to be interviewed about current or historical pain, but did not demonstrate non verbal indications of pain during the assessment. She was receiving an anticoagulant. A physician order [REDACTED]. The resident ' s care plan for communication impairment, dated 8/12/14 and updated 4/4/16, indicated the resident had difficulty with expression and reception of communication (finding the right words and understanding others). The care plan indicated the resident would sometimes respond with one to two word answers, and sometimes not at all. The resident ' s care plan for anticoagulant use, dated 3/10/15 and revised on 7/25/16, indicated the resident was at risk for bleeding due to the use of an anticoagulant. The goal was that the resident would maintain a therapeutic level of medication. Approaches included observing the resident for bruising, occult stools, nose bleeds and bleeding gums, and calling the physician if there were concerns. The resident ' s care plan for skin integrity, dated 8/15/14 with no updates, indicated she was at risk for impaired skin integrity related medication and fragile skin. The goal indicated the resident would have intact skin and no signs or symptoms of skin breakdown, irritation, or infection. Approaches included observing for bruising, conducting skin checks weekly, and geri sleeves to both upper arms. D. Initial Development of Bruising: A late entry nurse ' s note, written on 7/25/16 at 10:44 a.m., indicated the resident had blood drawn on 6/28/16, and that on 7/2/16, a bruise was noted to the top of her left hand. The bruise was described as being 3.3 cm by 2.5 cm. No additional description was present. A nurse ' s note dated 7/2/16 at 7:05 p.m. indicated the medication nurse had been informed the resident had a large bruise to her left hand, which was assessed as a hematoma over most of her hand. There was not documentation of the size or appearance of the area, whether the area was painful, or warm or cool to touch. The note did not indicate interventions put in place to address the hematoma. The note was signed by registered nurse (RN) #1. An incident report dated 7/2/16 at 8:04 p.m. indicated the following in pertinent part: The resident had an injury of unknown origin, which was described as a large hematoma to the top of her hand. The hematoma was measured at 3.3 cm x 2.5 cm. The area was not described as being swollen, and there was no description of the surrounding skin. No interventions were documented. The form indicated the resident ' s physician was notified and responded at 8:00, and the resident ' s daughter was notified and responded at 8:04 p.m. The report included a statement by certified nurse aide (CNA) #1, as taken on 7/2/16 at 8:30 p.m. The statement indicated the CNA had gone into the resident ' s room to change her and get her ready for bed and had noticed the resident ' s fingers were bruised. When she pushed up the sleeve, the CNA noticed the entire top of her left hand was bruised. The CNA indicated she reported the injury to the charge nurse and placed a compress. The report indicated the resident was on [MEDICATION NAME], had blood drawn on 6/28, and had a bruise. No follow up steps were documented. The form was not signed by the NHA, DON, medical director (MD) or pharmacist. A nurse ' s note dated 7/3/16 at 6:00 a.m. indicated the resident was on follow up for bruising to the back of her left hand. The note indicated the resident was sleeping and there were no signs or symptoms of discomfort. The note did not indicate the nurse had looked at the bruise, and no description or measurements were present. No interventions were noted. The note was signed by RN #2. A nurse ' s note dated 7/3/16 at 9:51 a.m. indicated the resident had bruising to her left hand, with [MEDICAL CONDITION] (swelling) noted. The note indicated no pain was observed, and that range of motion was within normal limits. The note did not document the size of the bruise, or quantify the swelling, and did not document any interventions. The note was signed by licensed practical nurse (LPN) #1. A nurse ' s note dated 7/3/16 at 6:58 p.m. indicated the resident was observed sitting in a common area in her wheelchair. She was observed to be alert, but disoriented, (noted to be her baseline) and there was no sign of pain. The resident was noted to have a purplish bruising and swelling on the top of her left hand. There was no change in her range of motion or mobility status. The note did not indicate any measurements of the area, describe the surrounding skin, or demonstrate any interventions. The note was signed by RN #3. A nurse ' s note, dated 7/3/16 at 11:58 p.m. indicated the resident continued on follow up for a bruise to the back of her left hand. The note indicated there were no changes, but did not provide a description of the bruise or the surrounding area, or measurements. The note did not document interventions. The note was signed by RN #2. A nurse ' s note on 7/4/16 at 1:19 p.m. indicated the resident continued on follow up for a bruise to the back of her left hand. The note indicated there were no changes noted, however, the writer (LPN #2) had not documented on the bruise prior, and there was not a description or measurement of the bruise or the surrounding area to substantiate the assessment of no change. No interventions were documented. A nurse ' s note on 7/4/16 indicated the resident was observed in her bed. No signs of pain were observed. The hand was described as remaining a purplish color, but the swelling had resolved. Vital signs were noted to be stable and the resident had good active range of motion to her left hand, fingers and wrist. The bruise was not measured, and the surrounding area was not described. No interventions were documented. The note was signed by RN #3. There was no documentation of the resident ' s hand on 7/5/16. A late entry nurse ' s note, which was effective on 7/6/16 but written on 7/26/16 at 9:43 a.m., indicated the writer (LPN #1) had assisted a CNA to transfer the resident into her wheelchair for breakfast, and had noted the left hand had