Every finding on record at Highline Post Acute

Based on interviews and record review, the facility failed to ensure residents were free from any significant medication errors, affecting one (#1) of three residents out of 10 sample residents.Specifically, the facility failed to provide Resident #1 with the physician-prescribed medication for human immune deficiency virus (HIV) disease.Resident #1 was admitted to the facility on [DATE] with a physician's order to receive the HIV medication Biktarvy. Biktarvy consists of three components, bictegravir, emtricitabine & tenofovir alafenamide (tenofovir). On [DATE], the nurse who admitted Resident #1 transcribed the Biktarvy order as tenofovir alafenamide only. The nurse did not recall why the order was changed, and there was no evidence that the pharmacist or the medical director reviewed the order before it was changed.Resident #1 continued on tenofovir only from [DATE] until [DATE] when the prescription read to discontinue. On [DATE], neither the facility nursing staff, the facility pharmacist who performed a monthly medication review prior to the medication being discontinued, nor the medical director reordered the medication for Resident #1. Antiretroviral (ART) therapy for HIV is a lifelong medication. From [DATE] until [DATE], Resident #1 did not receive any HIV medications.On [DATE], Resident #1 went to a local hospital to undergo his approximately every six to nine month viral load blood test. (Viral load blood test for HIV is used to determine how well the ART is working) The viral load blood work documented Resident #1 had a viral load of 65,900. According to the hospital gerontologist, had Resident #1 received his HIV medications as ordered, his viral load numbers would be approximately zero, an undetectable level that meant the virus was suppressed, preventing disease progression and transmission.Also on [DATE], when Resident #1 went to the hospital for his bloodwork, his medication orders sent from the facility did not include Biktarvy as prescribed in February 2025. The hospital physician wrote a medication order for Biktarvy on [DATE], and on [DATE], Resident #1 began taking Biktarvy, the medication he should have been on since [DATE] for his HIV.The facility's failure to administer Biktarvy as ordered created the likelihood for serious resident harm. According to the hospital gerontologist, tenofovir was not sufficient to treat HIV on its own. Serious harm was also likely due to the resident's exposure since February 2025 to an incomplete medication regimen, which can create an even greater drug resistance to Biktarvy for HIV (meaning Resident #1 may develop a resistance to the HIV drug Biktarvy due to it not being administered since February 2025).Findings include:I. Findings of immediate jeopardyA. Failure to administer medications as orderedThe facility failed to accurately transcribe the physician's order for a compound anti-viral medication for HIV, which led to Resident #1 not receiving the correct combination medication from [DATE] until [DATE]. When the incorrect medication order expired on [DATE], the medical director and the facility pharmacist were not consulted, and the medication was not renewed. The resident did not receive any anti-viral medications in the compound for HIV from [DATE] to [DATE].B. Facility notice of immediate jeopardyOn [DATE] at 2:50 p.m., the nursing home administrator (NHA), the director of nursing (DON), and clinical resource #1 were notified of the facility's failure to prevent a significant medication error by not ensuring Resident #1 received his HIV medication as prescribed. The medication error created a situation of immediate jeopardy for serious harm. C. Facility plan to remove immediate jeopardyOn [DATE], the NHA, DON, and clinical resource #1 presented the following plan to address the immediate jeopardy situation. It read in pertinent part, Immediate Action Done: On [DATE], Resident #1's medication list was printed and reviewed with the facility physician for accuracy. On [DATE], the hospital's infectious disease office (for Resident #1) was contacted regarding follow-up appointment recommendations for lab monitoring. Beginning [DATE], the DON or designee will prioritize reviewing current residents who are receiving clinically significant medications such as insulin, anticoagulants, cancer agents, antivirals, and medications for multiple sclerosis or Parkinson's. This review will focus on order accuracy. Once those residents are completed, the DON/designee will review all remaining residents. This plan will be completed by [DATE]. On [DATE], the DON or designee reviewed all resident orders with a discontinuation date using the order listing report to ensure accuracy. This was completed on [DATE]. Plan: (Facility name) Medication policy was reviewed on [DATE] by the NHA, the DON, and the medical director. Beginning [DATE], new admission orders will be reviewed against the discharge orders to ensure transcription accuracy. Any discrepancies identified will be clarified with the attending physician. This process will be ongoing. Beginning [DATE], the primary physician will review new admission orders in conjunction with the history and physicals to ensure accuracy. This will be an ongoing process. Beginning [DATE], consultant pharmacists will complete a review of new admissions for clinically significant risk within 72 hours of admission. This review will include assessment of high-risk medications, potential interactions, contraindications, missing indications, and duplicate therapies. Any concerns identified will be communicated to the facility immediately. On [DATE], the licensed practical nurse (LPN) who may not have transcribed the original order correctly was re-educated via phone by the assistant director of nursing (ADON). Education included the facility's policy regarding medication administration and reconciliation guidelines of noting who medications were verified with and any changes made during reconciliation. Beginning [DATE], the staff development coordinator (SDC) or designee re-educated all licensed nurses on the facility's medication administration and reconciliation policy. Education included documenting who was verified for each medication, noting any changes made during reconciliation, completing a two-nurse verification of order accuracy, and clarifying when a long-term medication has a stop date. Education was completed by [DATE] for 43 of 57 licensed nurses through in-person or phone education. Any nurse who has not yet received (the) education will not work the floor until training is completed. Licensed nurses who have not worked within the last 60 days have been terminated. Licensed nurses on a leave of absence will be educated upon their return and prior to working on the floor. Eleven licensed nurses were unable to be reached by the SDC or designee and will not be scheduled (to work) until the required education is completed. Beginning [DATE], the SDC/designee will educate agency licensed nurses on the facility's policy regarding medication administration and reconciliation guidelines. Education was uploaded to the agency portal on [DATE]. The agency platform requires the agency nurse to complete training before they can confirm the shift. On [DATE], the regional director of clinical services notified the pharmacy account representative of the error. A meeting has been scheduled with (pharmacy name) for [DATE] to review the error in detail and establish an ongoing plan for medication monitoring.D. Removal of immediate jeopardyOn [DATE] at 2:11 p.m., the NHA and clinical resource #1 were notified that, based on the plan for removal of immediate jeopardy, the plan was accepted and the immediate jeopardy situation removed. However, deficient practice remained at a G scope and severity, isolated, actual harm. II. Professional referenceAccording to the [DATE] guidelines for the use of antiretroviral agents in adults and adolescents with HIV, retrieved on [DATE] from https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/initiation-antiretroviral-therapy, The primary goals of antiretroviral therapy (ART) are to prevent HIV-associated morbidity and mortality and to prevent transmission of HIV to others. Durable viral suppression lowers the risk of both AIDS-defining and other HIV-related complications, improves immune function and overall health, and allows people with HIV to live a lifespan approaching that of people without HIV. High plasma viral load is a major risk factor for HIV transmission. The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) recommends ART for all people with HIV to reduce the morbidity and mortality associated with HIV infection (AI) and to prevent HIV transmission to sexual partners and infants. ART should be initiated as soon as possible after HIV diagnosis. The key to successfully maintaining viral suppression is continuous access to ART and full adherence to the prescribed regimen. Lack of adherence or intermittent access to ART can result in treatment failure and the emergence of drug resistance mutations that may compromise future treatment options.III. Facility policy and proceduresThe Administering Medication policy, revised 2019, was provided on [DATE] at 6:09 p.m. by the DON. It read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame.IV. Resident #1A. Resident statusResident #1, age less than 70, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included human immune deficiency virus (HIV) disease, psychotic disorder with delusions, dementia, depression and pain.The [DATE] minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required set-up or clean-up assistance with eating, toileting, oral hygiene and dressing. He required supervision with showers. He did not reject care from staff. The medication, Biktarvy, was not documented on the MDS assessment. B. Resident #1's interviewResident #1 was interviewed on [DATE] at 3:00 p.m. Resident #1 said he took whatever medication the nurses gave him at the facility. Resident #1 said he did not remember missing any medications, nor did he refuse any medications to his memory.C. Record reviewThe medication administration record (MAR) for Resident #1's HIV medication from [DATE] (Resident #1 was admitted on [DATE]) until [DATE] revealed:February 2025: Resident #1 received Tenofovir Alafenamide Fumarate, one oral tablet 25 mg (milligram) in the morning for HIV. The start date was [DATE]. The end date for the medication documented both [DATE] and [DATE]. The [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] MARs (until [DATE]) revealed Resident #1 received Tenofovir Alafenamide Fumarate, one oral tablet 25 mg (milligram) in the morning for HIV. The end date for the medication was [DATE].-Resident #1 did not receive Tenofovir, or any HIV medications from [DATE] through [DATE].The comprehensive care plan, initiated on [DATE], revealed Resident #1 had a diagnosis of HIV and was at risk for complications manifested by a decreased white blood count, fatigue, fluid volume deficit, nutrition, impaired skin integrity, infection, pain, and weight loss. The planned intervention was to administer medications as ordered.On [DATE], Resident #1 went to the hospital for routine HIV blood work. The hospital laboratory documented that the virus was detected above maximum quantitative range. The viral load (VL) was documented at 65,900. (See the hospital gerontologist's interview below; the resident's VL should have read approximately zero). The hospital documented it was unclear how long the resident had been without antiretrovirals. The hospital records documented Resident #1 stated it had been a few days since he received his HIV medication, but his viral load suggested longer. Biktarvy did not appear on his medication list for the hospital when he came from the facility. The hospital gerontologist for Resident #1 wrote a prescription on [DATE] for the resident to resume the medication Biktarvy.While at the hospital on [DATE], Resident #1 had a CBC (complete blood count) with WBC (white blood count) comprehensive blood test to count the red cells, platelets, and total white blood cells. The results indicated low and out of range for Resident #1.On [DATE], Resident #1 began Biktarvy oral tablet 50-200-25 mg (milligrams) (Bictegravir-Emtricitabine-Tenofovir Alafenamide Fumarate), one tablet by mouth one time a day for HIV. These were the three compounds in the medication Biktarvy that Resident #1 was to have received upon his admission on [DATE]. The [DATE] CPO documented Resident #1's medication Biktarvy was revised on [DATE] with a start date of [DATE]. The [DATE] physician's assistant (PA) note documented that Resident #1 had a history of HIV and had a history of being non-compliant with Biktarvy. However:-See above; the resident was not offered Biktarvy for approximately ten months, from the time of his admission into the facility in February 2025 until he received the medication on [DATE]. -See above; the MDS assessment documented that the resident did not reject care from staff, and the [DATE] and [DATE] MAR did not document any refusals of Biktarvy. -See below; interview with LPN #1 and LPN #2, on [DATE] at 10:20 a.m., revealed that Resident #1 was cooperative with care. Further, a [DATE] nursing progress note documented that the resident continued to take medications as ordered and was cooperative with care.V. Action taken after immediate jeopardy was identifiedThe [DATE] nursing progress note (during survey) documented that the ADON called and notified Resident #1's family member of a medication error involving Biktarvy that occurred upon admission in February 2025. The family member was informed that the error was identified during the resident's appointment at the hospital on [DATE] and that the correct medication had resumed since that time. The family member was also informed that corrective actions had been implemented to prevent recurrence of the error. VI. InterviewsThe hospital gerontologist was interviewed on [DATE] at 9:55 a.m. via telephone. The hospital gerontologist said when Resident #1 came to the hospital on [DATE], his VL blood work was over 65,000, and it should have been around zero had he received Biktarvy. The hospital gerontologist said it was unlikely the reason for the high bloodwork numbers was because the medication was not working, but rather because Resident #1 had not received his medication. The hospital gerontologist said he had seen Resident #1 for almost two years, since [DATE]. The hospital gerontologist said if the resident missed only a few days, it would be okay, but Resident #1's medication was critical for him to take. The hospital gerontologist said when Resident #1 came to the hospital on [DATE], his medication list from the facility did not have Biktarvy on it.LPN #1 and LPN #2 were interviewed on [DATE] at 10:20 a.m. Both LPNs said recently in [DATE], Resident #1 went to a follow-up appointment at the hospital, and after that appointment, he started the medication (Biktarvy). LPN #1 said Resident #1 did not reject medications that the nurses provided. Both said the resident was cooperative with care. The DON was interviewed on [DATE] at 1:28 p.m. The DON said Resident #1 was admitted to the facility in February 2025 with a physician's order for a medication called Biktarvy. The DON said Biktarvy was made of three components bictegravir, emtricitabine and tenofovir alafenamide. The DON said she thought that when the LPN entered the medication, it was entered as only tenofovir. The DON said she did not know why it was ordered incorrectly, or if anyone else reviewed the medication order prior to it being changed. The DON said she did not know if the LPN did not transcribe the order correctly, or the pharmacy had. The DON said she spoke to the LPN today ([DATE]) about the day Resident #1 was admitted on [DATE]. The DON said the LPN did not remember what happened that long ago, or which provider or source was used to verify the medication. The DON said that the medication was not transcribed correctly, which was a medication error. The DON said after Resident #1 went to the hospital for his blood work on [DATE], the hospital gerontologist wrote an order for Biktarvy, and it was provided to Resident #1 starting on [DATE]. The DON said Resident #1 did not receive his correct medication from the date he was admitted on [DATE] until [DATE]. The facility's medical director (MD) was interviewed on [DATE] at 1:50 p.m. The MD said she did not know how it was that Resident #1 did not receive the medication he was supposed to receive 10 months ago for HIV. The MD said the situation was like Swiss cheese that had a lot of holes. The MD said the situation had a lot of holes as to why or who missed the medication's correct physician order. The MD said she could not say whether or not Resident #1 would be affected by not having received his HIV medication.On [DATE] at 11:22 a.m., the facility pharmacist was interviewed via the telephone. The facility pharmacist said she had begun on [DATE] as the facility pharmacist. The facility pharmacist said the process for a newly admitted resident to the facility was for the nurse on duty to call or notify the pharmacist consultant, who would verify the physician's orders. The facility pharmacist said after that, a pharmacist assigned to the facility would perform monthly reviews of a resident's medications. The facility pharmacist said when she read residents' medications, she kept a lot in balance, including fall risks, and then made recommendations. The facility pharmacist said she reviewed the medications for the residents in the facility in the first part of [DATE]. The facility pharmacist said she did not know why Resident #1's HIV medication was not reordered. The facility pharmacist said she would do a review of her work and then return the call with follow-up information about Resident #1's medication. -However, the facility pharmacist did not call back as of [DATE], the end of the survey.On [DATE] at 2:32 p.m., the hospital gerontologist wrote via email, Missed HIV medications cause (s) the HIV viral load to rise and the patient's immune system to worsen (as measured by the CD4 count). This increases the risk of infections, certain types of cancers, and even common conditions like heart disease. When someone misses medications regularly, they can also develop resistance to those medications. It's actually a little worse that (Resident #1) was on tenofovir alone (one of the three components in Biktarvy). Tenofovir by itself is not sufficient to treat HIV. Exposure to an incomplete regimen like this creates an even greater opportunity for drug resistance to develop (in addition to not fully treating the HIV). So, while Resident #1 was completely off medicines for only a short time ([DATE] to [DATE]), he was not being fully treated since February 2025. This mistake should have been caught by his clinicians and/or pharmacy, even if they were not very familiar with HIV treatment options.The NHA and the DON were interviewed together on [DATE] at 2:20 p.m. The NHA and the DON both said the situation with Resident #1 happened prior to their employment in the facility as NHA and DON. Both the NHA and the DON said they were aware of the critical nature of the situation with Resident #1. Both the NHA and the DON said the situation with the wrongly transcribed medication would not happen again with the new systems put in place during the survey.

Based on observations, record review and interviews the facility failed to ensure an environment free of accident hazards for two (#1 and #19) of nine residents reviewed for accident hazards out of 21 sample residents.On 5/18/25 Resident #1 requested certified nurse aide (CNA) #1 to heat up an egg roll from his personal refrigerator in a microwave that was at the nurses' station. After heating up the egg roll, CNA #1 gave the egg roll to Resident #1, without using a thermometer to check the temperature of the egg roll, and told the resident not to touch the egg roll because it was very hot. However, Resident #1 immediately picked up the egg roll after CNA #1 gave it to him. Hot liquid came out of the egg roll and dropped on the resident's leg causing a second degree burn to Resident #1's left thigh On 5/19/25 the facility implemented a plan of correction in response to the incident which caused Resident #1's left thigh burn. The corrective actions included placing thermometers and temperature logs at each nurses' station for staff to take the temperatures of heated up food for residents and logging the temperatures prior to giving the food to the residents. However, on 6/30/25, during the survey, observations revealed the corrective actions implemented by the facility on 5/19/25 were not in place and none of the facility's three microwaves at the nurses' stations had a thermometer or a temperature log for staff to utilize.Additionally, on 6/19/25 Resident #19 was in the facility van, in his wheelchair, for an activity outing. Resident #19 was supposed to be secured in the van with a shoulder harness seatbelt placed across his chest, which also included a seatbelt extender attached to the seatbelt. The seatbelt extender was to be secured into a hook on the van floor. However, the seat belt was not secured properly on Resident #19. During the outing, another driver in front of the van made an abrupt turn which caused the transportation driver to quickly utilize the brakes. When the transportation driver suddenly stepped on the brakes, Resident #19 fell forward out of his wheelchair, onto his knees, and scraped his forearm which caused bleeding. Resident #19 sustained a 4 centimeter (cm) by 7 cm by 0.1 cm skin tear to his right forearm.The facility investigated the incident and determined the transportation driver did not fully secure Resident #19's seatbelt, which resulted in the fall. The facility implemented a plan of correction in response to the incident on 6/19/25, immediately after Resident #19 sustained the fall in the facility van and no other incidents in the van occurred following implementation of the plan of correction. -While the facility identified and corrected the deficient practice regarding the incident with Resident #19, it was identified during the survey that the facility continued to have current deficient practice related to accident hazards due to corrective actions not being in place for the incident with Resident #1 (see above). Specifically, the facility failed to:-Ensure staff checked microwaved food for safe temperature prior to serving the food to residents, which resulted in Resident #1 sustaining a second degree burn to his left thigh; and,-Ensure Resident #19 was secured properly in the facility's van, which resulted in the resident sustaining an abrasion to his right forearm after he fell out of his wheelchair when the van abruptly stopped. Findings include: I. Burn incident with Resident #1 on 5/18/25A. Facility policy and procedureThe Hot Liquid Safety policy, dated 2025, was provided by the nursing home administrator (NHA) on 7/1/25 at 1:37 p.m. via email. It revealed in pertinent part, Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns. Scalding is a burn caused by spills, immersion, splashes, or contact with hot water, food and hot beverages, or steam. Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure. The temperatures of hot liquids will be checked in the dietary department or at the nurses' station if the microwave is in place before distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit (F), hold the liquid in the dietary department until it reaches an appropriate temperature.II. Resident #1 A. Resident statusResident #1, age less than 65, was admitted on [DATE] and readmitted on [DATE] According to the June 2025 computerized physician orders (CPO), diagnoses include type 2 diabetes mellitus, dependence on renal dialysis, morbid obesity, peripheral vascular disease, history of falling, acquired absence of the right leg above the knee and acquired absence of the left leg below the knee.The 4/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set up or clean up assistance with eating. He required partial moderate assistance with toileting.B. ObservationsOn 6/30/25, beginning at 2:00 p.m., three microwaves were observed in the facility, one at each of the two nurses' stations and one in the activity room. None of the three microwaves had thermometers or a food temperature log for staff to utilize. On 6/30/25 facility staff said all three of the microwaves were used to heat residents' foods, but none of the staff members could provide thermometers to check the temperatures of the microwaved food items (see staff interviews below).C. Resident interviewResident #1 was interviewed on 6/30/25 at 3:20 p.m. Resident #1 said the egg roll item was from his own personal refrigerator. He said he asked CNA #1 to heat the egg roll (on 5/18/25) in the nurses' station microwave. Resident #1 said after CNA #1 gave the food to him, he picked up the egg roll and dropped it immediately because it was too hot to hold, and it fell on his leg. Resident #1 said he thought it was the liquid inside the egg roll that burned his leg. Resident #1 said the burn hurt and he had a lot of pain. He said the physician saw him and told him the burn would heal and he was given some cream that stopped the pain. Resident #1 said he still had a small scar on his leg from the incident. D. Facility investigation of Resident #1's burn incident and corrective actionsThe facility's investigation and corrective actions implemented in response to the incident were provided on 6/30/25 at 11:00 a.m. by the corporate consultant (CC) and the NHA. The facility's investigation documented that on 5/18/25 Resident #1 had food (from his personal room refrigerator) heated up in the microwave (at the nurses' station) by CNA #1. According to the resident, the food rolled onto his leg causing a burn. The temperature of the food was not checked prior to giving the heated food (from the microwave) to Resident #1.The facility implemented the following action plan in response to the incident. However, on 6/30/25, during the survey, observations revealed the corrective actions implemented by the facility on 5/19/25 were not in place and none of the facility's three microwaves at the nurses' stations had a thermometer or a temperature log for staff to utilize.Corrective Action: The staff immediately assessed the resident. Nursing management started educating staff on 5/19/25 on the policy and safe handling of food with microwaves. This education was provided by the assistant director of nursing (ADON). The education included what temperature the food needed to be, how to properly assess the temperature of food and log (how to document the food temperatures). The nursing administration put out thermometers and a food temperature log at each nurses' station on 5/19/25. On 5/19/25 a one-to-one education was provided to CNA #1 regarding proper safe handling procedures for food and drinks. Identification of others: All residents had the potential to be affected. The regional director of clinical services (RDCS) reviewed risk management from the last three months for any residents with burns and none were noted.Systematic changes: The ADON started education with staff on 5/19/25 on the policy for heating food/beverages per regulation. Monitoring: The director of nursing (DON)/designee would conduct twice weekly audits of designated microwaves (and) ensure that a temperature log was being used to document residents' food/beverages (or items residents requested to be heated in a microwave, not meal service). The DON/designee would audit twice weekly that a thermometer and a temperature log was at the designated area where microwaves were located. The DON/designee would present all findings of audits to the quality assurance and performance improvement (QAPI) committee for a minimum of 12 weeks and would continue until substantial compliance was met.E. Record reviewThe 5/18/25 nursing progress note documented Resident #1 sustained a burn injury to the left thigh from an egg roll that was heated in the microwave (at the nurses' station). A 2 cm by 4 cm superficial burn was noted on Resident #1's leg. Resident #1 reported that while attempting to open his egg roll, it slipped and fell onto his thigh and caused a burn. The incident was reported to the on-call physician and a physician's order was received for silver sulfadiazine cream (an antibiotic cream used to treat second and third degree burns).The 5/20/25 wound care physician note documented Resident #1 received a second degree burn on 5/18/25. The note documented the burn was on the resident's left anterior thigh and it received a status of not healed. The initial wound encounter measurements were 2 cm length by 6.5 cm width by 0.1 cm depth. Resident #1 reported a pain level of zero out of 10. The wound bed had 100 percent (%) epithelialization (a new layer of tissue formed over the damaged area). The periwound skin exhibited edema. The 5/27/25 wound care physician note documented Resident #1's wound was improving and not healed. The left anterior thigh had a burn and encounter measurements were 1.5 cm length by 2.3 cm width by 0.1 cm depth. The resident reported a wound pain of level zero out of 10. The wound bed had 100% epithelialization. The wound was improving. The periwound skin exhibited scarring.The 6/10/25 wound care physician note documented Resident #1's burn on his left anterior thigh was resolved. F. Staff interviewsThe DON was interviewed on 6/30/25 at 5:05 p.m. The DON said after the incident on 5/18/25 with Resident #1, she and the ADON educated all the staff and put thermometers at every nurses' station where there was a microwave. The DON said as of today (6/30/25), she did not know where the thermometers went that were placed at the nurses' station on 5/19/25. The DON said Resident #1 did not go to the hospital for his burn. The corporate nurse (CN) was interviewed on 6/30/25 at 5:20 p.m. The CN said any microwaves at nurses'stations and the activity room would be removed immediately per the management's decision because all three of the microwaves were used to heat and reheat residents' food. CNA #1 was interviewed on 7/1/25 at 11:20 a.m. via the telephone. CNA #1 said she was the one who served Resident #1 the egg roll (on 5/18/25). CNA #1 said almost every night Resident #1 asked for items to be heated in the microwave. CNA #1 said Resident #1 liked his food items very hot. CNA #1 said she should have only heated up the egg roll for about two minutes, but instead heated the egg roll for five or six minutes. CNA #1 said she did not use a thermometer to check the temperature of the egg roll. CNA #1 said she did not remember if there were any thermometers by the microwave on the nurses'station. CNA #1 said the egg roll was taken out of the microwave and immediately placed on Resident #1's bed side table. CNA #1 said she told Resident #1 to wait a few minutes for the egg roll to cool down because it was very hot. CNA #1 said she did not see Resident #1 drop the food item on his leg. CNA #1 said she was educated by the ADON after the incident about how to correctly heat foods in a microwave and how to use a thermometer. CNA #1 said she thought microwaved foods should only be heated to 140 degrees Fahrenheit. Licensed practical nurse (LPN) #5 was interviewed on 7/1/25 at 1:15 p.m. LPN #5 said the microwaves at the nurses' stations were used sporadically by the residents and Resident #1 asked for microwaved items only at night. LPN #5 said there were thermometers placed by the microwaves after Resident #1 was burned and the staff was educated on how to heat foods properly.G. Facility follow-upOn 6/30/25, the NHA and the maintenance director (MTD) took the microwaves out of the nurses' stations and the activity room. On 6/30/25 at 5:20 p.m. the NHA said since no thermometers were near the microwaves at the nurses' stations and activity room, he decided to remove the three microwaves. The NHA said the microwaves would be removed while the facility continued to review and revise the policy on safe food handling with heating up food and/or beverages. The NHA said new education would be provided to staff, which included that only the kitchen would have a microwave to reheat residents' food items.On 6/30/25 the ADON began re-educating all staff on microwaves and food service temperatures. The re-education also included where the thermometers and temperature log were to be kept. The re-education included how to perform a temperature check and what degrees foods needed to be served to the residents. Effective on 6/30/25, only one microwave in the main kitchen would be designated for all facility units staff to heat residents' food.A full house audit was completed by the CN on 6/30/25 at 6:15 p.m. on any burns in the last 90 days. No other residents were affected. II. Van incident with Resident #19 on 6/19/25A. Facility policy and procedureThe Transporting A Resident (Facility Van) policy, dated March 2025, was provided by the CN on 7/14/25 at 12:31 p.m. via email. It revealed in pertinent part, It is the policy of this facility to provide residents with safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary. The van will be well-maintained and equipped with safety features. Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs. Staff authorized to drive the van will have the necessary training and licensure to operate the vehicle as well as knowledge of van safety features. Copies of any necessary documentation will be kept in each employee's personnel file.B. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included Parkinson's disease, vascular dementia, unsteadiness on his feet, chronic obstructive pulmonary disorder (COPD), cognitive communication disorder, need for assistance with personal care, amputation of (a) great toe, obesity and hypertension (high blood pressure). The 5/23/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He required supervision/ touch assistance with oral hygiene, toileting and upper body dressing. C. Facility investigation of Resident #19's van incident and corrective actionsThe facility's investigation and corrective actions implemented in response to the incident were provided on 7/1/25 at 10:00 a.m by the CC.The investigation documented on 6/19/25, while out on an activity outing, Resident #19 did not have a seat belt (secured) across his lap in the facility van. Resident #19 said he fell out of his wheelchair because the truck in front of the van slammed on their brakes, and the facility van had to come to a sudden stop to avoid an accident. The facility implemented the following action plan in response to the incident:Resident #1 was returned to the facility after the fall and was assessed by the registered nurse (RN). Treatment was provided by a facility nurse. The staff present in the facility van at the time of the incident were immediately educated on 6/19/25 by the DON. The education included ensuring all residents were always secured appropriately with a seat belt while in the facility van.All residents had the potential to be affected.The DON conducted an audit of risk management over the last 60 days and no other residents were identified.The interdisciplinary team (IDT) completed a root cause analysis which was completed on 6/19/25.On 6/19/2025 the regional director of plant operations performed a safety check on the van.On 6/19/25 a training was provided by the regional director of plant operations to the DON and ADON (about van safety).On 6/19/2025 a training was provided by the regional director of plant operations to the facility's director of maintenance (MTD) regarding safety checks (of the facility van).The transportation driver was trained on 6/19/25 to ensure all residents were always secured appropriately with a seat belt while in the facility van. Additionally, any new employees that would provide transport would be educated prior to the start of their first transport.On 6/23/2025 additional coaching (van safety) was provided to the transportation driver by the NHA.The DON/designee would audit all transports prior to leaving the facility to see that the residents were secured appropriately with their seat belts. The audit would continue for 12 weeks minimum.The DON/designee would present audits to the QAPI committee monthly for a minimum of 12 weeks or until substantial compliance was achieved.The MTD would audit the van twice per week to ensure the safety of the van, and the audit would be recorded on a paper audit tool for 12 weeks minimum. The administration would present audits to the QAPI committee monthly for a minimum of 12 weeks and until substantial compliance will be achieved.-While the facility identified and corrected the deficient practice regarding the incident with Resident #19, it was identified during the survey that the facility continued to have current deficient practice related to accident hazards due to corrective actions not being in place for the incident with Resident #1 (see above).D. Record review The fall risk assessment, dated 3/22/25, documented Resident #19 was a moderate fall risk.The comprehensive care plan 8/22/24 revealed Resident #1 was at risk of falls related to Parkinson disease, amputation of the great toe, and muscle weakness. The interventions documented the resident needed a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, and personal items within reach.The nursing progress note, dated 6/19/25 (after the fall) and written by the ADON, documented Resident #19 was going on outings in the facility bus when he fell out of his wheelchair to his knees, then fell back and hit his head on his wheelchair. Resident #19 was observed to have two skin tears measuring 2.5 cm by 1.5 cm and 4 cm by 0.5 cm to his right arm, an abrasion to his right knee and a bruise to his nose. Resident #19 said he fell out of his wheelchair to his knees and hit the back of his head on the wheelchair. The resident was assessed by a RN and assisted back to his wheelchair. Neurological check(s) were initiated and wound treatment was placed. The 6/19/25 physician's progress note documented a verbal physician's order was given for wound care instructions to clean Resident #19's right arm wounds with cleanser, pat dry, skin prep the periwound (protect the skin surrounding the wound), apply a gauze dressing to the wound bed, and cover with bordered gauze as needed and QOD (every other day).The 7/1/25 wound care physician's note documented Resident #19 had a skin tear to the right forearm with dimensions of 4 cm by 5 cm by 0.1 cm. The drainage was scant and the periwound was pink in color. The 7/8/25 wound care physician's note documented the skin tear for Resident #19 was resolved.E. Staff interviewsThe transportation driver was interviewed on 7/10/25 at 11:43 a.m. The transportation driver said she put Resident #19 in the facility van. The transportation driver said she thought she had correctly secured Resident #19 with wheelchair tie downs to the wheels of the wheelchair and a seatbelt, which had an extender that was to be locked, to the van floor. The transportation driver said a driver in front of the van made a quick move that caused her to slam on the brakes. The transportation driver said when the brakes were abruptly stepped on, the activity assistant (AA) said Resident #19 had fallen. The transportation driver said she drove the van over to the side of the road, parked the van and put on the emergency lights. The transportation driver said she gave Resident #19 basic first aid placed Resident #19 back into his wheelchair, and because of blood, she bandaged the skin tear on his arm. The transportation driver said she called the DON and returned to the facility, which was about five to eight minutes away from where the incident occurred. The transportation driver said she only saw blood on Resident #19's arm. The transportation driver said the DON and a facility nurse took Resident #19 off of the van and took over the care of Resident #19. The transportation driver said no other residents were hurt that were in the van on 6/19/25. The transportation driver said the van worked correctly but she did not strap in Resident #19's seatbelt correctly. The transportation driver went into the van during the interview and demonstrated how the incident happened. The transportation driver said Resident #19's wheelchair wheels were properly secured on the van floorboard. The transportation driver said she then put a shoulder harness seatbelt across his chest, and added a seatbelt extender that was approximately two to three feet long. The extender was to buckle into the seat belt at one end, and at the other end of the extender was a hook that latched onto a metal loop on the floorboard to secure Resident #19 in place. The transportation driver said she did not know which part of the seatbelt was not secured. The transportation driver said it was either the extender end was not secured onto the seat belt, or it was the extender hook which was not latched onto the floor board of the van. The transportation driver said when she helped Resident #19 back into his wheelchair the entire seatbelt and extender were off which was why Resident #19 was able to fall forward out of his wheelchair. The transportation driver said she was educated the day of the incident by the DON. The transportation driver said the following day, the DON had her do a return demonstration in the van to show how to correctly secure residents.The DON was interviewed on 7/10/25 at 12:30 p.m. The DON said the transportation driver was educated prior to being allowed to drive residents in the van. The DON said it was a one time mistake and there had been no falls in the facility van since the incident on 6/19/25. The DON said Resident #19 did not need to go to the hospital after the fall. The DON said the facility's wound nurse and the facility's wound physician cared for the skin tear. The DON said only Resident #19's arm had a skin tear, and he had no other bruises or wounds after he was assessed. The DON said on 7/8/25 the wound physician documented that the skin tear was resolved. The DON said for several weeks, she or a designee would check the residents who attended field trips to ensure all of the residents on the van were secured correctly.

Based on observations, record review and interviews, the facility failed to ensure one (#10) of three residents reviewed for falls out of 10 sample residents received adequate supervision and services to prevent an accident. Specifically, the facility failed to: -Ensure a root cause was identified for Resident #10's fall on 3/16/25; and, -Ensure Resident #10's care plan was reviewed for appropriate fall interventions after a fall. Findings include: I. Facility policy and procedure The Safety and Supervision of Residents policy and procedure, reviewed 4/4/25, was provided by the nursing home administrator (NHA) on 4/8/25 at 12:02 p.m. It read in pertinent part, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented and documenting interventions. Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. II. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (DM), dementia, chronic obstructive pulmonary disease (COPD), unsteadiness on feet and chronic kidney disease. The 3/10/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He required substantial/maximal assistance with showers/bathing. He required partial/moderate assistance with toileting hygiene, upper and lower body dressing, personal hygiene, putting on/off footwear, and walking 50 feet with two turns. He required supervision/touching assistance with bed mobility, toileting and sit to stand transfers, shower transfers and walking 10 feet. The resident used a manual wheelchair. The assessment revealed he exhibited no behavioral symptoms or rejection of care. B. Record review Review of Resident #10's fall care plan, revised 6/6/18, revealed the resident was at risk for falls related to COPD, dementia, DM type 2, chronic kidney disease, hyperlipidemia, nicotine dependence, GERD (gastroesophageal reflux disease), neuropathy, HTN (hypertension), depression, BPH (benign prostatic hyperplasia) and history of falls. Interventions included encouraging the resident to wear shorts/pants with appropriate length, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed, providing a prompt response to all requests for assistance, educating and encouraging the resident to call for assistance with picking up items from the floor, educating the resident/family/caregivers about safety reminders and what to do if a fall occurred, encouraging the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensuring the resident was wearing non-skid shoes, rearranging the resident's room as needed and ensuring the bedside phone was within reach, therapy screening for restorative nursing program and therapy to evaluate and treat as indicated. -Review of the fall interventions revealed there had been no revisions to the care plan since 6/1/23. Review of Resident #10's secondary fall care plan, revised 7/25/24, revealed the resident had an unwitnessed fall and was at risk for recurring falls and unsteady gait related to cognitive impairment. Interventions, initiated 7/25/24, included medication regimen review as indicated, monitoring for complications related to the fall (change in neurological status, evidence of injury, loss of range of motion, pain) and notifying the physician promptly if observed, occupational therapy (OT) to screen for wheelchair management and smoking safety, keeping personal/frequently used items within reach, anticipating and meeting the resident's needs, educating/reminding the resident to call for assistance, encouraging activity as tolerated with rest periods between activities as needed, evaluation of medications for side effects that may increase fall risk, explaining all procedures and providing reassurance during mobility tasks to alleviate the fear of falling, keeping bed in low position with brakes locked, keeping the resident's call light within reach and initiating a restorative nursing program (initiated 9/19/23). -Review of the interventions revealed there had been no updates to the fall care plan since 7/25/24. -There was no documentation to indicate Resident #10's care plan was reviewed for the effectiveness of his fall interventions after his fall on 3/16/25. The 3/16/25 at 4:40 p.m. nurse's note revealed the certified nurse aide (CNA) called the nurse and said Resident #10 was on the ground in the main courtyard. The nurse went to the area and found the resident sitting down next to his wheelchair. Upon assessment, no apparent injuries were noted. The resident denied hitting his head, his pupils were equal, round, reactive to light and accommodation and his range of motion and vital signs were within normal limits. The resident was transferred to his wheelchair, with a maximum of two people safely. Neurological checks were initiated by the floor nurse. -The progress note did not identify a root cause for the resident's fall. The 3/17/25 at 11:32 a.m. physician's note revealed the reason for the physician's visit was follow up to a fall. Resident #10 was seen in his room, lying in bed comfortably and in no acute distress. The resident had a recent fall with no injuries. The physical examination did not show any trauma or bumps. Vital signs were stable. Resident #10 had a fall on 3/16/25 where he was found sitting next to his wheelchair in the courtyard. The note indicated staff were to continue follow-up with fall and neuroprotocol per facility. The 3/17/25 at 1:50 a.m. weekly nurse summary note revealed there had been no resident fall incident that week. -However there had been a fall the day before, on 3/16/25. -Review of the resident's progress notes revealed there was no further documentation of Resident #10's fall incident. -Review of Resident #10's EMR revealed there was no documentation to indicate a root cause for the resident's fall had been identified by the nurse on duty at the time of the fall or by the IDT. -Additionally, there was no documentation to indicate Resident #10's fall interventions had been reviewed for effectiveness or to determine if new fall interventions were needed. III. Staff interviews The director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on 4/7/25 at 12:46 p.m. The DON said the facility's process after a fall depended upon if it was witnessed or not, but the nurse would be called and a RN would do an assessment before the resident would get up. The DON said if a resident hit their head or if it was unwitnessed, the nurses would do neurological assessments and notify physicians and residents' representatives. The DON said the facility would do an IDT meeting after the fall on the following business day to prevent a recurrence. The DON said IDT included herself, the director of rehabilitation (DOR), social services and the NHA. The DON said IDT would meet to discuss and determine the root cause of the fall. The DON and the RCR said they were not aware that Resident #10 had a fall on 3/16/25. They said they did not see an IDT note/assessment and said the fall had not been documented into their risk management system. The DON said the nurse on duty at the time of Resident #10's fall did not enter the fall into risk management and therefore the facility did not have an IDT meeting to determine the root cause because they were not aware of the fall. The DON said that Resident #10 had not been assessed for the root cause of his fall and the resident's care plan had not been reviewed to determine if new fall interventions were needed. The DON said the risk management entry was important so that it could trigger the next steps for fall review. The DON said it looked like it was an agency nurse that did not enter the information and she said she would call and educate the agency nurses and re-educate the staff nurses regarding the appropriate fall process. The DON said since Resident #10 had not had an IDT review of his 3/16/25 fall, she would talk with the resident, the physician and the nurse and find out the root cause of the fall and update the resident's care plan appropriately.