a purple bruise and the top of the hand was swollen. The note indicated the fingers were not swollen, but did not describe the surrounding area. The note indicated arm protectors were in place. There was no documentation of either the resident ' s physician or the facility ' s medical director being notified of the resumed swelling, and documentation of the bruise ' s status on 7/6/16 was not available to the chart for monitoring purposes prior to 7/26/16. A nurse ' s note dated 7/7/16 at 5:32 a.m. indicated the resident ' s secondary agent under medical power of attorney had been called related to the resident ' s wedding ring potentially causing an injury to her hand. The agent granted permission to have the ring removed. There was not documentation in the note related to the appearance or condition of the resident ' s hand. The note was written by RN #4. A nurse ' s note dated 7/7/16 at 6:49 a.m. indicated the resident was sent to the emergency room at 6:30 a.m. The note did not contain documentation about the rationale behind the transfer, documentation that the physician was notified, or describe the condition of the resident ' s hand. The note was signed by RN #4. A late entry nurse ' s note, effective 7/7/16 and written on 7/22/16 at 10:56 a.m. indicated the resident ' s physician was called regarding the resident ' s hand, which was swollen and bruised. The note indicated the fire department had been contacted to remove a ring (the resident ' s wedding ring) and had agreed with the nurse ' s assessment that the resident needed to be seen by a physician, and an order was obtained to send her to the emergency room . The note was signed by RN #4. E. hospitalization and subsequent operations: An ambulance report dated 7/7/16 at 6:24 a.m. indicated the facility had called the fire department to remove the resident ' s wedding ring from her hand. The report indicated the ring had been removed, but the fire department personnel had been concerned about the condition of the resident ' s hand and had independently called for a transport. The fire department indicated they were told the resident had blood drawn from the hand the previous Friday and her hand had begun to swell over the previous week. The report indicated the resident was observed laying in her bed with her left hand swollen, and discolored black and blue. The resident was transferred to the hospital. An emergency department intake report, dated 7/7/16 at 6:47 a.m. indicated the resident presented to the emergency department with significant ecchymosis (a discoloration of the skin caused by bleeding underneath) and swelling to the back of her left hand, which also extended onto the palm, her wrist, and the metacarpals (first knuckle) of her fingers. The fingers were noted to be slightly swollen, with the tips of her fingers being pink with good capillary refill. The report indicated the resident had a venipuncture (blood draw) approximately six days prior (7/1) at which time she began to have progressively worsening swelling to her left hand. The report indicated it was not clear whether the swelling had been gradual or acute, and the nursing facility denied any known trauma. An operative report, prepared on 7/9/16 at 6:07 a.m. by Physician #2, indicated the resident underwent [REDACTED]. The surgery also included the incision and drainage of a deep hematoma in her left hand and wrist that was placing pressure on the surrounding tissues, a limited fasciotomy (a surgical cutting of the thin tissues surrounding a muscle or another organ to relieve pressure), excisional preparation of devitalized skin (removal of necrotic skin tissue), and the removal of a deep abscess (a pocket of infected tissue) in the resident ' s wrist. The report indicated the resident presented for surgery with a massive swelling that mainly involved the dorsal aspect (back) of her left hand, with an 8 x 10 cm bulla (a fluid filled blister in the skin) on the dorsal radial aspect of her hand (The back side of her hand along her thumb) that extended to the wrist. Multiple additional bullae were observed on the resident ' s ring and little finger. The hand and arm were noted to be mottled (marked with spots and blotches) and tense. The post-operative [DIAGNOSES REDACTED].). A second operative report, prepared on 7/9/16 at 9:18 p.m. by Physician #2, indicated the resident received a second operation for monitoring to ensure the perioperative tissues (areas surrounding the previous operation) remained vital. The skin flaps over the previous hematoma were noted to be dusky, with some necrotic tissue along the edges, which was removed. The resident was noted to have some residual deep hematoma in her hand and wrist. The report concluded that the appearance of the hand was improved, however, a second follow up operation would be required. A third operative report, prepared on 7/10/16 at 8:12 p.m. by Physician #2, indicated the resident continued to have additional hematoma noted in her wrist, and had additional devitalized skin removed. A fourth operative report, prepared on 7/16/16 at 12:24 p.m. by Physician #2, indicated the resident ' s hand had been treated with [MEDICATION NAME] for debridement following her operation on 7/10/16, however, there was necrotic skin requiring removal. The report indicated a 4 x 4 cm area of full thickness skin loss, involving eschar (a hard necrotic tissue) to the dorsal surface of the resident ' s hand, which was removed. The report concluded the resident was placed on a [DEVICE], and would require a split-thickness skin graft to close the wound when it was determined to be ready. F. Interviews: A member of the resident ' s family was interviewed on 7/25/16 at 12:30 p.m. The family member said the resident ' s agent under power of attorney had received a call on 7/4/16 indicating the resident had a bruise on her hand from a recent blood draw. The family member said they were not informed of how large the bruise was or that it was swollen, and did not receive any follow up phone calls on 7/5/16 or 7/6/16. The family member said one of the resident ' s daughters called every day, and had not been informed of any concerns about the area. The family member said on the morning of 7/7/16, the facility had called the fire department to come in and cut off the resident ' s wedding ring, at which point the fire department had become concerned about the condition of the resident ' s hand and had called for an ambulance to take her to the hospital. The family member said the resident had been admitted to the hospital on [DATE] and had been taken into surgery on 7/8/16 to release the pressure in the resident ' s hand. The resident required three additional surgeries and eventually, a large area of skin on the back of her hand was removed due to necrosis. The facility member said they had been told the resident would require a fifth surgery to place a skin graft over the back of her hand. The resident ' s primary care physician (Physician #1) was interviewed on 7/26/16 at 10:15 a.m. He said he had received a call from the facility indicating the resident ' s arm had suddenly swollen up, and had given an order for [REDACTED]. The physician said he took all of his own calls because he was in practice by himself, and there was no other person in his office the facility could have spoken to. When told the resident had gone to the hospital on [DATE], the physician said he needed to double check the date, but that was around the time when the facility had called him. The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 7/26/16 at 12:15 p.m. The DON said the resident was on [MEDICATION NAME] (an anticoagulant) and frequently developed bruises when she had her blood drawn. As a result, the facility had determined the bruising on the resident ' s hand had been from a blood draw, and confirmed the size of the bruise as documented in the initial nursing note was 3.3 cm x 2.5 cm. The DON and NHA confirmed the initial documentation of the bruise did not describe the area as being raised or swollen, or indicate the bruise spread to most of her hand. The NHA said the bruise needed to be monitored for at least 72 hours to see if it was improving, staying the same, or getting worse. She agreed without thorough documentation about the initial size and appearance of the bruise, the nursing staff would have a difficult time making an evidence based decision about any changes. The DON confirmed the incident report indicated the resident ' s physician had been notified on 7/2/16 at 8:00 p.m., but said the physician was on vacation. The DON said she had not assessed the bruise, and the assistant director of nursing (ADON), who was the facility ' s wound nurse, had done an assessment on 7/4/16. The assistant director of nursing (ADON), who was the facility ' s wound nurse, was interviewed on 7/26/16 at 1:24 p.m. She said she had assessed the resident ' s hand on 7/4/16. She said at the time, the resident had a large bruise that was all over her hand, which was dark purple and almost black in color. She said the bruise contained a raised area that was 2.5 x 3.3 cm, and it too was dark purple, almost black. She said at the time, the raised area was the only thing that was swollen. The ADON said she had not touched the swollen area, and as such was not sure whether it was hard or soft, or if there was a difference in the temperature of the area. The ADON said in regards to assessing and monitoring skin concerns, the assessing nurse should document the way the wound looks, including color, size, and swelling, as well as if there were concerns with pain or range of motion. She said the purpose of this was to establish a baseline for the wound so nursing staff would be able to track it through its progression to make a quantitative, evidence based assessment of whether the wound had improved, remained the same, or deteriorated. Licensed practical nurse (LPN) #1 was interviewed on 7/26/16 at 1:38 p.m. She said she had seen the bruised area twice, on 7/3/16, and on 7/6/16. She said when she had seen it on the third, there was a large bruise on the resident ' s hand, and some swelling. She said she had seen it again on 7/6/16, when she was assisting the resident into the dining room. She said the resident had arm protectors on, which she indicated by demonstration came down to the middle of the resident ' s hand. She confirmed as a result she had not been able to see the whole area that had previously been bruised, but said the area she did see appeared to be very swollen from the fingers down across the whole back of the resident ' s hand. She said the hand aside from her finger tips was purple, but the fingers did not appear swollen at that point. The resident ' s primary care physician (Physician #1) was interviewed a second time on 7/26/16 at 1:05 p.m. He confirmed he had been on vacation on 7/2/16, but said he did not have any phone calls from the facility on that day. He said his call log indicated he received two phone calls on 7/3/16, but he did not have voicemails for either of those calls. He said he did not receive a phone call on 7/7/16 about the resident requiring transfer to the emergency room , but received a call on 7/8/16 indicating the resident ' s bruise had worsened and she had been sent to the hospital the day prior. The NHA and DON were interviewed on 7/26/16 at approximately 2:40 p.m. They confirmed the facility ' s medical director had not been notified of the resident ' s bruise, and confirmed that once they had been unable to reach the resident ' s physician, the medical director should have been contacted to ensure medical oversight of the bruise since the resident was on [MEDICATION NAME]. The NHA was interviewed on 7/28/16 at 11:15 a.m. She said the facility had made a recent switch to an electronic system for the tracking of non-pressure related wounds, and based on the concerns with thoroughness of the assessments, the facility would be reverting to a paper tracking that would prompt a more thorough assessment of bruising. The NHA also said bruises would be followed until they resolved, and that she would be initiating training about these changes with the staff.