Based on interviews and record review, the facility failed to ensure that one (#1) of eight residents out of 16 sample residents remained as free from accidents as possible. Resident #1, severely cognitively impaired and with a history of elopement on 6/8/24 and frequent exit-seeking behaviors in January 2025 and February 2025, left the facility without staff knowledge on 2/5/25 between 9:30 p.m. and 10:30 p.m. He was not located until approximately 8:00 a.m. the next day. The facility's failures in responding to his elopements created a reasonable expectation, absent immediate correction, that an adverse outcome resulting in serious harm, impairment, or death would occur. Record review revealed that on 6/8/24, Resident #1 eloped from the facility and was found across the street later that day. On 6/11/24, the resident was evaluated as being at risk for future elopement. His care plan was updated the same day with interventions that read, in part, to allow the resident to wander in safe areas, to encourage attendance and participation in activities, to attempt to refocus when exhibiting behavior, and for staff to complete the elopement risk evaluation (assessment) per facility policy. -The update did not note that the resident had eloped 6/8/24, did not identify specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), identified on the elopement assessment 6/11/24. Further, there was no plan to increase his level of supervision. Record review revealed that on 2/5/25, Resident #1 eloped from the facility a second time. He was last seen at approximately 9:30 p.m. in the building and was noted as missing by a certified nurse aide (CNA) at approximately 10:30 p.m. The time of elopement was uncertain. On 2/6/25 at approximately 8:00 a.m., facility staff located Resident #1 approximately one mile from the facility, outside an establishment with his wheelchair, wearing a coat, pants, and shoes. His vital signs were stable, but he was very cold and shivering. -Record review revealed a quarterly elopement assessment completed 12/26/24 per care plan directive (see above), failed to take into account all the resident's risks from medication, diagnoses, and his prior elopement. -Record review revealed no further care plan updates or an increase in the resident's supervision level after 6/11/24, even though the resident's medication and treatment administration record from January 2025 documented that Resident #1 had exit-seeking behaviors where he was difficult to redirect 22 out of a possible 31 days. And, the medication and treatment record from February 2025 documented that Resident #1 had exit-seeking behaviors on four out of the five days leading up to his elopement on 2/5/25. -Record review revealed the facility's investigation of Resident #1's elopement on 2/5/25 failed to identify root causes to prevent a recurrence or consider lapses in the facility's response. Interviews revealed delays in implementing the facility's policy/protocol once it was determined that Resident #1 was missing. Further interviews revealed that despite documentation and knowledge of Resident #1's behavior on 2/5/25, staff had a conflicting understanding of Resident #1's elopement risk and the resident's exit-seeking behaviors. On 2/25/25 at 12:45 p.m., an Immediate Jeopardy was identified based on the facility failures above that created a situation of potential serious harm for Resident #1, requiring immediate corrective action. Findings include: IMMEDIATE JEOPARDY I. Immediate Jeopardy A. Findings of Immediate Jeopardy Resident #1, with a brief interview for mental status (BIMS) assessment of three out of 15 (severe cognitive impairment), was admitted on [DATE]. An elopement assessment dated [DATE] revealed that Resident #1 was not at risk for elopement. However, less than three months later, on 6/8/24, Resident #1 eloped from the facility. He was assessed on 6/11/24 as being at risk for future elopement following the incident. His care plan was updated the same day with interventions that read, in part, to allow the resident to wander in safe areas, to encourage attendance and participation in activities, to attempt to refocus when exhibiting behavior, and for staff to complete the elopement risk assessment per facility policy. -However, the update did not note that the resident had eloped 6/8/24, did not identify specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), identified on the elopement assessment 6/11/24. Further, there was no plan to increase his level of supervision. Record review revealed an inaccurate assessment of the resident's elopement risk on 12/26/24, and no care plan updates or an increase in the resident's supervision level after 6/11/24, even though staff documented in January 2025, Resident #1 had exit-seeking behaviors where he was difficult to redirect 22 out of a possible 31 days and in February 2025, had exit-seeking behaviors on four out of the five days leading up to an elopement on 2/5/25. On 2/5/25, Resident #1 eloped from the building a second time. He was last seen at approximately 9:30 p.m. and was noted as missing by a CNA at approximately 10:30 p.m. The time of elopement was uncertain. Facility staff began looking for the resident in the building, at the neighboring nursing facility, and in the neighborhood. The director of nursing (DON), nursing home administrator (NHA), and police were not notified until 3:00 a.m. on 2/6/25, after facility staff were unable to locate the resident. On 2/6/25 at approximately 8:00 a.m., facility staff located Resident #1 approximately one mile from the facility with his wheelchair, wearing a coat, pants, and shoes. His vital signs were stable, but he was very cold and shivering. Resident #1 was taken back to the facility and was placed on one-to-one staff supervision for the initial 72 hours and then on 15-minute checks. Resident #1 was also monitored for exit-seeking behaviors every shift, although the behaviors remained unspecified on his care plan. On 2/24/25 (during the survey), the facility completed a COC (change of condition) assessment for Resident #1. The revised COC assessment revealed the resident's score for elopement was 32, indicating a high risk for elopement. As of 2/25/25, the facility had not identified specific behaviors/concerns or identified new interventions to address Resident #1's high risk for elopement. Interviews with staff on 2/24/25 and 2/25/25 revealed that the director of nursing (DON) was not aware of Resident #1's ongoing exit-seeking behaviors, although staff reported the resident wandered, especially in the evening and at night, pushed on doors, and talked about going outside often. The facility failures above created a situation of Immediate Jeopardy for serious harm for Resident #1 that required immediate corrective action. On 2/25/25 at 12:45 p.m., the DON, the nursing home administrator (NHA), and the nurse consultant (NC) were notified of the Immediate Jeopardy situation. B. Facility plan to remove the Immediate Jeopardy On 2/25/25 at 6:51 p.m., the NHA provided a plan to remove the Immediate Jeopardy situation. The removal plan read: The facility will reassess all residents for elopement risk and identify triggers or predictive behaviors. The IDT (interdisciplinary) team will review and update care plans for residents at risk of elopement with individual resident centered approaches/strategies. The DON or designee will educate all staff on strategies and interventions for preventing elopement. The DON or designee will educate all staff on supervision, monitoring and reporting residents who are exit seeking. The DON or designee will educate nursing staff on notifying the NHA/DON of residents who are exit seeking, behaviors/triggers to monitor and strategies/interventions. The NHA or designee will educate all staff on the missing person policy, including timely required notifications at shift change. The education was to be completed prior to the first shift for new hires and agency staff. The DON or designee will review the behavior tracking five times per week for exit seeking behavior Residents and family will be educated regarding not assisting other residents to leave the facility and the process for signing in and out when leaving the facility by the NHA or designee. All staff on all shifts received education on the process for the front doors, wandering, elopement policy to include predictive behaviours and elopement prevention strategies, elopement binder missing persons policy and residents safety by the DON or designee. Any staff on leave received education on their next scheduled work day. An elopement risk assessment will be completed on admission and quarterly by the IDT team. Residents determined at risk by the IDT team will have a care plan in place to prevent elopement. The DON or designee will audit new admissions for elopement risk, determine if the facility can meet the resident's needs and ensure a care plan with appropriate interventions is in place if appropriate. New hires will receive education on wandering, elopement policy and elopement binder, and resident safety by the DON, director of social services or designee(s). A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAPI meeting for a minimum of three months or until the pattern of compliance is maintained. C. Removal of Immediate Jeopardy The NHA and the NC were notified on 2/26/25 at 12:17 p.m. after the implementation of the plan (see above) was verified by the surveyors onsite (see below) that the removal plan was accepted, and the Immediate Jeopardy was removed. After the removal of Immediate Jeopardy, the deficient practice remained at a scope/severity level D, isolated with no actual harm. The facility provided the following on 2/26/25: -Shift report training and expectations with a roster showing which nursing staff completed the training as of 2/26/25. -Spreadsheet showing the audit conducted on 2/26/25, the reassessment of risk, and the new interventions implemented for the residents whose assessment had changed. -Elopement binder and the facility policy on elopement was updated on all nurses stations by 2/26/25. -Documentation of Resident #1's care plan with updated behaviors updated by 2/26/25. -A spreadsheet of residents with completed and updated wandering assessments with an updated IDT note and updated care plan interventions if needed dated 2/25/25. -Communication of education and updated door locking policy provided to facility residents, family members, and staff on 2/25/25 and 2/26/25. -The elopement policy with education, including when to notify the IDT team if a resident was suspected missing, including education sign in sheets to show which staff had received training on 2/25/25 and 2/26/25. -Education sign in sheets were provided to show which staff had received the training on 2/25/25 and 2/26/25. On 2/26/25 between 9:30 a.m. and 12:00 p.m. the following staff were interviewed and confirmed they had received elopement training and how to use the elopement binder: dietary manager, housekeeping, ADON (assistant director of nursing), receptionist, CNA #4, licensed practical nurse (LPN) #5, human resources, maintenance, receptionist, and activity aide. II. Facility policy The Elopements and Wandering Residents policy, 2023, was provided by the NHA on 2/24/25 at 12:33 p.m. The policy read in pertinent part, The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team. The IDT team will evaluate the unique factors contributing to risk in order to develop a person centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize the risks associated with hazards will be added to the resident's care plan and communicated to the appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. The designated facility staff will look for the resident. If the resident is not located in the building or on the grounds, the NHA or designee will notify the policy department and serve as the designated liaison between the facility and the police department. Post-elopement, staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. III. Resident #1 A. Resident status Resident #1, age less than 80, was admitted to the facility on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included dementia, depression, and type 2 diabetes. The 12/27/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial assistance with showering and toileting. He required supervision for transfers and walking. He was independent with his wheelchair. An elopement assessment, dated 3/22/24, revealed that Resident #1 was not at risk for elopement. Resident #1 was interviewed on 2/24/25 at 10:00 a.m. He said he went outside every day. He said he loved going outside. B. First elopement - Facility failures in response 1. Elopement 6/8/24 On 6/8/24 at 2:26 p.m., a nursing note documented that around 8:00 a.m. on 6/8/24, a CNA told the nurse that Resident #1 was not in his room. The nurse checked the smoking area and other empty rooms in the building. They started searching outside the building. Resident #1 was found 30 minutes later near a daycare across the street from the facility. The NHA and the DON were notified. An elopement evaluation (assessment), completed on 6/11/24, indicated that Resident #1 was at risk for elopement based on his diagnosis of dementia, independent ambulation with a wheelchair, had wandering behaviors as part of his past, was cognitively impaired, had verbalized desire to go home or attempting to open doors, and he had a change in status or routine. A care plan for elopement risk, initiated on 6/11/24, revealed Resident #1 was at risk for elopement/exit-seeking/wandering related to dementia and intermittent delusions and that he was redirectable without agitation. Interventions included allow wandering in safe areas, approach in calm manner, assess for pain and medicate as needed, attempt to refocus, document and notify physician if behavior interferes with daily functioning, educate on facility protocol for check in/out logs, educate on potential risks and the facility protocol for leaving the facility, elopement risk assessment, encourage participation in activities of choice and encourage expression of feelings. 2. Failures in facility response The resident's care plan update did not note that he had eloped on 6/8/24, did not identify specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), identified on the elopement assessment 6/11/24. Further, there was no plan to increase his level of supervision. C. Continuing failures after 6/8/24 1. A quarterly elopement assessment, completed on 12/26/24, indicated that Resident #1 was independent in his wheelchair, wandered without a sense of purpose, had a diagnosis that may have impacted cognition, took one medication that could increase restlessness of agitation, had not expressed desire to leave the facility, exhibited unsafe wandering or elopement attempts but was easily redirectable. It documented that Resident #1 did not wander out of the facility but wandered into different rooms. Based on the assessment completed, resident #1 scored a 12. (The facility did not provide a scoring tool, however, lower scores indicated lower risk.) Consistent with the quarterly assessment above, Resident #1's 12/27/24 MDS assessment documented that the resident did not have wandering behaviors. -However, the 12/26/24 elopement assessment was inaccurate. Resident #1 took two medications that could increase restlessness or agitation, had two medical diagnoses that may have impacted his cognition, and had one elopement in the prior year. See also interviews below; staff reported the resident wandered, especially in the evenings and at night, and pushed on doors. 2. A review of Resident #1's medication and treatment administration record from January 2025 documented that Resident #1 had exit-seeking behaviors where he was difficult to redirect 22 out of a possible 31 days. The medication and treatment record from February 2025 documented that Resident #1 had exit-seeking behaviors on four out of the five days leading up to his elopement on 2/5/25. Record review revealed no care plan updates describing Resident #1's exit-seeking behavior and how staff might respond or a plan to increase the resident's supervision level, despite the documentation on the medication and treatment administration records for January 2025 and February 2025, and staff documentation the resident was now difficult to redirect. D. Second elopement - Failures in facility response 1. Elopement 2/5/25 On 2/6/25 at 7:27 a.m., a nursing note by LPN #3 documented that Resident #1 was missing. The note read that during the dinner time medication pass (2/5/25), Resident #1 was in his room eating and carrying his guitar. After dinner, the nurse requested the two CNAs working on his side of the hall to collect meal trays from all the rooms. At that time, the nurse did not see Resident #1 in his room and asked the CNA in charge of his daily care to look for him. -The CNA came back to the nurse later and stated that Resident #1 was on the Capital side of the building. At night, after the nurse's lunch, he started passing medication and did not see Resident #1 in his room. He asked the CNA to look for Resident #1. At the same time, the nurse went to check on another resident who was not feeling well. The CNA returned and stated that Resident #1 was still wandering in the Capital side of the building. -At 10:45 p.m., the CNAs working the graveyard shift (10:00 p.m. to 6:00 a.m.) had come in, and the new CNA in charge of Resident #1's care stated that Resident #1 was not in his room. She reported that the resident was not seen during shift change. The nurse instructed the CNA to look for the resident. -After a few hours of looking for him, Resident #1 was not found in the building or neighborhood. The DON was notified, and a report was given about the situation. On 2/6/25 at 7:35 a.m., a late entry nursing note by LPN #3 documented that on 2/5/25, Resident #1 went missing from the property around 10:45 p.m. All staff on shift started looking for him in each room within the facility and around the neighborhood. The DON and police were notified. Resident #1 was found on 2/6/25 between 8:00 a.m. and 9:00 a.m. All vital signs were stable, labs were done, skin was intact and cold on touch, no frostbite noted, and no signs of pain or discomfort noted. Resident #1 was placed on one one-on-one monitoring with a one-to-one sitter and 72-hour charting. On 2/6/25 at 8:40 a.m., a nursing note documented that after a long search, Resident #1 was found a few blocks away from the facility. Resident #1 appeared very cold and was shivering. He was brought back to the facility, where warm blankets awaited him. His vital signs were stable. A head-to-toe assessment revealed no sign of injury. One-on-one care was provided to Resident #1 immediately. The provider ordered lab work, a urine test, and an electrocardiogram (EKG). A review of the facility investigation of Resident #1's elopement 2/5/25 to 2/6/25 revealed the investigation was initiated on 2/6/25. It read that Resident #1 was noted missing by staff around 11:40 p.m. on 2/5/25. He was last seen by staff around 9:30 p.m. on 2/5/25. He was found by the DON and the NHA around 8:00 a.m. on 2/6/25, a few minutes away from the facility, in front of a business. He was brought back to the facility and assessed. CNA #1 was interviewed by the DON (no date or time). CNA #1 was in charge of Resident #1's care and reported she did her rounds when she came in and noted the resident was not in his room between 10:30 p.m. and 10:45 p.m. CNA #1 reported she let the nurse know at the time, and they began searching for the resident. This concluded all interviews provided in the facility's investigation. Resident #1's care plan was updated on 2/6/25 to add a one-to-one sitter, and nursing notes indicated he had the sitter from 2/6/25 until 2/9/25 at 11:30 p.m., with the nurse and staff monitoring him the rest of the night. On 2/9/25, the care plan read 15-minute checks were added and sometime later, removed from the care plan. 2. Failures in facility response a. Record review See the facility investigation above. The facility failed to conduct a comprehensive investigation to identify root causes to prevent a recurrence or consider lapses in the facility's response. See care plan additions above. As of 2/25/25 (during survey) Resident #1's care plan still lacked specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), in addition to failing to document either of his elopements. Further, there was no evidence an elopement assessment was conducted after 2/6/25 until 2/24/25, during the survey. E. Interviews 1. Staff interview Staff interviews revealed that Resident #1 was known to wander, especially in the evening and at night, pushed on doors, and talked about going outside often. a. CNA #3 was interviewed on 2/24/25 at 1:10 p.m. CNA #3 said the staff did not do shift reports at this facility. She said facility staff would leave without giving a report. She said she walked around to lay eyes on all her residents at the beginning of her shift. She said she worked with Resident #1. She said she had noticed a decline in his cognition. She said he used to be able to go outside to smoke and find his way back to his room by himself. She said that now, he wandered more aimlessly, so she made the effort to take him out to smoke when he wanted to. She said if nobody was with him or reminded him, he would wander everywhere. b. CNA #2 was interviewed on 2/24/25 at 2:55 p.m. CNA #2 said Resident #1 was very fast in his wheelchair. She said he refused care and staff had to approach him in another way, and he would usually let her do his care. She said he was very forgetful and did not call for help. She said he could walk but was not supposed to. She said he wandered around the building a lot, especially in the evenings and at night. She said he talked about going outside often. CNA #2 said she worked with Resident #1 the night he eloped. She said she was working from 2:00 p.m. to 10:00 p.m. She said he ate dinner in the dining room around 5:00 p.m. on 2/5/25. She said she brought him to the nursing station at the Cherry Creek hallway (where he lived) after dinner for a snack. She said she last saw him around 9:00 p.m. at the nursing station. She said she left at 10:00 p.m. She said that the CNA taking over for Resident #1's portion of the hall was not there yet, so she gave a report to the other CNA who was taking over the other part of the hall. She said she got a call from the DON in the middle of the night asking when was the last time she had seen Resident #1. c. LPN #1 was interviewed on 2/25/25 at 9:30 a.m. LPN #1 said Resident #1 was an elopement risk. She said he was independent with pedaling in his wheelchair and was very fast. She said his cognition had declined in the last few months, and he seemed more forgetful. She said that on every shift, she documented his exit-seeking behavior. She said his exit-seeking behavior was pedaling around the facility in his wheelchair and pushing at doors. She said that sometimes he was redirectable with a snack or activity, and other times, he would get agitated when a staff member tried to redirect him. She said the nurses used a report sheet to indicate he was on elopement precautions. She said this included documenting exit-seeking behaviors and extra monitoring. She said he was on frequent checks, meaning every 15 minutes, and she parked the cart outside his room to keep an eye on him throughout her shift. d. LPN #3 was contacted by phone. A message was left to return the call on 2/25/25 at 4:25 p.m. However, LPN #3 did not return the call. 2. Management interview Management (NHA, DON, and nurse consultant/NC) interviews revealed the DON was not aware of Resident #1's exit-seeking behaviors before his elopement on 2/5/25 to 2/6/25. The interviews further revealed staff conducted a search on foot and by car in the surrounding neighborhood once the resident was discovered missing. Finally, interview revealed there had been a delay, contrary to facility expectations, in contacting management about Resident #1's elopement. a. The NHA, the DON, and the NC were interviewed together on 2/24/25 at 5:00 p.m. Contrary to the treatment and medication records for January 2025 and February 2025 (see above), the DON said Resident #1 wandered in circles but was not exit-seeking. She said he did not wander into other residents' rooms. She said there was nothing about him that seemed unsafe. She said the residents became unsafe if they were heading towards the door, and he did not do that. Also, contrary to the treatment and medication records for January 2025 and February 2025 (see above), the DON said staff redirected him with snacks or activities. She said she was unable to have any meaningful conversations with Resident #1 due to his low BIMS score and cognition. The NHA said facility exit doors opened and were then alarmed if the egress bar was pushed for 15 seconds. The NHA said he went to the facility on 2/6/25 at 4:00 a.m. The NHA said the staff that worked the overnight shift on the evening of Resident #1's elopement looked for the resident in the surrounding neighborhood on foot and in their cars. The NHA said the facility was unable to determine if Resident #1 left after a family member walked out the front door or what exactly happened. The NHA said the staff members working that evening (2:00 p.m. to 10:00 p.m.) said they did not see anyone leave behind them. The NHA said staff parking was in the back of the building and staff came in the side door or through the front door, and family members parked in the street in front of the facility. The NHA said one of the facility doors had since been made inactive to enter after Resident #1's elopement. The DON said the facility cameras were not working the night Resident #1 eloped. The DON said staff checked all the side doors after his elopement and confirmed all the doors worked correctly. The DON said Resident #1 was found outside near a local business, wearing a coat, a hat, and shoes the facility thought belonged to the resident. The DON said a CNA reported that the last time she saw Resident #1, he was wearing house slippers and provided the description of Resident #1 to the police. The DON said the facility identified one CNA scheduled to relieve the day shift staff at 10:00 p.m. had arrived late to the floor (on 2/5/25), but she was not aware how late the CNA had arrived. The DON said that the facility investigation had not included checking to see if all staff came in at 10:00 p.m. as scheduled. The DON said the staff reported to her that they did their walking rounds as they came into the facility at 10:00 p.m. The DON said she came to the facility immediately upon being notified around 3:00 a.m. on 2/6/25 that Resident #1 was missing, and the NHA called 911 while he was en route to the facility and told a nurse to call the hospital. The DON then arrived at the facility, where the police met her and started their own surveillance. The DON said she got in a car with the assistant director of nursing (ADON) and tried to find the resident. The DON said if a CNA thought a resident was missing, the CNA should notify the nurse they could not find a resident. The nurse should broaden the search and look in every room, every shower room, and ask all the other staff to help search. The DON said that after searching for 20 minutes maximum, the staff should call the DON, and the DON should call the NHA. The DON said she should have been notified by midnight, at the very latest, that Resident #1 was missing. The DON said that after finding Resident #1, the resident did not articulate where he went and willingly got in the car. He said only that he left to get coffee and did not answer any other questions. The DON said she updated the medical director about the resident's elopement. She said a family member might have exited the facility unaware that Resident #1 was behind them. The DON said some of the staff would have been pulled off the floor to look for Resident #1 when they identified he was missing. The DON said the front double doors to the facility door locked at 6:00 p.m., preventing people from both leaving and entering. The DON said it was an automatic lock and was not locked manually. The DON said a person had to push on the front door for 15 seconds as it had an egress handle or enter a code on the keypad. The DON said the staff reported the door was locked at the time they exited to look for Resident #1. The DON said the staff could enter the facility by entering a code into the keypad. The DON said the facility updated Resident #1's care plan with interventions following the elopement that occurred in June 2024, and the expectation was to have a complete resident record to provide the best care for the resident. The DON said this was to ensure the facility staff could do the best work they could and provide the best care for the resident even with staff turnover. b. The NHA, the DON, and the NC were interviewed together again on 2/27/25 at 11:31 a.m. The NC said Resident #1 used his wheelchair and walked behind his wheelchair, using it like a walker. The NC said the medication administration times and care task completion records for Resident #1 were reviewed post-investigation to determine a timeline of Re[TRUNCATED]

Based on record review and interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital. Findings include: I. Record review A request was made to the director of nursing (DON), the nursing home administrator (NHA) and the nurse consultant (NC) on 2/25/25 at 4:00 p.m. for the facility's hospital transfer agreement. -The facility provided a statement documenting a request made to two hospitals for transfer agreements on 2/25/25. The facility was unable to provide a written agreement for the one area hospital. II. Staff interviews The NHA, the DON and the NC were interviewed together on 2/26/25 at 3:30 p.m. The NHA said they were not able to locate the transfer agreement with the local hospitals that they had in place. The NHA said when they noticed this on 2/25/25, they initiated a new hospital transfer agreement.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) Plan policy, revised April 2014, was provided by the nurse consultant (NC) on 2/27/25 at 5:00 p.m. The policy read in pertinent part, The facility shall develop, implement and maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality and resolve identified problems. The objectives of the QAPI plan are to provide a means to identify and resolve present and potential negative outcomes related to resident care and services, provide structure and process to correct identified quality and/or safety deficiencies, establish and implement plans to correct deficiencies and to monitor the effects of these action plans on the resident outcome and help departments, consultants and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services or committees. II. Cross-reference citation Cross-reference F689: The facility failed to prevent an elopement of the resident. On 2/5/25, Resident #1 eloped from the building a second time. The time of the resident's elopement was uncertain and a delay in shift change reporting may have contributed to not knowing the resident's location prior to 10:30 p.m. Facility staff began looking for the resident in the building, at the neighboring nursing facility and in the neighborhood. The director of nursing (DON) and the police were notified on 2/6/25 at 3:00 a.m. after facility staff were unable to locate the resident. On 2/6/25 at approximately 8:00 a.m., facility staff located Resident #1 approximately one mile from the facility outside a local establishment. The medication and treatment administration record from January 2025 documented that Resident #1 had exit seeking behaviors where he was difficult to redirect on 22 out of a possible 31 days. The medication and treatment record from February 2025 documented that Resident #1 had exit seeking behaviors on four out of the five days leading up to the elopement on 2/5/25. As of 2/25/25, the facility had not identified specific behaviors/concerns or identified new interventions to address Resident #1's high risk for elopement. The facility's failure to identify specific exit-seeking behaviors/concerns and interventions to address residents' elopement risks put residents in a situation where a serious outcome was likely to occur and created an immediate jeopardy situation. III. Staff interviews The DON, the nursing home administrator (NHA) and the NC were interviewed together on 2/27/25 at 11:31 a.m. The NHA said the facility's interdisciplinary (IDT) team met with the medical director (MD) every month to discuss issues the facility had identified. The NHA said if needed, the facility also created an ad hoc (as needed) QAPI for specific situations that might arise. The DON said the facility had daily huddles or small meetings at each nurses station to talk to the facility staff, and those changes in Resident #1's behaviors were never brought up in the huddles. The DON said Resident #1's electronic medical record (EMR) should have documented he was exit seeking and if so, then the question staff should answer was, could he be redirected. The DON said she thought Resident #1's EMR behavior documentation order was written in a way that was not clear to the facility staff. The NC said Resident #1's EMR was updated (during the survey) to clarify the language of his behavior monitoring and documentation.

Based on interviews and record review, the facility failed to ensure they had activities to meet the needs and preferences of the residents for three (#6, #4 and #2) of five residents reviewed for activities out of 16 sample residents. Specifically, the facility failed to meet the socialization and activity needs for Residents #6, #4 and #2. Findings include: I. Facility policy and procedure The Activity Assessment policy, revised October 2009, was received from the nursing home administrator (NHA) on 2/28/25. It documented in pertinent part, In order to promote the physical, mental and psychosocial well-being of residents, an activity assessment is conducted and maintained for each resident. The activities assessment is used to develop an individual care plan that will allow the resident to participate in his/her choice and interest. The completed activity assessment is part of the resident's medical record and should be updated as necessary, but at least annually. II. Activity calendars The January 2025 activity calendar included the same activities each week. The only activity on Sundays were activities open for shopping. The only activities on Saturdays included news with coffee plus movie time. There were no animal related activities or outings on the calendar. The February 2025 activities calendar included the same activities each week. The only activities offered on Sundays were activities open for shopping. The only activities on Saturdays included news with coffee and movie time. Bingo was offered on 11 out of 28 possible days as an activity. III. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease (plaque buildup in arteries), chronic obstructive pulmonary disease (group of lung diseases that block airflow) and bipolar disorder. The 12/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required supervision with toileting, bathing and walking. The assessment documented the resident's activity preferences included reading books and newspapers, listening to music, being around animals, keeping up with the news, doing activities with groups of other people and going outside when the weather was good. B. Resident interview Resident #6 was interviewed on 2/26/26 at 4:00 p.m. Resident #6 said she had lived at the facility for over five years. She said in the past year or year and a half, there had not been nearly as many activities compared to prior. She said the facility did bingo quite a bit but they did not do activities that they used to do that she enjoyed. She said some of the activities she used to enjoy that were no longer offered included jewelry making, art and music. She said in the past year or two years there had not been any outings outside of the facility. She said the residents used to go on outings to do shopping, and go see museums and shows. She said she really enjoyed the outings. She said she spent more time in her room now that there were not as many activities. She said she colored a lot by herself in her room and the facility provided supplies for that. She said staff handed out an activity calendar for each month but did not personally invite her to participate in activities. C. Record review The activity assessment for Resident #6, completed on 12/17/23, documented that Resident #6 enjoyed 1960's folk music, reading, being around animals, keeping up with the news, going out for fresh air and gardening. -The assessment had not been updated in one year and two months. The activities care plan, initiated on 7/18/2020 and revised on 1/11/25, documented that Resident #6 enjoyed folk music from the 1960's, being around animals, keeping up with the news, going out for fresh air and gardening. Interventions included encouraging Resident #6 to participate in activities of choice, offering materials and supplies so she could maintain independent activities, staff was to personally invite and escort her to activities, providing a monthly activity calendar and providing a daily sheet with activities. -However, Resident #6 said staff did not invite her to activities. -There was no documentation of the resident enjoying independent activities in her activity assessment. IV. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure, chronic kidney disease and type 2 diabetes mellitus. The 11/16/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required supervision or set up help with his activities of daily living (ADL) and utilized a walker for mobility in the facility. B. Resident interview Resident #4 was interviewed 2/24/25 at 3:41 p.m. Resident #4 said the facility had a bus to take residents on outings but he did not know why there had not been outings for the residents to attend. Resident #4 said activities used to be scheduled on the weekends. He said the facility used to have games, including card games and a poker game, which he led. Resident #4 said he felt the facility's residents were not participating in activities like they used to and he enjoyed activities with more physical activity that kept him stimulated. Resident #4 said movies were shown in the dining room only at certain times because noise from the kitchen was too loud in the dining room. He said movies were usually in the smaller activity room. C. Record review Resident #4's quarterly activities assessment, dated 8/12/24, documented it was very important for him to do his favorite activities. The assessment documented the location of his activities preferences as anywhere. Resident #4's activity care plan, initiated 4/11/24, documented he was currently interested in watching television (TV), watching sports channels, attending spiritual activities on Sunday, weekly catholic visits, socializing with peers and attending the weekly book club. Pertinent interventions, initiated 4/11/24, included that activities staff would provide Resident #4 with a monthly activities calendar and daily activity sheets and activities staff would socialize with Resident #4 when inviting him to group activities. -Resident #4's activity assessment and care plan did not include his preferences for card games or facility outings. V. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included type 2 diabetes mellitus, dementia, spinal stenosis (narrowing of the spinal cord canal) and dependence on a wheelchair. The 11/30/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. She required maximum assistance with bathing and moderate assistance with dressing, set up assistance with eating, and was independent with her motorized scooter. The assessment documented it was very important for her to do her favorite activities. B. Resident interview Resident #2 was interviewed on 2/26/25 at 4:00 p.m. Resident #2 said she would like more activities on the weekends. C. Record review Resident #2's most recent activity assessment was completed on 11/28/23, upon a re-admission to the facility. The assessment documented it was important to the resident to do her favorite activities and do things with groups of people. The assessment documented she enjoyed independent and group activities, enjoyed bingo, socials and happy hours, crafts and more. She previously enjoyed gardening, cooking and going to the mall. Resident #2's care plan, revised 5/19/22, documented she enjoyed both independent and group activities. She enjoyed bingo, socials and happy hours, crafts and more. Pertinent interventions, revised 2/28/23, included that Resident #2 declined group activities because she preferred to engage in independent leisure activities or was uninterested in the group activities being offered. VI. Staff interviews The NHA and the activities consultant (AC) were interviewed together on 2/27/25 at 9:00 a.m. The NHA said activities assessments could be done on change of condition. The AC said there was an initial activities assessment done upon admission and annually and he would expect a quarterly participation activities assessment for the residents. The AC said the purpose of the quarterly assessment was to gauge the participation and make any changes or accommodations needed moving forward. The NHA said he was not aware that the movies scheduled on the weekends were not enough for the residents. He said the activities and outings were open to all residents. The NHA said activities staff typically went door to door to encourage residents to attend the activities. The AC said some residents were able to follow the monthly calendar but some residents needed a reminder about an activity. The AC said it was best practice to follow an all hands on deck approach to activities in the facility. He recommended always putting verbiage in a resident's care plan if a resident needed notification of activities specifically. The NHA was interviewed again on 2/27/25 at 10:00 a.m. The NHA said the outings activity calendar was not given out to all the residents. The NHA said activities staff could drive the facility bus and therapy staff joined the outing. The NHA said the calendar for outings was posted by the therapy department (located at the back of the facility) and it had previously been posted by the activities department (located at the front of the facility),but he said the outings calendar had not been posted this week (during the survey). The NHA said the monthly activities calendar and outings calendar were two separate calendars, but he said in December 2024 there was an outing scheduled on the monthly calendar to go see Christmas lights. The NHA said the therapy staff had also invited residents to attend an activity they hosted or outing but the facility was limited to how many people could join the outings or cooking classes. The NHA said the facility had not had many complaints about activities until the February 2025 resident council meeting. The activities assistant (AA) was interviewed on 2/27/25 at 10:00 a.m. The AA said in addition to the monthly calendar, the activities department passed out a daily sheet that included the activities scheduled for the current day. She said the daily sheet also included trivia. The AA said the activities staff knocked on resident's doors to remind them an activity was taking place. The AA said there were two activities staff members scheduled each day.

Based on interviews and record review, the facility failed to protect and keep residents safe from physical abuse by a facility employee for one (#1) of three residents reviewed for alleged physical abuse by a facility employee of eight sample residents. On 8/18/24 Resident #1 was physically assaulted by a nonclinical employee of the facility. The facility failed to protect Resident #1 from being physically abused by a facility employee. The incident occurred in an outside smoking patio and was caught on the facility's video surveillance. The assault began following the initiation of an argument where the staff was asking the resident to pay him back and the resident and staff began to argue. As the argument continued the facility employee punched the resident in the head and face with so much force that the resident fell out of his manual wheelchair. Because the video surveillance had no audio capability; and Resident #1, the assailant and resident witnesses were reluctant to speak freely about the incident, it was unknown exactly what words were exchanged between the facility employee and Resident #1. The assault on Resident #1 by the facility employee caused Resident #1 significant bodily injury including two types of brain bleed, a subdural hematoma and a subarachnoid hemorrhage; fractures of the resident's nasal bones and facial contusions swelling and bruising of the head. The resident's injuries were so severe that he was admitted to the hospital's trauma intensive care unit (ICU) for treatment. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/3/24, resulting in the deficiency being cited as past noncompliance with a correction date of 8/20/24. I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 9/3/24 at 3:15 p.m. It read in part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: -Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. II. Incident of physical abuse A. Physical abuse investigation The facility investigation revealed Resident #1 was a victim of physical abuse by an employee of the facility. The investigation of the abuse began on 8/18/24 immediately following the abuse incident occurring on 8/18/24 at 8:21 a.m. The report documented the events of the incident (see below). The allegation was substantiated by video surveillance (no audio) and a resident witnessing the incident. Resident #1 was outside in the smoking area where he and housekeeper (HSK) #1 were observed on the facility's video surveillance having a conversation/arguing. Three other residents were in the smoking area. The investigation said the other residents were reluctant to say what happened. Only Resident #7 was able and willing to give a statement of what he observed. Resident #7 said he heard Resident #1 and HSK #1 arguing about money. HSK #1 was asking the resident when he was going to pay HSK #1 back; Resident #1 called HSK #1 a racial name and after that HSK #1 started punching Resident #1 over and over and did not stop. Resident #1 fell out of his wheelchair and HSK #1 then picked him up and put him back in his wheelchair. -The NHA and the director of nursing (DON) were interviewed on 9/3/24 at 11:10 a.m. The NHA said the video surveillance (visually) confirmed Resident #7's version of events. -The video surveillance had been turned over to the local police department for their investigation and was not available for review during the survey (9/3/24). Resident #1 did not report the abuse to staff initially; he called his family at approximately 9:00 a.m. to report the abuse to his representative and the resident's representative called the facility at 9:10 a.m. and reported the physical abuse incident to the nurse, licensed practical nurse (LPN) #1. After receiving verbal notification of the allegation, LPN #1 went to Resident #1's room to assess him for injuries and find out what happened. At first, the resident did not want to talk but told LPN #1 that HSK #1 hit him but he was not sure why. Resident #1 said HSK #1 had been a good guy and had never done anything like this before that morning. Upon initial assessment, by LPN #1, Resident #1 was found to have bruising on his right eye, upper lip, right temple, a swollen nose, and a bump on his right eyebrow and right shoulder. LPN #1 encouraged Resident #1 to go to the hospital for an exam but he declined. LPN #1 notified the resident's physician and in-facility x-rays were ordered. The resident was given Tylenol and ice packs for the swelling. HSK #1 was interviewed on 8/18/24 just after the incident, by the on-duty nurse while on speakerphone with the DON. When asked, HSK #1 admitted to hitting Resident #1. LPN #1 asked HSK #1 to leave the premises immediately and was placed on suspension. HSK #1 handed over his keys and left without further incident at approximately 9:15 a.m. Resident #1's representative arrived at the facility and talked Resident #1 into going to the hospital for evaluation and treatment. Resident #1 was transferred to the hospital emergency roiagnom on [DATE] at 12:00 p.m. B. Record review The hospital transcript report dated 8/18/24 documented that the patient presented after he was assaulted by a staff member at his facility. The patient states that he was struck in the face. Denies other injuries. He reports left-sided facial pain and swelling, and abdominal pain. He has right-sided chest wall pain to palpation (touch) only. The hospital radiology report dated 8/18/24, revealed the resident had the following injuries: -Anterior parafalcine subdural hematomas (trapped blood that develops between the inner layers and the tough outer covering of the brain) measuring up to four millimeters (mm) at maximal diameter; -Small volume subarachnoid hemorrhage (brain bleed) along the paramedian right frontal sulci (frontal lobe of the brain); -Right nasal bone fractures, new from prior exam; and, -Left periorbital contusion (bruising/trauma around the eye). The resident was admitted to the trauma ICU for treatment of his injuries. III. Resident witness interview Resident #7 was interviewed on 9/3/24 at 4:15 p.m. Resident #7 said that he saw Resident #1 and HSK #1 arguing. He believed Resident #1 was punishing the HSK's buttons. HSK #1 then punched Resident #1. IV. Facility corrective actions A. Immediate action The NHA provided a follow-up action plan, dated 8/18/24, and evidence of the corrective actions, the plan documented: Issue identified: The facility was notified of an allegation of abuse of a resident by staff on 8/18/24. Immediate action items: The resident's condition was assessment and provided treatment. -Immediate suspension/ removal from facility property of the staff assailant during the investigation. -The resident's family and physician were notified.The police, adult protective and the State oversight office were notified and an investigation was initiated. B. Interventions put into place Root cause analysis: The possible root cause was ineffective management of the resident's behaviors. Action items: -Staff education on resources for the employee assistance program; stress management and management of resident behavior; completed on 8/20/24. Other staff were to receive training by their next working shift or by 8/26/24 whichever was first. -Resident witnesses were interviewed, completed on 8/19/24. -A mental health provider was contracted to provide counseling services to the three resident witnesses of the incident, completed on 8/20/24. Identification of others: -Complete audit of all staff for a completed background check. Missing background checks were requested. Completed by 8/20/24. -All residents and resident representatives of residents who were not interviewable were interviewed to determine if any had a similar experience of being abused (emotionally or physically) by a staff; completed on 8/20/24. -Skin evaluations were completed on residents who were not interviewable to assess for any potential injuries of unknown origin, completed on 8/20/24. System Changes: -Abuse identification, prevention and reporting; how to recognize resident triggers; and how to address resident in the moment of distress training was provided to all staff; initiated on 8/19/24 and completed with all active staff by 8/20/24. Other staff to receive training by their next working shift or by 8/26/24 whichever was first. -The NHA/designee will ensure that all newly hired staff receive training on abuse and neglect identification, prevention and reporting prior to having resident interaction. This will be ongoing. Monitoring: -Ongoing interviews with 10 randomly selected residents on staff treatment, for 12 weeks through 11/4/24. -Ongoing interviews with 10 randomly selected staff on staff treatment and other related concerns, for 12 weeks through 11/4/24. -The Quality improvement plan was submitted to the quality assurance quality improvement (QAPI) committee for review and monitoring for at least the next three months (through November 2024). V. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged to the hospital on 8/18/24. According to the August 2024 computerized physician's orders (CPO), diagnoses included cerebral infarction (stroke), Parkinson's disease (a disease that causes unintentional movements) and mobility abnormalities. The 5/15/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident used a manual wheelchair for mobility and needed substantial to maximal assistance with transfers, and lower body dressing; partial assistance with upper body dressing; and was dependent on staff for toileting hygiene and bathing. The assessment documented the resident did not reject care assistance and was not physically aggressive toward others. VI. Staff interviews The NHA and DON were interviewed together on 9/3/24 at 11:00 a.m. The NHA said the facility had no prior warning that HSK #1 would assault a resident. HSK #1 had been a long-time employee of the facility and had never had any disciplinary issues. HSK #1 was well-liked by the residents and they were upset that he was no longer working in the facility. The NHA said HSK #1's behavior was unacceptable; he was suspended immediately upon discovery of the incident and terminated the following day. The NHA said the police were notified of the assault. The NHA said the police took possession of the video evidence and were investigating the incident. The DON said they immediately provided all staff education on stress management, abuse prevention, identification and reporting and behavior management. LPN #1 was interviewed on 9/3/24 at 3:20 p.m. LPN #1 said she was preparing Resident #1's medications when he passed by; she was heading to his room when the resident's representative called. LPN #1 said the resident's representative said she just received a call from Resident #1 saying that HSK #1 punched him in the face. LPN #1 said she went immediately to assess Resident #1. LPN #1 said Resident #1 had dried blood under his eye, a cut to his lip and facial swelling. She said at first Resident #1 would not say what happened but after additional questioning, he told LPN #1 that HSK #1 hit him. LPN #1 said she immediately called the DON to report the incident and asked the staff to find and bring HSK #1 to the office for a phone call. She said while on the phone with the DON, HSK #1 admitted that he hit Resident #1. LPN #1 said that HSK #1 was escorted off the premises following the phone call with the DON. LPN #1 said Resident #1 was on continual assessment and monitoring since he initially declined to go to the hospital for assessment. She administered ice for the resident's facial injuries and swelling and conducted routine neurological assessments (checking for signs and symptoms of brain trauma). The resident's representative arrived and was able to talk the resident into going to the hospital.

Based on observations, record review and interviews, the facility failed to ensure a phone was consistently available and functional for resident use on two of two units. Specifically, the facility failed to consistently provide operational phones for residents to use from their rooms or other private areas and relay messages left for residents. Findings include: I. Facility policy and procedure The Communications Within and External to the Facility policy, dated 2024, was received from the nursing home administrator (NHA) on 8/15/24 at 6:14 p.m. It read in pertinent part, The facility will protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility. The facility will provide reasonable access to a telephone. Reasonable access means that telephones, computers and other communication devices are easily accessible to residents and are adapted to accommodate resident's needs and abilities, such as hearing or vision loss. II. Resident interviews Resident #47 was interviewed on 8/12/24 at 10:30 a.m. Resident #47 said she never received the messages that were left for her on the voicemail on the phone at the nurse's station. Resident #47 said she used to have a phone in her room but the facility disconnected the lines. Resident #47 said the phones at the nurse's stations were often missing and it was hard to find a phone to call her family. Resident #47 said she felt cut off from her family and friends. Resident #47 was interviewed a second time on 8/14/24 at 2:36 p.m. Resident #47 said the phone in her room was disconnected two months prior. Resident #47 said the facility did not give the residents notice prior to the phones being taken out, but the facility staff told them how to use the facility phones if they asked. III. Resident council interview Residents who frequently attended monthly resident council meetings and the resident council president (#79, #47, #84 and #68) were interviewed on 8/13/24 at 2:30 p.m. The residents were identified as alert and oriented through facility and assessment. Resident #68 and Resident #47 said the residents that used the facility phones did not have privacy and had to stand at the desk and speak in front of everyone at the nurse's station. Resident #68 said the residents who were bedridden could not get to the nurse's station to make a phone call. Resident #68 said many residents wanted to make phone calls but could not do so. Resident #68 said there was a landline phone in the facility library but the library was too busy to take private phone calls. Resident #68 said the facility administration team used the library for their meetings and the residents at the facility did not have access to the room they needed or preferred. Resident #47 said since the phones were removed from resident rooms she had been cut off from her family and she had not talked to her cousin in two months. Resident #47 said her family could not get ahold of her and could not directly call her. Resident #47 said she never received messages whenever her family called her. IV. Observations On 8/15/24 at 10:33 a.m. a sign was observed near the reception desk at the facility. The sign read in pertinent part, New resident phones at each nurse's station. They are for residents and family only, this is for families to call their loved ones and for residents that need to use the phone to call out. Feel free to give family members a call. Please answer them when they ring, it is for a resident. The sign listed four phone numbers for each unit's phone line. At 12:23 p.m. the cordless phone at the Union nurse's station was not observed on the phone charger or at the nurse's station desk. -The assistant director of nursing (ADON), who was at the nurse's station did not know where the phone was and did not think a resident had it. V. Record review A grievance form, dated 4/8/24, revealed a resident's representative had concerns that the nurses at the Union nurse's station were not answering the phone or returning messages. On 4/11/24 a maintenance request ticket was put in with the maintenance department to check the phone systems as the phones were intermittently not working. The grievance was resolved on 4/15/24 with a note that said the phones were working and the resident's representative was able to get through to the nurse's station. A grievance form, dated 6/6/24, revealed a resident wanted a new phone system. The resident said the phones at the nurse's stations were not charged, the buttons were too small and there was not enough privacy. The grievance was resolved on 6/6/24, with the resolution being that the resident could use the phone in the library. -However, residents felt the library was not private enough for resident phone conversations and was not always accessible to the residents (see group interview above). VI. Staff interviews Certified nurses aide (CNA) #4 was interviewed on 8/15/24 at 10:19 a.m. CNA #4 said there were phones available for the residents at each nurse's station. CNA #4 said the residents' families called the reception desk at the facility and it was then transferred to the appropriate unit. CNA #4 said the nurse at the station answered the calls and diverted the call to residents from there. Licensed practical nurse (LPN) #4 was interviewed on 8/15/24 at 10:49 a.m. LPN #4 said there were cordless phones at each nurse's station. LPN #4 said the residents came to the nurse's station to get the phone or the nurse brought it to the resident if they could not get out of bed. LPN #4 said once the receptionist transferred the call to the unit, the facility receptionist went to the unit and stood there until the nurse answered the phone. LPN #4 said the facility receptionists took messages and gave them to the unit nurse to pass onto the respective resident. Receptionist #1 was interviewed on 8/15/24 at 12:08 p.m. Receptionist #1 said residents had a phone at each unit. Receptionist #1 said the facility receptionists took messages and gave them to the nurse on the unit or the resident themselves. The social services director (SSD) was interviewed on 8/15/24 at 12:14 p.m. The SSD said resident phone calls came through the reception desk and were diverted to whichever unit the resident resided on. The SSD said the unit nurse either took a message or gave the phone to the resident to take the call. The SSD said the unit phones were put in place around six months prior, and before that, there were phone lines in each residents' room. The SSD said she did not know why the phone lines were taken out of the residents' rooms. The SSD said she had received some grievances regarding family members leaving messages that were not followed through or not being able to get their call through to the cordless phone. -However, residents continued to feel as though they did not have adequate access or privacy to make phone calls (see resident interviews above).

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews for CNA #1, CNA #2, CNA #5, CNA #6 and CNA #7 in order to determine potential training needs. Findings include: I. Facility policy and procedure The Performance Evaluations policy and procedure, revised September 2020, was provided by the regional director of clinical services (RDCS) on 8/19/24 at 1:18 p.m. It read in pertinent part, The job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be conducted on each employee at the conclusion of his/her 90 day probationary period, and at least annually thereafter. Performance evaluations may be used in determining employee's promotion, shift/position transfer, demotions, terminations, wage increases and to improve the quality of the employee's work performance. The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (further training), and goals. II. Record review Annual performance reviews were requested on 8/14/24 at 1:20 p.m for CNA #1 (hired on 3/31/21), CNA #2 (hired on 8/23/22), CNA #5 (hired on 12/22/22), CNA #6 (hired on 5/20/2020) and CNA #7 (hired on 5/1/14 ). -The facility was unable to provide annual performance evaluations for 2023-2024 for all five CNAs. -The director of nursing (DON) said the five CNAs did not have annual performance reviews and had not completed annual in-service education based on the outcome of their reviews. Cross-reference F947 for failure to ensure CNAs received annual training as required. III. Staff interviews The DON was interviewed on 8/15/24 at 11:50 a.m. The DON said she had just recently become the DON at the facility. She said annual performance reviews had not been completed. The RDCS was interviewed on 8/15/24 at 11:26 a.m. The RDCS said the annual performance evaluations had not been completed as required. She said, during the survey, the facility had put a plan in place to ensure annual performance reviews were completed timely.

Based on observations and interviews, the facility failed to provide food and drinks that accommodate resident allergies, intolerances and preferences for residents in one of two dining rooms and for one (#63) of four residents reviewed for preferences out of 46 sample residents. Specifically, the facility failed to: -Ensure residents in the secured unit were offered drinks of choice at meal time; and, -Ensure Resident #63 received the meal items that he ordered. Findings include: I. Facility policy and procedure The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 8/15/24 at 1:30 p.m. It read in pertinent part, Upon a resident's admission (or within 24 hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. When possible, the staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to identify more widespread concerns about meal offerings, food preparation. II. Failure to ensure residents in the secured unit were offered drinks of choice at meal time A. Observations During a continuous observation of the lunch meal service in the secured unit on 8/12/24, beginning at 11:12 a.m. and ending at 1:00 p.m., the following was observed: At 11:28 a.m. the lunch meal cart arrived at the secure unit. At 11:35 a.m. the facility staff served four residents their meal trays. Each of the four residents had a glass of cranberry juice on their meal tray. At 11:36 a.m. the facility staff served two residents their meal trays. Each of the two meal trays had a glass of cranberry juice on the tray. At 11:41 a.m. the facility staff served six more residents their meal trays. All six meal trays had a glass of cranberry juice on the tray. -All twelve of the residents eating in the secured unit dining room had a pre-poured glass of cranberry juice sent on the meal tray cart on each resident's meal tray. -No other drinks were on the resident meal tray carts or offered to residents. During a continuous observation of the lunch meal service in the secured unit on 8/13/24, beginning at 10:16 a.m. and ending at 1:00 p.m., the following was observed: At 11:55 a.m. the lunch meal cart arrived at the secure unit. At 12:01 p.m. facility staff began serving residents their meal trays. At 12:03 p.m. the facility staff served four residents their meal trays. Each of the four residents had a glass of cranberry juice on their meal tray. At 12:16 p.m. the facility staff served seven more residents their meal trays. Each resident had a glass of cranberry juice on their meal tray. -A total of eleven residents eating in the secured unit dining room had a pre-poured glass of cranberry juice sent on the meal tray cart on each resident's meal tray. -No other drinks were on the resident meal tray carts or offered to the residents. During a continuous observation of the lunch meal service in the secure unit on 8/14/24, beginning at 11:15 a.m. and ending at 2:00 p.m., the following was observed: At 12:04 p.m. the lunch meal cart arrived at the secure unit. Between 12:04 p.m. and 12:22 p.m. the facility staff served nine residents seated in the dining room their meal trays and each of the nine residents had a glass of cranberry juice on their meal tray. -A total of nine residents eating in the dining room had a glass of pre-poured cranberry juice sent on the meal tray cart on each resident's meal tray. -No other drinks were on the resident meal tray carts or offered to the residents. B. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 8/15/24 at 10:46 a.m. CNA #2 said the staff asked the residents for their preferences. She said the residents' dislikes and allergies were listed on their care plans and the meal tickets. CNA #2 said the staff asked residents what their drink preferences were. She said if a resident was unable to choose, the facility sent the resident cranberry juice because it was good for the resident's bladders. CNA #2 said the dietary staff used to send pitchers of different juices and milk to the secure unit for meal time but no longer did so. CNA #2 said the drinks for residents living on the secure unit were poured in the kitchen and sent in the meal tray cart at meal time. -However, staff were not observed asking residents the drink preferences during multiple meal service observations. The director of nursing (DON) was interviewed on 8/15/24 at 1:30 p.m. The DON said the staff should offer a choice of drinks to residents and if a resident was unable to state their preferences, the staff could ask the resident's family for preferences. The DON said facility staff should be taking orders for the residents' drinks. The DON said the staff should show the residents a choice between two different beverages if that helped the resident choose. The DON said she was unsure if the residents in the secure unit all choose cranberry juice as their preferred drink. 47064 III. Failure to ensure Resident #63 received the correct meal items A. Resident #63 1. Resident status Resident #63, age less than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure (disrupted oxygen exchange), chronic kidney disease (decrease kidney function), type 2 diabetes (abnormal glucose) and hypertension (high blood pressure). The 6/3/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment indicated the resident was on a therapeutic diet. 2. Resident interview Resident #63 was interviewed on 8/12/24 at 10:18 a.m. Resident #63 said he preferred to eat his meals in his room. He said he often received food items on his meal trays that he did not order and he was frequently missing items he did order. Resident #63 said he would order sugar-free options like jello and he would receive regular jello versus sugar-free jello. Resident #63 was interviewed again on 8/13/24 at 1:34 p.m. Resident #63 said he did not get his mashed potatoes and received rice instead for his lunch on 8/13/24. Resident #63 said nobody wanted to eat rice with pot roast. Resident #63 said he did not want to eat his food because it was not what he had ordered. Resident #63 said nobody informed him that the rice was being served for lunch instead of mashed potatoes. 3. Observations and staff interviews On 8/13/24 at 1:34 p.m. Resident #63's lunch tray was delivered. Resident #63's lunch meal ticket indicated Resident #63 had ordered mashed potatoes with gravy, pot roast, milk and a Glucerna (supplement drink). Resident #63's lunch tray had pot roast, rice, milk and a Glucerna. -Resident #63 received rice on his lunch tray instead of the mashed potatoes he had ordered. CNA #1 was interviewed on 8/13/24 at 1:41 p.m. CNA #1 said Resident #63 did not receive mashed potatoes on his plate. She said the resident received rice, pot roast, milk and Glucerna. CNA #1 reviewed Resident #63's meal ticket and said the resident had ordered mashed potatoes. -CNA #1 did not offer to get resident mashed potatoes or another alternative despite the resident's order being delivered incorrectly. IV. Resident group interview Four residents (#47, #68, #79 and #84) who were identified as interviewable by the facility and assessment, were interviewed on 8/13/24 at 2:30 p.m. The residents said they could circle menu items they wanted on their meal ticket but they did not always receive what they ordered. The residents said the kitchen served all of the residents the same food items. The group said the kitchen staff gave the residents what the kitchen wanted to serve and did not explain why the residents did not get what they ordered. V. Additional staff interviews The DON and the regional director of clinical services (RDCS) was interviewed on 8/15/24 at 1:30 p.m. The DON said the CNAs needed to notify the nurse or unit manager if a resident refused their meal. The RDCS said the facility had given education to CNAs about offering alternative menu items to residents and making sure the care plan reflected it. The DON and the RDCS said they were not aware residents were not receiving the alternative menu items they had requested. The DON and the RDCS said they were not aware that residents were not receiving the menu items they had requested. Dietary aide (DA) #2 was interviewed on 8/15/24 at 1:56 p.m. DA #2 said the CNAs took the residents' orders and were responsible for helping the residents fill out their meal tickets. DA #2 said all of the residents received the same meals despite what was written on their meal tickets.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination; -Ensure safe and appropriate storage of food items in the refrigerators and pantry; and, -Ensure safe holding temperatures for food items were maintained. Findings include: I. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/20/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B. Observations During a continuous observation of the lunch meal service on 8/13/24, beginning at 10:20 a.m. and ending at 1:40 p.m. the following was observed: At 10:28 a.m. dietary aide (DA) #1 began preparing sandwiches. DA #1 donned (put on) a pair of gloves and grabbed several slices of bread out of a plastic bag. DA #1 grabbed and opened a jar of mayonnaise. Using the same gloves, DA #1 held the slices of bread and applied mayonnaise. DA #1 set down the bread and opened the cold table tray lid by grabbing the handle with his gloved hand. With the same gloved hands, DA #1 picked up slices of lettuce and deli meat and set them on the sandwich. At 10:41 a.m. DA #2 donned a pair of gloves and opened the cold table tray lid by grabbing the handle. Using the same gloves, DA #2 picked up a plastic bread bag, undid the twist tie and pulled out two slices of bread. With the same gloved hands, DA #2 set the pieces of bread on the cutting board, grabbed deli meat and set it on the bread. DA #2 left the station, still wearing the same gloves, and went to retrieve a block of cheese slices out of the main walk-in refrigerator. DA #2 peeled off the plastic wrapper around the block of cheese slices. With the same gloved hands, DA #2 removed the deli slices that were on the bread, placed a cheese slice onto the bread, then replaced the deli meat on top of the cheese slice. DA #2 wiped his nose with his wrist and the back of his gloved hand, then placed the top slice of bread on the sandwich and wrapped it in plastic wrap. At 11:30 a.m. the lunch tray line began. Throughout the lunch service, the nutritional services director (NSD) moved the pita bread using gloved hands to make room for other items on the plate. -Between each tray the NSD was handling meal tickets, serving handles and tongs with the same gloved hands. At 12:12 p.m. cook (CK) #1 opened the steam oven using gloved hands and grabbed a plastic bag of pita bread. Using the same gloved hands, CK #1 took several pieces of pita bread out of the bag and set them on individual plates to be served. At 12:16 p.m. CK #1 grabbed another plastic bag of pita bread. Using the same gloved hands, CK #1 took the pita bread out of the bag and put it into the steam table bin to be served. -CK #1 had handled plate warmers and serving tongs using the same gloved hands prior to grabbing the pita bread bag. At 12:18 p.m. DA #1 was handling meal tickets using gloved hands. With the same gloved hands, DA #1 took a hotdog bun out of the plastic packaging and set it on the griddle. Using the same gloved hands, DA #1 held the hot dog bun to steady it as she put the hot dog inside. DA #1 used the same gloved hands to handle meal tickets, a serving handle, then the microwave handle. Using the same gloved hands, DA #1 again picked up the hotdog and hotdog bun and set it onto a plate. At 12:22 p.m. the NSD set a meal ticket on top of a lunch plate. The meal ticket was touching the hotdog bun. At 12:26 p.m. the NSD took the temperature of a batch of gyro meat that was cooking in the steam oven. The NSD said the temperature was eight degrees below what it needed to be and grabbed a set of tongs from the container that had cooked gyro meat in it. The NSD used the same tongs to lay the steam oven batch of gyro meat onto the griddle, then put the tongs back into the bin of cooked gyro meat on the steam table. At 12:59 p.m. DA #2 opened the cold table tray lid with gloved hands. Using the same gloved hands, DA #2 sifted through several pieces of lettuce before selecting a few pieces and putting them on a plate. Using the same gloved hands, DA #2 lifted another cold table tray lid and pulled out two tomato slices before putting them on the same plate. On 8/15/24 at 1:56 p.m. DA #2 began preparing a sandwich. DA #2 donned gloves and opened the cold table tray lid, the lid for a jar of mayonnaise and the kitchen tool drawer. Using the same gloved hands, DA #2 grabbed a slice of cheese and several slices of deli meat before setting them onto a slice of bread. C. Staff interview The NSD was interviewed on 8/14/24 at 2:50 p.m. The NSD said ready-to-eat foods should be handled with clean gloves. The NSD said gloves should be changed and hand hygiene should be performed after touching items such as tongs, meal tickets and handles to equipment. II. Failed to store food items correctly in the refrigerators and the dry storage A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/20/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices and sugar shall be identified with the common name of the food. In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (f)) or less for a maximum of seven days. The day of preparation shall be counted as day one. B. Observations On 8/12/24 at 9:15 a.m. an initial walkthrough of the kitchen was conducted. The following was observed in the dry food storage area: -There was an unlabeled undated bin of what appeared to be flour; and, -There was an unlabeled and undated container that held an open bag of rice. The rice was still in the open bag and the container did not have a lid on it. On 8/13/24 at 10:25 a.m. the following was observed in the Seasons unit refrigerator: -A used surgical mask was sitting on a container of popsicles in the freezer; -An opened and undated bag of lettuce; -An opened and undated bag of shredded cheese; -An opened and undated bag of tortillas; -A four ounce container of applesauce that was opened and undated; -Three unlabeled and undated sandwiches; -A container of store-bought pre-cut cantaloupe was on the refrigerator shelf with a use by date of 8/11/24; -An insulated lunch bag with no name or label was on the bottom shelf of the refrigerator; and, -A black backpack was on the top shelf of the refrigerator. -There was not a thermometer in the freezer at the time of observation. On 8/14/24 at 10:08 a.m. the following was observed in the main kitchen: -The walk-in refrigerator contained three bottles of heaving whipping cream with an expiration date of 8/13/24 and -In a different refrigerator, there was a carton of herbal tea with a use by date of 4/26/24. -In the main kitchen dry goods storage area, the same container that held an open bag of rice (initially observed on 8/12/24 - see above) was still present. The rice was still in the open bag and the container did not have a lid on it. The rice was not labeled or dated. On 8/14/24 at 3:05 p.m. the following was observed in the activities department refrigerator: -An open and undated jar of jelly; -An open and undated jar of mayonnaise; and, -An opened and undated jar of salsa. -The daily temperature log was missing entries for 8/10/24 through 8/12/24. On 8/14/24 at 3:10 p.m. the following was observed in the Seasons unit refrigerator: -Two opened and undated boxes of donuts; -An opened and undated bag of lettuce; -An opened and undated bag of shredded cheese; -An opened and undated bag of tortillas; -A container of store-brand pre-cut cantaloupe with a use by date of 8/11/24; -An opened and undated container of whipped cream; -An opened and undated bottle of chocolate sauce; and, two undated sandwiches. -The used surgical mask (see observation from 8/13/24 above) was still sitting on top of the bag of popsicles in the freezer. -The NSD was unable to find a thermometer in the freezer. On 8/14/24 at 3:18 p.m. the following was observed in the library refrigerator: -An open and undated bag of frozen juice and an open and undated pint of ice cream were labeled with residents names, opened, unlabeled, and undated bag of granola was at the bottom of the fridge, an unlabeled and undated squeeze bottle of an unidentified green liquid was found on the shelf of the refrigerator. -The NSD was unable to find a thermometer in the freezer. C. Staff interview The NSD was interviewed on 8/12/24 at 9:30 a.m. The NSD said she had ordered thermometers for all of the refrigerators and freezers at the facility the week prior. The NSD was interviewed a second time on 8/14/24 at 2:50 p.m. The NSD said she was not sure how often the facility refrigerators were cleaned out or checked but it was going to be part of her cleaning list and her daily walkthroughs. The NSD said she also wanted to train the facility staff on food labeling and storage. III. Maintain safe holding temperatures for food items A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/20/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Time/temperature control for safe food cold holding shall be maintained at 5 degrees Celsius (C) (41 degrees Fahrenheit) or less. Time/temperature control for safety food that is cooked to a temperature and for a time specified under SS 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 degrees Celsius (135 degrees Fahrenheit) or above. B. Observations On 8/14/24 at 11:21 p.m. DA #2 took the temperatures of the food items. A bin of sliced tomatoes was 45 degrees F, a bin of sliced cucumbers was 50 degrees F and a bin of tzatziki sauce (yogurt based condiment) was 52 degrees F. -The temperatures of these items were above the safe temperature parameters for cold foods of 41 degrees F or less. At 11:26 a.m. the NSD educated DA #2 on the safe holding temperatures for cold food items and had DA #2 put the containers of tomatoes, cucumbers and tzatziki sauce into larger ice baths. -The temperatures of the tomatoes, cucumbers, and tzatziki sauce were not re-assessed to ensure they had reached appropriate cold-holding temperatures prior to the start of lunch service. At 1:22 p.m. final temperatures were taken of the foods served during lunch service. The sliced gyro meat measured 116 degrees F. -The temperature of this item was below the safe holding temperature parameters for hot foods of 135 degrees F or greater. -At 1:26 p.m. the NSD served a resident a plate of the sliced gyro meat for a resident without reheating it. C. Staff interviews DA #2 was interviewed on 8/14/24 at 11:21 p.m. DA #2 said a holding temperature of 45 degrees F for a cold food item was okay because it was over the 41 degree F measurement on their reference sheet. The NSD was interviewed on 8/14/24 at 2:50 p.m. The NSD said the procedure for time and temperature control for food was heating hot food again to make sure it was a safe temperature prior to serving. She said cold food items should be stored in an ice bath for service to ensure the food maintained the correct temperature. The NSD said the ideal holding temperatures for hot foods was above 135 degrees F and for cold foods was below 36 degrees F. The NSD said she did not think the steam table was holding temperatures well and she would look into ordering new equipment.

Based on record review and interviews, the facility failed to ensure five (#1, #2, #5, #6 and #7) of five certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure five CNAs (#1, #2, #5, #6 and #7) received 12 hours of annual training. Findings include: I. Facility policy and procedure The In-Service Nurse Aide Training Program policy and procedure, revised December 2016, was provided by the regional director of clinical services (RDCS) on 8/19/24 at 2:08 p.m. It read in pertinent part, All nurse aide personnel shall participate in regularly scheduled in-service training classes. Annual in-services must: -Be no less than 12 hours per employment year; -Address areas of weakness as determined by nurse aide performance reviews; -Address the special needs of the residents as determined by facility staff; -Include training that addresses the care of residents with cognitive impairment; and, -Include training in dementia management and abuse prevention. II. Training review Documentation of annual trainings was requested on 8/14/24 at 1:20 p.m for CNAs #1, #2, #5, #6 and #7. -The facility was unable to provide documentation of the 12 hours of required annual training. III. Staff Interviews The nursing home administrator (NHA) was interviewed on 8/15/24 at 11:45 a.m. The NHA said the facility did not have a staff development coordinator (SDC) for a while and recently promoted a floor nurse to be the SDC full time. He said the SDC was responsible for tracking the CNAs annual training. He said the facility used a computer-based program for training for all the facility staff. The RDCS was interviewed on 8/15/24 at 11:26 a.m. The RDCS said when the computer-based training program was reviewed, it revealed not all CNAs had not been completing their scheduled training. She said the facility did not have a tracking system in place to track staff training. She said going forward, the facility would review the computer-based training in the middle of every month to ensure all required training was being completed. She said newly hired CNAs training would be reviewed before the CNAs began working with the residents.

Based on record review and interviews, the facility failed to ensure one (#2) of three residents out of 46 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #2's insulin (medication used for blood glucose) was consistently administered in a timely manner per the physician's orders. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy The Administering Medications policy and procedure, revised December 2012, was received from the regional director of clinical services (RDCS) on 8/15/24 at 1:36 p.m. It revealed in pertinent part, Medications shall be administered in a safe and timely manner and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record (MAR) space provided for that drug and dose. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: the date and time the medication was administered. III. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure (disrupted oxygen exchange), [NAME]-chiari syndrome (structural abnormality in the skull that causes part of the brain to move into the spinal canal), spina bifida ( abnormality affecting the spine), hydrocephalus (cerebral fluid build up in the spine) and type 2 diabetes (abnormal glucose). The 7/11/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment revealed the resident had received seven insulin injections during the assessment period. B. Resident interview Resient #2 was interviewed on 8/12/24 at 11:03 a.m. Resident #2 said he received an insulin injection every evening. Resident #2 said he was not sure what the administration time of his insulin was because he received his injections at different times. Resident #2 said not all nurses followed his administration times and he was lucky he had not had any issues with his blood sugars yet. C. Record review The August 2024 CPO documented the following physician's order for insulin: Lantus (insulin glargine) inject 25 units subcutaneously in the evening for type two diabetes. Give half dose (12) units if the resident is not eating by mouth/not eating and notify the provider, ordered 5/1/24. Review of the August 2024 medication administration record (MAR) revealed the following: The Lantus insulin 6:00 p.m. dose was not administered timely on the following days: -On 8/2/24, the medication was administered at 8:30 p.m., one hour and 30 min after the allowed administration time; -8/6/24, the medication was administered at 7:30 p.m., 30 minutes after the allowed administration time; -8/10/24, the medication was administered at 9:40 p.m.,two hours and 40 minutes after the allowed administration time; -8/11/24, the medication was administered at 11:53 p.m., four hours and 53 minutes after the allowed administration time; and, -8/13/24, the medication was administered at 7:38 p.m., 38 minutes after the allowed administration time. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 10:13 a.m. She said medications could be administered one hour before or one hour after the scheduled administration times. LPN #1 said anything outside the allowed administration time window was not considered safe. LPN #1 said the physician should be notified about the late administration to see if it was still safe to be administered. LPN #1 said the nurse should write a progress note to document the physician was called and how the resident responded to having received the medication late. LPN #1 said insulin medications were important to administer on time because it could impact the resident negatively by not controlling the blood glucose levels effectively. The director of nursing (DON) was interviewed on 8/15/24 at 12:18 p.m. The DON said medications could be safely administered 30 minutes before or 30 minutes after the scheduled administration time window. -However, the 30 minutes before and 30 minutes after the scheduled administration time was different from the one hour before and one hour administration time window that LPN #1 said was acceptable. The DON said the physician should be notified of any medications administered outside the safe to administer window and nurses were to document in a progress note that the physician was contacted. The DON said administering an insulin medication late could lead to blood glucose levels being too high. The DON reviewed the administration times for Resident #2's Lantus insulin(see record review above) and said she believed the insulin was given on time but the nurses had documented the administration late. The DON said she believed it was just a late documentation error because the evening nurses, who administered the insulin, should have already passed the medication cart and keys off to the night shift nurses by the time the insulin was documented as given. The DON said the nurse should have documented the administration time at the time it was given as the record documents the medication being given late to the resident.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services for two (#23 and #46) of four residents reviewed for ADLs out of 46 sample residents. Specifically, the facility failed to: -Ensure Resident #23 and Resident #46 received timely repositioning and toileting/incontinence care; and, -Ensure Resident #23 received proper assistance with meals, snacks and hydration. Findings include: I. Facility policy and procedure The Urinary Continence and Incontinence - Assessment and Management policy, revised August 2022, was provided by the nursing home administrator (NHA) on 8/15/24 at 1:30 pm. It read in pertinent part, The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The physician and staff will address treatable causes or contributing factors related to urinary incontinence, Including: implementing a fluid and/or bowel management program to meet assessed needs. II. Resident #23 A. Resident status Resident #23, over the age of 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included dementia, major depressive disorder, anxiety, protein-calorie malnutrition, contracture of the right hand and severe bilateral glaucoma (high eye pressure). The 7/11/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. She was totally dependent on staff for care for oral hygiene, toileting hygiene, bathing, transfers and dressing below the waist, including footwear. She needed substantial/maximum assistance with eating, dressing above the waist, eating, personal hygiene and moving from a lying to sitting position in bed. The assessment indicated Resident #23 used a wheelchair for mobility. B. Observations During a continuous observation of the lunch meal service in the secure unit on 8/13/24, beginning at 10:16 a.m. and ending at 1:00 p.m., the following was observed: At 10:45 a.m. Resident #23 was seated in her wheelchair at a dining room table and yelled out. Two unidentified staff members were seated in the dining room but did not speak to or offer redirection to Resident #23. At 10:50 a.m. Resident #23 was sitting with her eyes closed and appeared to be sleeping. At 11:10 a.m. an unidentified staff member offered a snack to a resident seated next to Resident #23, however Resident #23 was not offered a drink or snack. At 11:55 a.m. the lunch meal cart arrived at the secure unit. At 12:01 p.m. the facility staff began serving residents their meal trays. At 12:05 p.m. a meal tray was placed on the dining room table in front of Resident #23. At 12:16 p.m. Resident #23 remained seated at the front dining room table while the facility staff assisted other residents with their lunch meals. At 12:24 p.m. an unidentified staff member placed a divided plate of puree food in front of Resident #23. At 12:28 p.m. CNA #3 was seated on Resident #23's left side. A white towel was draped over Resident #23's shoulders and chest. The white towel had fallen off her right shoulder and only partially covered her left shoulder. CNA #3 assisted Resident #23 during meal time and offered her a bite of food. CNA #3 turned away from Resident #23 to talk to CNA #1 seated next to him. While CNA #3 spoke to CNA #1, Resident #23's head leaned forward to her left and her food spilled from her mouth onto her shirt and the towel draped over her. At 12:29 p.m. CNA #3 offered Resident #23 a drink of lemonade. While Resident #23 took a drink of lemonade, the beverage spilled from her mouth down the front of her sweatshirt. CNA #3 continued to assist Resident #23 with her meal and speak to CNA #1 after offering Resident #23 bites of food. At 12:36 p.m. CNA #3 offered Resident #23 bites of her oral nutritional supplement. At 12:44 p.m. CNA #3 continued to assist Resident #23 and was offering her bites of her supplement. The white towel that was covering the resident's shirt fell down into her lap and pieces of food were on her shirt and the towel in her lap. At 1:50 p.m. Resident #23 was sitting in her wheelchair at the front dining room table, with the same towel in her lap and food on her shirt that had fallen on her on her an hour prior. During a continuous observation in the secure unit on 8/14/24, beginning at 9:15 a.m. and ending 1:03 p.m. the following was observed: At 9:15 a.m. Resident #23 was seated in her wheelchair at a dining room table. At 9:22 a.m. Resident #23 was assisted from the table in her wheelchair so the floor under the table could be swept and mopped. Resident #23 remained in the dining room seated in her wheelchair. At 9:31 a.m. Resident #23 was assisted back to the front table in her wheelchair. At 10:18 a.m. activities assistant (AA) #1 began offering coffee to residents in the dining room. -Resident #23 was not offered a drink during this time. At 10:57 a.m. a resident seated at the same table as Resident #23 was offered water and a snack. -However, Resident #23 was not offered a drink or snack. At 11:06 a.m. Resident #23 was seated in her wheelchair leaning forward with her eyes closed. At 11:11 CNA #3 offered snacks to residents in the dining room. -However, Resident #23 was not offered a snack. At 11:20 a.m. Resident #23 lifted the left side of her shirt to her mouth and began to chew on her shirt. At 11:38 a.m. Resident #23 continued to sit at the front table with her head down. At 11:55 a.m. Resident #23 continued to sit in her wheelchair and lifted the left side of her shirt to her mouth and began to chew on her shirt again. Resident #23 continued to chew on her shirt periodically until 12:01 p.m. leaving a wet spot on the front of her shirt approximately five inches long. At 12:04 p.m. the lunch meal cart arrived at the secure unit. At 12:09 p.m. Resident #23 was still seated in her wheelchair, she lifted the left side of her shirt to her mouth and began to chew on her shirt. Resident #23 continued to chew on her shirt until 12:11 p.m. At 12:24 p.m. CNA #3 placed a towel over Resident #23's shoulders and chest and then assisted Resident #23 to her room in her wheelchair. -Resident #23 sat in her wheelchair in the dining room for over three hours, was not repositioned or redirected and was not offered a snack or drink when other residents in the dining room were offered a snack or drink. The resident was not offered checked during the timeframe for incontinence. At 12:41 p.m. CNA #3 assisted Resident #23 back to the dining room; Resident #23 was wearing a different set of clothes, including a dry shirt. C. Record review Resident #23's ADL care plan, revised 6/25/2020, documented she had an ADL self-care performance deficit related to her diagnoses of dementia, confusion, imbalance and blindness Pertinent interventions included for staff to assist with ADLs as needed, revised 2/18/23. Resident #23's discharge care plan, revised 10/17/23, documented she would stay long term in the facility due to her vision problems and dementia and did not wish to be discharged . Pertinent interventions included to offer and frequently reposition the resident while in the wheelchair as tolerated, revised 9/12/23. Resident #23's skin care plan, revised 10/6/21, documented she had a potential for skin/pressure injury development due to decreased mobility, a history of fractures, incontinence and dementia. Pertinent interventions included to instruct and assist the resident to shift weight in her wheelchair often, revised 2/18/23 Resident #23's bowel and bladder incontinence care plan, revised 7/13/22, documented she was incontinent of bowel and bladder. Pertinent interventions included encouraging the resident to drink fluids during the day to promote voiding responses (11/15/19) and to routinely check and change the resident and assist the resident upon rising, before and after the meal, before bedtime and as needed (6/28/21). Resident #23's malnutrition care plan, revised 2/29/24, documented she was at risk due to her diagnoses of dementia, severe stage bilateral open angle glaucoma, high blood pressure, chronic kidney disease, bilateral cataracts, anxiety and depressed mood and protein calorie malnutrition. Pertinent interventions included assisting the resident with meals and fluids as needed, catering to the resident's food preferences, encouraging adequate nutrition and hydration and the resident was unable to retain nutrition education due to dementia, all revised 10/13/23. Resident #23's certified nurse aide (CNA) task schedule for August 2024 (8/1/24 to 8/15/24) documented staff were to offer and reposition Resident #23 while she was in her wheelchair every two hours as tolerated. -The task was marked completed three times on 8/13/24 and three times on 8/14/24, however the task was not marked completed between the hours of 6:30 a.m. to 1:30 p.m. on either day. D. Staff interviews CNA #2 was interviewed on 8/15/24 at 10:46 a.m. CNA #2 said a resident who was on the check and change program should be checked for incontinence episodes at least every two hours. CNA #2 said Resident #23 was a dependent resident who always needed assistance with toileting, repositioning and changing her clothes. CNA #2 said Resident #23 should be offered puree snacks that included applesauce, pudding and ice cream. CNA #2 said she had been trained to assist residents at meal time and the staff should always face the resident and observe the resident during meal time. CNA #2 said Resident #23 needed assistance at meals and usually needed to be fed during meal time. CNA #2 said Resident #23 was provided a towel to place over her torso to keep her clean during meals and discourage Resident #23 from chewing on her shirts and leaving a wet mark. The director of nursing (DON) was interviewed on 8/15/24 at 1:30 p.m. The DON said the CNAs received training that covered how to assist residents at meal time. The DON said the CNA should sit down next to the resident and assist the resident as needed, the staff should face the resident and, immediately after meal time, the resident should be helped with hygiene and the removal or changing of clothing protectors. The DON said residents who were on the check and change program did not have to be checked every two hours, and instead could be checked every four hours or longer if the resident did not prefer to be woken up during the night. The DON said if a resident was on a repositioning program and/or a check and change program it should be included in the resident's care plan. She said the care plan task went on the kardex (CNA task list). 50219 III. Resident #46 A. Resident status Resident #46, age 69, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included unsteadiness on feet, abnormalities of gait and mobility and need for assistance with personal care. The 6/28/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. The resident required partial to moderate assistance with all activities of daily living (ADL). The resident was frequently incontinent of both bowel and bladder. B. Resident interview Resident #46 was interviewed on 8/12/24 at 10:29 a.m. Resident #46 said the facility staff did not want to assist her with incontinence care sometimes. C. Observations On 8/13/24 Resident #46's room was observed during a continuous observation, beginning at 9:56 a.m. and ending at 1:10 p.m. The following was observed: At 10:11 a.m. an unidentified nurse checked in on Resident #46 and asked if she was dry. Resident #46 said she was just changed. At 11:11 a.m. an unidentified activities aide came into Resident #46's room to offer her popcorn. At 11:38 a.m. an unidentified CNA checked in with Resident #46 and asked if she needed any ice water. Resident #46 declined. At 12:01 p.m. an unidentified activities staff member walked into Resident #46's room to speak with her roommate. The staff member said hello to Resident #46 briefly before leaving the room. At 12:28 p.m. an unidentified CNA delivered a lunch tray to Resident #46's roommate. Resident #46 was observed to be asleep in her chair. At 12:30 p.m. an unidentified CNA delivered a lunch tray to Resident #46. At 12:32 p.m. Resident #46 initiated her call light. At 12:35 p.m. the DON answered the call light. Resident #46 requested silverware, which the DON retrieved for the resident. At 1:06 p.m. an unidentified CNA retrieved Resident #46's lunch tray. At 1:08 p.m. Resident #46 initiated her call light At 1:10 p.m. CNA #4 went into Resident #46's room and shut the door (see interview below). D. Record review The incontinence care plan, revised 10/6/23, revealed Resident #46 had mixed bladder incontinence due to a history of urinary tract infections and impaired mobility. Pertinent interventions included establishing voiding patterns and monitoring/documenting intake and output per facility policy. The communication care plan, revised 10/6/23, revealed Resident #46 had communication problems resulting from hearing deficits. Pertinent interventions included anticipating and meeting Resident #46's needs, asking yes or no questions when appropriate and using simple, brief and consistent words and cues when communicating. The cognitive impairment care plan, revised 7/12/24, care plan revealed Resident #46 had cognitive loss related to altered cognitive performance. Pertinent interventions included anticipating needs and meeting them promptly. The 4/29/24 bowel and bladder assessment revealed Resident #46 had a neurogenic bladder and was on the check and change program. The assessment revealed Resident #46 required one-person assistance for mobility and she was usually bed-bound. The 7/19/24 nursing summary revealed Resident #46 was on the check and change program. The 7/30/24 nursing summary revealed Resident #46 was on the check and change program. The summary revealed Resident #46 was incontinent and she sometimes called the nursing staff in to change her. Resident #46 was very hard of hearing and nursing staff had to raise their voice and get close so the resident could lip read when communicating. E. Staff interviews CNA #4 was interviewed on 8/13/24 at 1:17 p.m. CNA #4 said Resident #46 used her call light to be changed. CNA #4 said Resident #46 used her call light whenever she needed to be changed. CNA #4 said Resident #46 had been incontinent of both bowel and bladder during the care provided just before the interview. CNA #4 was interviewed a second time on 8/15/24 at 10:19 a.m. CNA #4 said the check and change program meant the residents were checked and changed every two hours. CNA #4 said this frequency did not vary by resident and was consistent across the board, meaning every resident had to be checked at least every two hours. CNA #4 said she was not sure where these checks were recorded in the resident's electronic medical record (EMR). -However, a continuous observation revealed Resident #46 was not checked or changed for over three hours (see observations above). Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 11:47 a.m. LPN #1 said the check and change program was used for residents who were incontinent. LPN #1 said the CNAs did not have an established time-frame for the check and change program, but they knew they needed to check the residents and have their schedule established for the day.

Based on observation, record review and interviews, the facility failed to ensure one (#24) of two residents with limited mobility reviewed for range of motion (ROM) out of 46 sample residents received appropriate treatment and services to increase range of motion and.or to prevent further decrease in range of motion. Specifically, the facility failed to ensure Resident #24 was provided with a restorative nursing program as was recommended by the director of rehabilitation (DOR). Findings include: I. Facility policy and procedure The Restorative Nursing Services policy, revised July 2017, was provided by the nursing home administrator (NHA) on 8/15/24 at 1:31 p.m. It read in pertinent part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (example physical, occupation, or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. The resident or representative will be included in determining goals and the plan of care. Restorative goals may include, but are not limited to, supporting and assisting the resident in: adjusting or adapting to changing abilities, developing, maintaining or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self-esteem and participating in the development and implementation of his/her plan of care. II. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician's orders (CPO), diagnoses included chronic obstructive pulmonary disorder (COPD), type 2 diabetes mellitus, acute and chronic respiratory failure with hypoxia (deficiency for oxygen reaching the brain), dizziness, unsteadiness on feet, depression and shortness of breath. The 5/9/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mentals status (BIMS) score of 12 out of 15. He was dependent on staff for toileting and personal hygiene. He required moderate assistance with mobility. B. Resident interview Resident #24 was interviewed on 8/14/23 at 9:46 a.m. Resident #24 said he hoped to get stronger to return to independent living. Resident #24 said he had eight sessions of physical therapy upon admission. He said the therapy sessions had stopped on 6/7/24 after he was hospitalized and he was not told why. He said he would like to continue with therapy and walk independently. The resident said he was not receiving a restorative nursing program The resident said he used a wheelchair for mobility. C. Record review Physical therapy documentation was requested from the DOR on 8/15/24 at 9:50 a.m. The facility did not provide the physical therapy documentation The activities of daily living (ADL) care plan, revised 5/9/24, revealed the resident had a self care performance deficit. The interventions included for physical and occupational therapy to evaluate and provide treatment per the physician's order. The resident had a physician's order for a physical therapy evaluation and treatment, ordered on 6/13/24. A restorative nursing program referral was completed by the DOR on 6/13/24.The referral documented the restorative nursing program would include a range of motion (ROM) and a transfer program. The program and the program frequency included ROM and strengthening of the lower extremity, straight leg raises, hip abduction in the spine, shoulder flexion and two sets of ten repetitions of upper body rows using a three pound weight. -A review of the resident's electronic medical record (EMR) did not reveal documentation indicating a restorative nursing program was in place. D. Staff interviews The DOR was interviewed on 8/14/24 at 10:11 a.m. The DOR said he made a referral for a restorative nursing program for Resident #24 to be initiated with an effective date of 6/14/24. The DOR said he did not see any documentation in the resident's EMR that the program had been implemented. The DOR said he did not know the reason there was no documentation or why the program had not been implemented. The DOR was interviewed again on 8/15/24 at 9:45 a.m. The DOR said the restorative nurse aides (RNA) should have implemented the program. The DOR said he would speak with the director of nursing (DON) to review and monitor all restorative nursing programs. RNA #1 was interviewed on 8/14/24 at 11:41 a.m. RNA #1 said she had not been working with Resident #24. She said she had seen the referral for the program but had not been told by anyone to initiate the program. RNA #1 said she had been trained and felt comfortable completing ROM exercises and transfers with the resident. The director of nursing (DON) was interviewed on 8/15/24 at 2:15 p.m. The DON said she was in charge of the restorative nursing program. She said there were two trained RNAs that were currently working at the facility. She said Resident #24 should have received restorative nursing care and the resident's plan of care should have been updated to include this service. The DON said she would immediately educate RNAs and monitor all restorative programs.

Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two (#19 and #24) of three residents reviewed for respiratory care out of 46 sample residents. Specifically, the facility failed to ensure Resident #19 and #24 received oxygen therapy in accordance with their physician's orders. Findings include: I. Facility policy and procedure The Oxygen Administration policy, revised October 2010, was provided by the director of nursing (DON) on 8/15/24 at 1:31 p.m. It revealed in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review residents' care plans to assess for any special needs of residents. II. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, need for assistance with personal care, chronic pain, major depressive disorder, and fibromyalgia. The 6/7/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required supervision with touch assistance and verbal cues for transfers, dressing, toileting, personal hygiene and set-up assistance with eating and dressing. The assessment documented the resident was receiving oxygen. B. Observations On 8/12/24 at 9:48 a.m. Resident #19's nasal cannula (tubing device that supplies oxygen through the nose) was in her nose connected to a room oxygen concentrator with a setting of 3 liters per minute (LPM). On 8/13/24 at 11:50 a.m. the resident was lying in bed. The oxygen concentrator was on and was set at 3 LPM of oxygen via nasal cannula. The nasal cannula was in the resident's nose. On 8/14/24 at 2:35 p.m., licensed practical nurse (LPN) #5 assisted Resident #19 to perform a routine breathing exercise. LPN #5 placed a pulse oximetry reader (device used to measure the level of oxygen in a person's blood) on the resident's right index finger to check her oxygen and heart rate levels. The device registered a measurement of 94 percent (%) oxygen saturation. Resident #19's oxygen saturation levels dropped below 90%, to 83%, during the respiratory treatment. LPN #5 stayed in the resident's room to ensure the resident's oxygen levels returned to above 90%. On 8/15/24 at 10:15 a.m. the resident was receiving oxygen at 3 LPM via nasal cannula. C. Resident interview Resident #19 was interviewed on 8/13/24 at 11:04 a.m. The resident said she did not know the number of liters of oxygen she was receiving. She said the facility staff controlled the oxygen concentrator settings. She said the oxygen helped her to breathe better. D. Record review The respiratory care plan, revised 12/13/23, documented Resident #19 had altered respiratory status and difficulty breathing related to COPD and shortness of breath while laying flat. Care plan interventions included the resident's participation in a respiratory program to enhance functionality. Further interventions included applying oxygen via nasal cannula at 4 LPM continuously and administering medications as ordered by the physician. The August 2024 CPO documented a physician's order for oxygen at 4 LPM via nasal cannula continuously to keep the resident's oxygen saturation level at or above 90%, ordered on 8/2/24. A review of the August 2024 electronic medical record (EMR) from 8/2/24 to 8/15/24 revealed the licensed nursing staff documented the resident was receiving 4 LPM of oxygen via nasal cannula. -However, observations on 8/12/24, 8/13/24, 8/14/24 and 8/15/24 revealed Resident #19 was receiving 3 LPM, not 4 LPM as was ordered by the physician. III. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included COPD, type 2 diabetes mellitus, acute and chronic respiratory failure with hypoxia (deficiency for oxygen reaching the brain), dizziness, unsteadiness on feet, depression and shortness of breath. The 5/9/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He was dependent with toileting and personal hygiene and required moderate assistance with mobility. The assessment did not indicate the resident was receiving oxygen therapy. B. Observations On 8/12/24 at 11:16 a.m. Resident #24 was lying in bed watching television with an oxygen cannula on the right side of his bed. The resident's oxygen concentrator was set to 3 LPM. -However, the resident had a physician's order for 2 LPM of oxygen continuously (see record review below). On 8/13/24 at 1:31 p.m. Resident #24 remained in bed with his oxygen concentrator set at 3 LPM. The nasal cannula was connected to the oxygen concentrator and was in the resident's nose. On 8/14/24 at 12:34 p.m. Resident #24 was observed sitting upright in bed in his room preparing to eat lunch. Resident # 24's nasal cannula was in his nose and was connected to the oxygen concentrator. The oxygen concentrator was set at 3 LPM. While eating lunch, the resident started to experience difficulty breathing. Resident #24 used the remote control of the bed to recline his bed down, catching deep breaths several times, for approximately two minutes before he was able to continue eating. C. Resident interview Resident #24 was interviewed on 8/14/24 at 1:00 p.m. The resident said several times during meal times he had experienced difficulty swallowing and that it had affected his breathing. He said he was supposed to be receiving continuous oxygen at 2 LPM via nasal cannula. The resident said he was unable to tell how much oxygen per liter flow he was receiving because the oxygen concentrator was placed above the head of his bed. Resident #24 said the nursing staff were the ones that set the liter flow of his oxygen concentrator. D. Record review The care plan, revised 8/2/24, revealed Resident #24 was on oxygen therapy related to ineffective gas exchange and respiratory illness. Care plan interventions included oxygen settings at 2 LPM continuously via nasal cannula. The August 2024 CPO included a physician's order for oxygen continuously at 2 LPM, ordered 8/2/24 for oxygen at 2 LPM continuously. A review of the August 2024 MAR from 8/2/24 to 8/15/24 revealed the licensed nursing staff documented the resident was receiving 2 LPM of oxygen via nasal cannula. -However, observations on 8/12/24, 8/13/24 and 8/14/24 revealed Resident #24 was receiving 3 LPM, not 2 LPM as was ordered by the physician. IV. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 8/14/24 at 1:20 p.m. CNA #8 said the nurses communicated the oxygen flow rates for each resident to the CNAs. She said the CNAs did not adjust the oxygen settings. She said the licensed nurses set the liter flow on the residents' oxygen concentrators. CNA #8 said Resident #19's concentrator was set at 3 LPM of oxygen per nasal cannula and Resident #24's oxygen concentrator was set at 3 LPM. CNA #8 said it was important to follow the physician's orders as communicated to her by the licensed nurse. LPN #1 was interviewed on 8/14/24 at 1:31 p.m. LPN #1 said she was familiar with Resident #19 and Resident #24. She said nurses and CNAs were responsible for monitoring the level of oxygen each resident was receiving and ensuring it was accurate according to the physician's order. LPN #1 said both residents were on the incorrect liter flow of oxygen. LPN #1 adjusted Resident #19's oxygen concentrator to 4 LPM and Resident #24's oxygen concentrator to 2 LPM to match their physician's orders. LPN #4 was interviewed on 8/14/24 at 1:36 p.m. LPN #4 said Resident #24 had a physician's order for 2 LPM of oxygen continuously. LPN #4 said she was unsure why Resident #24 was on the incorrect liter flow of oxygen. She said she should have checked the liter flow at the beginning of her shift when she was administering the resident's morning medications. The director of nursing (DON) was interviewed on 8/14/24 at 1:45 p.m. The DON said a physician's order was required for any medication or treatment. She said, in an emergent situation, oxygen could be administered but a physician's order should be obtained within 24 hours of the change. The DON said it was the responsibility of all nursing staff to ensure residents were on the correct liter flow of oxygen at the beginning of their shift and intermittently throughout their shift. The DON said not following a physician's order for oxygen therapy could result in medical complications such as shortness of breath and cell damage to the brain. The DON said she initiated audits (during the survey) of all the residents receiving oxygen therapy to ensure they were on the correct liter flow of oxygen. The DON said she would provide education to all nursing staff regarding oxygen liter flow to prevent future incidents of residents receiving the incorrect liter flow of oxygen.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of three medication carts and one of two medication storage rooms. Specifically the facility failed to: -Ensure medications were properly labeled with resident names; -Ensure medications were stored according to route of administration; -Ensure food was not stored with medications; and, -Ensure medications were not stored in a dormitory style. Findings include: I. Professional reference According to the Trulicity package insert, retrieved on 8/19/24 from https://uspl.lilly.com/trulicity/trulicity.html#mg, Store Trulicity in the refrigerator , do not freeze Trulicity. Do not use trulicity if it has been frozen. II. Facility policy and procedure The Storage of Medications policy and procedure, dated November 2020, was received from the regional director of clinical services (RDCS) on 8/15/24 at 1:36 p.m. It revealed in pertinent part, The facility stores all drugs and biologicals in a safe, secure and orderly manner. Nursing staff are responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. Medications requiring refrigeration are stored in refrigerators located in the drug room at the nurse's station or other secured locations. Medications are stored separately from food and are labeled accordingly. III. Observations and staff interviews On 8/14/24 at 11:01 a.m. the Cherry Creek long hall medication cart was observed with licensed practical nurse (LPN) #1. The following was observed: One vial of glargine insulin (used for blood glucose management) with an open date of 8/6/24. -The vial was not labeled with a resident's name. The vial had house stock written on the bottle. LPN #1 was interviewed on 8/14/24 at 11:04 a.m. LPN #1 said the glargine insulin vial was the facility's house stock for emergencies, for example when there was a new physician's order and the medication had not been delivered from the pharmacy. LPN #1 said the vial should have had the resident's name on it to identify it belonged to a certain resident as each resident should have their own vial or pen for insulin. On 8/14/24 at 12:13 p.m. the Capitol Hill medication cart was observed with registered nurse (RN) #1. The following was observed: -One vial of Lantus insulin was stored next to Latanoprost 0.005% eye drops in the medication cart. RN #1 was interviewed on 8/14/24 at 12:25 she said medications should be stored according to the route they were to be administered to prevent infections. On 8/14/24 at 12:18 p.m. the Capitol Hill medication storage room was observed with RN #1. The following was observed: -The medication storage refrigerator was unlocked and there were four 237 milliliters (ml) cartons of Boost (supplement drink) on the shelf with Lorazepam (antianxiety controlled medication), liquid cephalexin (antibiotic) and two boxes of Trulicity injectable pens (used for glucose control). -The medication refrigerator was a dormitory style refrigerator where the freezer compartment was in the main compartment of the refrigerator. The freezer compartment had built up ice around and in the freezer. RN #1 was interviewed on 8/14/24 at 12:25 p.m. RN #1 said there should not be food or oral nutritional supplements in the refrigerator with medications. RN #1 said the ice build up in the freezer compartment could potentially cause temperature fluctuations and medications needed to be kept within a certain temperature range. IV. Additional staff interviews The director of nursing (DON) was interviewed on 8/14/24 at 11:18 a.m. The DON said insulin vials or pens should have the resident's name on them to verify who the medication belonged to. The DON said she would pull the vial of glargine insulin from the medication cart. The DON was interviewed a second time on 8/15/24 at 12:14 p.m. The DON said the facility had obtained a new vial of glargine insulin to replace the glargine insulin vial that had no name on it from the Cherry Creek long hall medication cart. The DON said food and nutritional supplements should not be stored with medications in the medication refrigerator in order to prevent contamination. The DON said medications should be stored according to the route they were to be administered in the medication carts to prevent contamination/infection. The DON said dormitory style refrigerators should not be used for medication storage as their temperatures could fluctuate and compromise medications. The DON said she was not aware the facility had any dormitory style refrigerators.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree, level five minced and moist and level six soft and bite sized as indicated on their meal tray cards. Findings include: I. Professional reference The International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (a tool to standardize mechanically altered diets and liquids) (January 2019), retrieved on 8/20/24 from https://iddsi.org/Resources/Patient-Handouts read in pertinent part, Level four pureed foods have a smooth texture with no lumps. The level five minced and moist texture: Meat should be served finely minced or chopped to a four millimeter (mm) (slightly larger than one eighth of an inch) lump size served in a thick, smooth, non-pouring sauce or gravy; vegetables should be cooked, finely mashed or blended to finely chop them into four mm lump size pieces. Rice requires a sauce to moisten it and hold it together. Rice should not be sticky or gluey and should not separate into individual grains when cooked and served. The rice may require a thick, smooth, non-pouring sauce to moisten and hold the rice together. The level six soft and bite-sized texture: Meat should be cooked tender and chopped so pieces are no bigger than one and a half centimeter (cm) by one and a half cm lump size. If the meat cannot be served soft and tender, modify and serve as a level five mince and moist product. Vegetables should be steamed or boiled with final cooked size no bigger than one and a half cm by one and a half cm (approximately one half of an inch). (Stir fried vegetables are too firm and are not suitable). Rice requires a sauce to moisten it and hold it together. Rice should not be sticky or gluey and should not separate into individual grains when cooked and served. The rice may require a thick, smooth, non-pouring sauce to moisten and hold the rice together. Bread: no regular dry bread, sandwiches or toast of any kind should be served for puree, level five or level six diets. Use IDDSI level five minced and moist sandwich recipe to prepare bread, use pre-gelled 'soaked' breads that are very moist and gelled through the entire thickness. II. Facility policy and procedure The Therapeutic Diets policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 8/15/24 at 1:30 p.m. The policy read in pertinent part, Diet order should match the terminology used by the food and nutrition department. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. Snacks will be compatible with the therapeutic diet. If the resident or resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives. III. Record review The menu extensions and modifications for modified texture diets were provided by the consulting registered dietitian (CRD) on 8/15/24 at 3:00 p.m. The menu extensions documented the following modifications for the mechanically altered food items served during lunch meal service on 8/13/24 and breakfast and lunch meal service on 8/14/24: The modified texture diet menu extensions for the lunch meal on 8/13/24 were documented as follows: -Puree texture included: Puree roast beef, puree cilantro brown rice, puree carrots and puree banana cake; -Level five minced and moist texture included: Minced and moist roast beef, cilantro brown rice and minced and moist carrot and minced and moist banana cake; and, -Level six soft and bite sized texture included: Soft and bite sized roast beef, cilantro brown rice, soft and bite sized carrots and soft and bite sized banana cake. The modified texture diet menu extensions for the breakfast meal served on 8/14/24 were documented as follows: -Level six soft and bite sized texture: serve the biscuit and gravy as puree biscuit and gravy. The modified texture diet menu extensions for the lunch meal on 8/14/24 were documented as follows: -Puree texture included: Puree hamburger, puree potatoes, puree white roll and vanilla pudding; -Level five minced and moist: Minced and moist hamburger, minced and moist dice potatoes, white roll and vanilla pudding; and, -Level six soft and bite sized: Soft and bite sized hamburger, diced potatoes, white roll and vanilla pudding. III. Meal service observation During a continuous observation of the lunch meal service in the secure unit on 8/13/24, beginning at 10:16 a.m. and ending at 1:00 p.m., the following was observed: The posted menu in the dining room documented the lunch meal consisted of pot roast, glazed carrots, cilantro brown rice and banana cake. At 11:55 a.m. the meal tray cart arrived in the secure unit. At 12:14 p.m. a meal tray was delivered to Resident #86 by an unidentified staff member. Resident #86's meal tray card documented she was prescribed a level six soft and bite sized diet. Resident' #86 was served a meal that included roast beef, rice, and carrots sliced in one to one and a half inch pieces. -The facility failed to add gravy to Resident #86's rice and failed to cut Resident #86's carrots into pieces no bigger than one and a half by one and a half centimeters according to the IDDSI recommendations for a level six soft and bite sized diet (see professional reference above). At 12:16 p.m. a meal tray was delivered to Resident #23. Resident #23 received puree food items on a divided plate. The puree rice on Resident #23's plate appeared to have visible pieces of rice that were not blended and smooth. While assisting Resident #23 at meal time, an unidentified staff member asked Resident #23 if she liked the food and Resident #23 replied, No. At 12:29 p.m. Resident #81's meal tray card documented he was prescribed a level five minced and moist diet. Resident #81 was served a meal that included carrots sliced into one to one and a half inch pieces. -The facility failed to cut or chop Resident #81's carrots into four mm lump size pieces according to the IDDSI recommendations for a level five minced and moist diet (see professional reference above). At 12:24 p.m. the nutritional services director (NSD) was interviewed. The NSD was notified the carrots were cut into one inch to one and a half inch pieces. The NSD said she did not yet have full access to her menu program for menu extensions. The NSD said the carrots might be too big based on the IDDSI description and the staff usually cut the vegetables into bite sized pieces. At 12:29 p.m. Resident #28's meal tray card documented she was prescribed a level six soft and bite sized diet. Resident #28 was served a meal that included roast beef, rice, and carrots sliced in one to one and a half inch pieces. -The facility failed to add gravy to Resident #86's rice and failed to cut Resident #86's carrots into pieces no bigger than one and a half by one and a half centimeters according to the IDDSI recommendations for a level six soft and bite size diet (see professional reference above). At approximately 1:00 p.m. at the conclusion of the lunch meal, the puree food items provided to Resident #23 were observed to have small visible lumps in the puree entree, puree carrots and puree rice. -The facility failed to puree the food items in Resident #23's meal until the food was smooth with no lumps according to the IDDSI recommendations (see professional reference above). During a continuous observation in the secure unit on 8/14/24, beginning at 9:15 a.m. and ending 1:03 p.m. the following was observed: The posted menu in the dining room documented the breakfast meal consisted of biscuits and sausage gravy, and the lunch meal consisted of a beef gyro with cottage fries and a dinner roll. At 9:49 a.m. certified nurse aide (CNA) #3 delivered a meal tray to Resident #86 that included scrambled eggs and biscuits and gravy. Resident #86's meal tray card documented she was prescribed a level six soft and bite sized diet. The biscuit was served whole, lightly browned on the edges and dry on the bottom with sausage gravy over the top of the biscuit. CNA #3 cut Resident #86's biscuit into one inch pieces. -The facility failed to serve Resident #86 the biscuit and gravy as puree biscuit and gravy per Resident #86's level six soft and bite sized diet (see professional reference above). At 12:15 p.m. activities assistant (AA) #1 delivered a meal tray tray to Resident #81. Resident #81's meal tray card documented he was prescribed a level five minced and moist diet. Resident #81 received a sandwich on a bun with meat in strips approximately one inch long, a dinner roll and cottage fries (french fried potatoes with skin on). -The facility failed to serve Resident #81's meat finely minced or chopped to a four millimeter size, serve Resident #81's vegetables without skin and finely mashed or blended to finely chop them into four mm lump size pieces and modify his dinner roll so it was not served dry according to the IDDSI recommendations (see professional reference above). IV. Staff interviews CNA #2 was interviewed on 8/15/24 at 10:46 a.m. CNA #2 said she had received training on mechanically altered diet textures and how to recognize them. She said if a resident received an item prepared incorrectly according to their prescribed diet, she would inform the kitchen. CNA #2 said she did not see that Resident #81 was served potatoes that were not modified correctly during the 8/14/24 lunch meal. Dietary aide (DA) #2 was interviewed on 8/15/24 at 1:56 p.m. DA #2 said residents prescribed level five and level six mechanically altered diets should not have toast but were able to have bread with crusts removed. DA #2 said if the menu extension called for diced potatoes, those on puree and level five and level six mechanically altered diets could have mashed potatoes unless the kitchen already had diced potatoes prepared. Cook (CK) #1 was interviewed on 8/15/24 at 2:13 p.m. CK #1 said he worked as an agency employee but would soon be an employee of the facility. CK #1 said he had not had prior education on mechanically altered textures. DA #1 was interviewed on 8/15/24 at 2:14 p.m. DA #1 said the previous dietary manager said residents on soft and bite-sized texture diets could be served grilled or toasted buns. -However, according to the IDDSI guidelines, no regular dry bread, sandwiches or toast of any kind should be served for puree, level five or level six diets. IDDSI level five minced and moist sandwich recipes should be used to prepare bread or the use of pre-gelled 'soaked' breads that were very moist and gelled through the entire thickness were appropriate. The NSD and the CRD were interviewed together on 8/15/24 at 2:36 p.m. The NSD said she had not had any recent training regarding mechanically altered diets but was working on refreshing her knowledge. The NSD said the kitchen staff were not too knowledgeable on what the different diet textures were and what residents on mechanically altered diets could not have. The CRD said the facility made an error serving potato skins on the french fries on 8/14/24. The CRD said the issue was that the facility had ordered french fries with potato skin on them. The CRD said toasting buns for residents prescribed the soft and bite-sized diet texture's hamburger buns was a mistake.

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 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 8/21/24 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, undated, was received from the nursing home administrator (NHA) on 8/15/24 at 6:14 p.m. It read in pertinent part, It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. High-contact resident care activities include device care or use for feeding tubes. III. Resident #55 A. Resident status Resident #55, age less than 65, was admitted on [DATE]. According to the August 2024 computerized physicians orders (CPO), diagnoses included dysphagia (a swallowing disorder) and severe protein-calorie malnutrition. The 7/24/24 minimum data set (MDS) assessment documented the resident was using a feeding tube. B. Observations On 8/12/24 at 10:45 a.m. there was no sign indicating Resident #55 needed EBP was observed on his door. -However, according to the resident's care plan and August 2024 CPO, Resident #55 was supposed to have a sign outside his room to indicate he was on EBP (see record review below). On 8/15/24 at 10:39 a.m. there was no sign outside Resident #55's room to identify the resident was on EBP. Licensed practical nurse (LPN) #4 entered Resident #55's room, washed her hands, and donned a new pair of gloves. LPN #4 proceeded to remove the dressing over Resident #55's feeding tube and switched the line providing enteral nutrition. LPN #4 left Resident #55's room to gather more supplies, then came back and washed her hands. LPN #4 donned a new pair of gloves, applied a wound cleansing solution to the feeding tube site and wiped it with gauze. LPN #4 applied a new dressing over Resident #55's feeding tube site, removed her gloves and used alcohol based hand sanitizer to sanitize her hands as she exited the room. -LPN #4 failed to wear a gown while providing care for Resident #55's feeding tube. -At 12:07 p.m. an EBP sign was observed on Resident #55's door and drawers containing PPE had been placed outside the resident's room. C. Record review The 6/18/24 care plan, revised 6/29/24, revealed Resident #55 required EBP during high-contact resident care activities due to the presence of an indwelling device. Pertinent interventions included utilizing gowns and gloves during high-contact resident care activities (including device and wound care) and placing EBP notification/signage near the resident's room to alert staff and visitors of the precautions. A review of the August 2024 CPO revealed the following physician's order for EBP: EBP: full PPE with high contact care or activities due to device/wound. Ensure signage is in place, ordered 6/18/24. D. Staff interviews LPN #4 was interviewed on 8/15/24 at 10:49 p.m. LPN #4 said residents with any type of wound or indwelling/invasive line needed EBP. LPN #4 said EBP meant the staff needed to don a gown and gloves before providing care. LPN #4 said nursing staff did not have to follow EBP for feeding tubes, as they were considered a non-sterile exchange. The infection preventionist (IP) was interviewed on 8/15/24 at 11:15 a.m. The IP said EBP was for residents with indwelling lines and wounds, including feeding tubes. The IP said the need for EBP was identified on admission and the facility also did monthly audits. The IP said a gown and gloves were required when switching lines and changing dressings for residents who were on EBP. The IP said Resident #55 should be on EBP. The director of nursing (DON) was interviewed on 8/15/24 at 12:25 p.m. The DON said nursing staff should wear a gown, gloves and mask when providing care for residents with indwelling lines, feeding tubes, drains and wounds. The DON said a resident with a feeding tube needed EBP.

Based on observation, record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for two (#11 and #3) of five residents reviewed for wound care management out of 13 sample residents. Resident #11 was admitted to the facility on [DATE] for long term care. She did not have any skin injuries prior to December 2023. Between 12/20/23 and 12/27/23, Resident #11 developed several traumatic injuries, including a blister on her left calf. The origin of the blister was not communicated to the management team and not investigated. Resident #11 was being followed by a wound care physician with routine treatments for wounds on her hands. On 12/29/23 the deterioration of the left calf wound (blister) was mentioned in the progress notes without any evidence of communication to the wound care physician. The left calf blister deteriorated and the resident developed cellulitis (skin infection) which was treated unsuccessfully at the facility. On 1/4/24 Resident #11 was hospitalized and diagnosed with severe cellulitis and potential sepsis (a serious condition in which the body responds improperly to an infection) due to the wounds on her legs. In addition, the facility failed to: -Accurately document all ongoing skin concerns for Resident #3; and, -Complete weekly skin assessments for Resident #11 and #3 thoroughly and accurately. Findings include: I. Facility policy and procedures The Skin Tears, Abrasions and Minor Breaks policy, revised September 2013, was provided by the nursing home administrator (NHA) on 1/11/24. It read in pertinent part: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in skin. Documentation Record the following information in the resident's medical record: 1. Complete in-house investigation of causation. 2. Generate 'Non-Pressure' form. 3. Document physician and family notification, and resident education (if completed) in medical record. 4. How the resident tolerated the procedure. 5. Any problems or resident complaints related to the procedure. 6. Any complications related to the abrasion (pain, redness, drainage, swelling, bleeding, decreased movement). 7. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. 8. Interventions implemented or modified to prevent additional abrasions (clothes that cover arms and legs). 9. When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/ Accident. Reporting 1. Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if the abrasion is uncomplicated or not associated with significant trauma. 2. Notify the physician of any abnormalities (excessive bleeding, localized swelling, redness, drainage, tenderness, pain). 3. Report other information in accordance with facility policy/guideline and professional standards of practice. II. Resident #11 A. Resident status Resident #11, age 81, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included chronic heart failure, high blood pressure, arthritis and kidney disease. The 11/10/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate assistance with activities of daily living (ADLs) and used a manual wheelchair for ambulation. The assessment documented the resident's skin was intact and she did not have any pressure, venous or diabetic skin injuries. She did not have cellulitis or other infections on her legs. B. Record review Resident #11's care plan for skin, initiated on 10/18/19 and revised on 11/7/23, revealed the resident was at risk for skin injury. The resident had a history of rash under her breast and abdominal folds, history of scratches and trauma to the right shin. Interventions included to check skin weekly, monitor the healing of the wounds and refer the resident to a wound care physician when necessary. -Resident #11's care plan did not mention any current or ongoing skin problems that the resident had prior to her hospitalization on [DATE]. The medical administration record (MAR) for January 2024 revealed the resident was receiving the following treatments: Doxycycline oral tablet 100 milligrams (mg), one tablet twice a day for cellulitis of left lower extremity. The treatment was initiated on 12/28/23, with a stop date on 1/7/24. Right shin was cleaned with skin prep and kept open to air daily. The order was initiated on 12/29/23. Left elbow skin tear was cleaned with wound cleanser, covered with xeroform and border gauze three times a week and as needed. The order was initiated on 12/31/23. Left posterior calf was cleaned with wound cleanser and dressed with xeroform, covered with pad that was wrapped in kerlix every other day. The order was started on 12/31/23. Right shoulder wound was cleaned with a wound cleanser and dressed with honey gel to wound bed and bordered gauze. The dressing was changed every other day. The order was initiated on 12/31/23. Right thumb was cleaned with a wound cleanser, dressed with honey gel to wound bed and covered with bordered gauze. The dressing was changed every two days. The order started on 1/1/24. Right third finger-was cleaned with wound cleanser, dressed with honey gel to the wound bed and covered with gauze and changed every second day. The order was started on 12/31/23. Resident #11's weekly skin assessments were reviewed between 12/1/23 and 1/4/24. -The skin assessments were inconsistently completed and did not include all areas of concern that were documented on the MAR/treatment administration record (TAR) or in the wound care notes by a wound care provider. The progress notes on 12/29/23 and 12/30/23 revealed that the resident's left calf wound had yellow drainage and clear discharge weeping from the blisters. -It was unclear if the condition of the wound was communicated to the wound care physician. -There were no additional notes. The note on 1/2/24 mentioned that a provider (not specified wound care or primary care) was contacted to evaluate the wound and request pain medications as the resident was in a moderate amount of pain during the wound care. -There were no additional notes documenting what the provider's response to the request was. A progress note on 12/21/23 by a wound care physician documented that Resident #11 had the following skin problems: -Wound #1 on right shin had a vascular etiology (origin) and was improving; -Wound #2 and wound #3 were related to fungal infection under the breast; -Wound #4 on the left thumb had trauma etiology and was resolved at the time of the assessment; -Wound #7 on the right thumb had a trauma etiology; and, -Wound #8 on the left elbow had a trauma etiology documented as a skin tear. -The progress note did not document what or where wounds #5 and #6 were or if they were resolved. The 1/4/24 wound care physician note documented some of the wounds under different numbers from the previous assessment. The 1/4/24 note summarized that wounds to the right thumb and left elbow were initially noted on 12/20/23 and the wounds to the left posterior calf, right shoulder and third right finger were noted on 12/27/23. The wound on the left calf was documented as a blister measuring 25 centimeters (cm) by 42 cm. The 1/4/24 note documented in pertinent part, There was a moderate amount of sero-sanguinous drainage with a mild odor. The wound was deteriorating. The patient has been on doxycycline since 12/28/23 left lower extremity worsening cellulitis, edema, and ulcerations. Patient in significant pain. Please send (patient) to the emergency department (ED) as soon as possible for treatment, vascular evaluation and urgent surgical consultation. Cellulitis with necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin). On 1/4/24 Resident #11 was sent to the ED for evaluation of the left lower extremity wound. C. Hospital records The ED admission note on 1/4/24 documented Resident #11's primary diagnosis as multiple open wounds of lower leg of unknown etiology. Severe unaddressed cellulitis, scattered full thickness skin loss. Significant slough and nonviable (non living) tissue. Resident #11 was admitted to the hospital for wound care and potential sepsis. The resident was started on a broad spectrum antibiotic. D. Staff interviews The medical director, who was also Resident #11's primary care provider (PCP), was interviewed on 1/8/24 at 2:30 p.m. He said he was aware that the resident was in the hospital for treatment of cellulitis. He said the resident developed cellulitis in the facility and was treated with antibiotics. He said the resident was followed by a wound care physician who documented the progression of the wound and initiated hospitalization . The PCP said the wounds on Resident #11's hands (thumbs/fingers) were the result of wheelchair use when the resident was self propelling. He said Resident #11 was offered to wear gloves when she was propelling herself in her wheelchair. He said he did not know how the wounds on the resident's legs started or what the cause of the wounds were. The PCP said the resident's skin conditions were treated appropriately and timely and he did not believe there was a delay in care for Resident #11. The NHA was interviewed on 1/8/24 at 2:40 p.m. He said he was not aware that some of Resident #11's wounds were traumatic in origin. He said he was aware of the wounds on the resident's hands from propelling herself in her wheelchair but he did not know how the wounds on the resident's legs started. He said he started an investigation for Resident #11 and initiated an audit of the wounds in the building to make sure all trauma injuries were investigated. The director of nursing (DON) was interviewed on 1/8/24 at 3:45 p.m. He said he was new to the position and he was not familiar with the details of Resident #11's hospitalization . He said all wounds should be documented on the weekly skin assessment form. Any changes that were observed in wound development must be documented in daily progress notes and communicated to the physician on the same day if any worsening of the wounds were noted. He said he initiated education to all nursing staff in the building and was auditing all residents with current skin conditions to make sure all trauma injuries were investigated and all wounds were accurately documented on skin assessments. The NHA was interviewed a second time on 1/9/24 at 4:30 p.m. He said facility-wide education to nursing staff was implemented on 1/8/24 and all residents with skin conditions were evaluated again. The NHA provided a record of staff interviews that he completed on 1/8/24 to establish the origin of the trauma wounds for Resident #11. The NHA said that he had a discussion on 1/8/24 with the wound care provider and came to an agreement that all wounds that were identified as trauma injuries would be directly communicated to the NHA for a timely investigation. E. Facility follow-up On 1/12/24 the facility submitted additional documentation related to the wound care for Resident #11. The additional information included completed education to all nursing staff on wound care assessment and documentation, logs of attendance and a letter of termination for the nurse who failed to communicate timely changes in the deteriorating wound on the left calf for Resident #11. III. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included paraplegia, heart failure, anxiety disorder and history of cellulitis. The 11/19/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required assistance from two people for transfers and personal hygiene and moderate assistance with other ADLs. She had impairment on both legs and was using an electric wheelchair for ambulation. The assessment documented the resident's skin was intact and she did not have any pressure, venous or diabetic skin injuries. She did not have cellulitis or other infections on her legs. B. Observations Resident #3's skin was observed on 1/9/24 at 11:30 a.m. in the presence of licensed practical nurse (LPN) #1. LPN #1 cleaned and dressed both wounds as ordered in the TAR (see below). In addition, the resident had an observable scratch on the right lateral shin and an open area on her left elbow. Resident #3 said the right lateral shin was itching and she scratched it. The open area on the right elbow was from rubbing on the armrest on her chair when she was repositioning herself. She said she did not mention the wound to the nursing staff before today. C. Record review Resident #3's care plan for skin, initiated on 8/4/23 and revised on 11/3/23, revealed the resident was at risk for skin injury due to paraplegia (paralysis of legs). Interventions included to check skin weekly and keep skin clean and dry. The January 2024 TAR revealed the resident was receiving the following treatments: Left lateral shin wound was cleaned with wound cleanser, dressed with xeroform and covered with bordered gauze three times a week. The order was initiated on 12/30/23. Right scapula (shoulder blade) wound was treated with betadine and open to air daily. The order was initiated on 12/29/23. Resident #3's weekly skin assessments were reviewed between 12/1/23 and 1/4/24. -The skin assessments were inconsistently completed and did not include all areas of concern that were documented on the MAR/TAR or in wound care notes by a wound care provider. -The assessments did not include wound measurements or the date when the wounds were initially noted. A 12/21/23 wound care note by a wound care physician documented the resident had two wounds. The wound on the scapula (shoulder blade) was documented as cellulitis and the wound on left lateral shin had a trauma etiology. -There were no additional wound care physician notes documented after the 12/21/23 note. D. Staff interviews LPN #1 was interviewed on 1/9/24 at 11:45 a.m. He said he did not know how Resident #3 acquired her wounds. He said he did not know the resident had scratches on her right shin and an open area on her left elbow. He said he would contact her physician and obtain an order for the wound care. The director of therapy services (DTS) was interviewed on 1/11/24 at approximately 12:15 p.m. He said Resident #3 was evaluated on 1/9/24 for proper positioning in her electric wheelchair and a physician's order was placed for better back support. He said the back support would provide better positioning for the resident and minimize the friction between her elbow and the armrest. The DTS said both armrests on the electric wheelchair were reinforced with extra cushioning. The DON and the NHA were interviewed on 1/11/24 at 12:30 p.m. The DON said the resident's wound care physician was contacted and notified of the newly identified open areas. A physician's order was obtained for a temporary wound dressing until the wound physician could complete a full assessment of the wounds. The DON said the resident was included in the audits for skin assessments that were initiated on 1/8/24. He said he would make sure the resident's medical record was updated with accurate skin conditions and skin treatments were consistent. The NHA said the trauma injury on the resident's left shin was investigated on 1/9/24 and it was discovered to be caused by a sharp corner near the resident's sink. He provided a written investigation regarding the resident's wound. The NHA said the sink area was assessed by the maintenance personnel and all sharp edges were covered.

Based on observation, interview and record review the facility failed to ensure the residents were free from resident-to-resident abuse. Specifically the facility failed to ensure two of 50 sample residents (#51, and #111) were safe from repeated verbal and physical altercations with each other. These failures resulted in injury from physical altercations. The findings include: A. Resident Data Resident #111 shared a semi-private room with one roommate; sample resident #51 1. Resident #51 Resident #51 was a [AGE] year-old male admitted to the facility on [DATE]. According to his face sheet, [DIAGNOSES REDACTED]. According to the resident's most recent minimum data set ((MDS) dated [DATE], the resident needed extensive assistance for bed mobility transfers, walking in the room and corridor, dressing, toilet use, personal hygiene, and supervision for locomotion on and off the unit. He was also identified as being "not steady" on any transfer. Record review revealed a nurse's progress note in resident #51's record dated as a late entry 10/17/11, 3-11 shift, documented in pertinent part, "Resident had an altercation with roommate (resident #111). Resident was agitated because he stated roommate hit him in his face. Upon assessment, resident had a scrape on left cheek which is reddened. Resident stated that he wants 9-1-1 to be called and to press charges. I explained to resident I could not do that and that an incident report would be filed and reported to the DON (director of nursing). DON called and left a voice mail about incident. Resident calmed down during the night. Reported (altercation) to the next shift to keep monitoring." A care plan dated 10/13/11 that stated, "(Resident) has made false statements (related to) roommate and his relationship. (Resident) and roommate (resident #111) have a history of not getting along and have been offered opportunities to move but refuse. On 10/11/11 stated roommate has on different occasions kicked him in legs and knees - claim was unsubstantiated upon investigation." Review of a document titled, "Highline community resident check sheet" dated from 10/11/11 to 10/15/11 revealed that resident #51 was identified as the subject: -On 10/11/11 6:00 p.m. through 11:00 p.m., there were signed initials, however, no location of the resident was noted and all other times were left blank. -There were three resident check sheets dated 10/12/11. On one sheet it identified resident #51 and stated that from midnight through 7:00 a.m. he was documented as "sleeping." However, no employee signature was present. He was noted as being in, "bed" from 7:15 a.m. until 3:00 p.m. No checks were completed from 3:15 p.m. until 5:00 p.m. From 5:00-5:45 p.m., he was noted as sleeping. On that sheet there was no documentation from 6:00 p.m. through the rest of the day. Another 15-minute check sheet, dated 10/12/11, indicated the resident was sleeping or in bed until 6:30 a.m. The rest of the check was incomplete. The third 15-minute check sheet, dated 10/12/11, indicated the resident was in the hall from 9:15 a.m. to 10:00 a.m., however the check prior indicated the resident was in bed. The third check indicated the resident was in the MDR (main dining room) from 12:15 p.m. until 1:15 p.m. However the first check mentioned indicated the resident was in bed. On the third check, dated 10/12/11 from 1:30 p.m. through 2:30 p.m., the resident was recorded in the hall. However, the documentation was conflicting in that on the first check, dated 10/12/11, the resident was noted in bed at that same time he was in the hall. Two resident check sheets, dated 10/14/11, contained no documentation from 2:15 p.m. to 10:45 p.m. 2. Resident #111 Sample resident #111, a [AGE] year-old, who according to the face sheet was admitted to the facility on [DATE] with the following diagnoses; care involving use of rehabilitation procedures, late effects of [MEDICAL CONDITIONS] affecting unspecified side, artificial opening status, symbolic dysfunction, muscle weakness, lack of coordination, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] and other non-organic [MEDICAL CONDITION]. According to the minimum data set (MDS), dated [DATE], resident #111 had short- and long-term memory problems, inattention, disorganized thinking, and altered level of consciousness and psychomotor [MEDICAL CONDITION]. Additionally, the MDS indicated physical behaviors directed toward others, and he required extensive assist for all activities of daily living (ADL). According to the care plan updated 8/31/11 for resident #111, "Has episodes of angry outburst with verbal abuse related to dx (diagnosis) of [MEDICAL CONDITION], exhibits episodes of verbal aggression towards others and is not easily redirected and may become physically aggressive i.e.: (sic) attempting to hit, spitting." The intervention section of the care plan read, "If (nickname of resident #111) is agitated and continues with abusive behaviors toward others redirect to private area as appropriate." a. Record Review/Social Services Notes On 7/21/11, "Spoke with spouse (name), she asked if there was another (different) roommate for her husband. She also said that her children were afraid of the roommate". Spouse asked, "what made us think they would be a good match. I (social worker) will look at the possibility of move." On 8/16/11, "Reviewed (increased behavior) spitting & pulling staff's hair." On 8/22/11, "Attempted to talk w/(with) elder (#111) re: disagreement w/roommate over the weekend." On 8/23/11, "Attempted to talk w/ (with) (name of resident #111) re: disagreement w/roommate over the weekend. (Name of resident #111) was unable to be woke up for a period of time but his speech was garbled, I was unable to understand what he was saying." On 8/24/11, "Per CNA (certified nurse aide) (name of resident #111) had been yelling & cursing at his roommate. (Name of resident #111) stated that he was not happy with his current roommate & did not want to be in the same room." On 8/26/11, "Spoke w/(with) (name) r/t (related to) the incident from 8/20/11 & (name of resident #111) spouse request to have the roommate moved repeatedly." On 9/14/11, "Spoke to (name) (resident #11 spouse). Let her know regarding concern she had about roommate running into (name) (resident #111) belongings." On 10/14/11, "Told by nursing that elder (#111) is upset. States he wants his roommate moved". Resident #111 "roommate did not want to move." b. Social Services Assessments/ Updates: On 8/24/11, "Has periods of (increased) agitation, verbal outburst (with) cursing." On 10/18/11, "(name of resident #111) has adjusted well to move to Capitol Hill (unit in the facility) & to new roommate." c. Psychosocial Assessment On 5/8/11, (sic), "Verbal aggression yelling, cursing call people name at times, spits." On 9/12/11, "Has had episodes for verbal aggression toward roommate w/(with) threatening nature." d. Nurses' Notes On 8/20/11, "Resident accused his room (roommate) of touching his property, his roommate was upset and angry." On 10/12/11, "Cont (continue) on chart for res-res (resident to resident) altercation." On 10/13/11, "Cont (continue) f/u (follow up) on pt-pt (patient to patient) altercation." On 10/15/11, "Resident on charting for res-res altercation, 15 min (minute) checks." On 10/16/11, "Resident (#111) laying in his bed yelling out loud with his roommate's name." On 10/17/11, "Resident (#111) had an altercation with his roommate. Roommate stated, 'He hit me and spit on me'." 3. Observations On 10/18/11 at 8:30 a.m., resident #51 was observed sleeping in his bed. Resident #111 had his curtain pulled. With the curtain pulled there was less than a foot of clearance between the curtain and a fan to get to the bathroom. Observation of resident #51 on 10/18/11 at 1:03 p.m. revealed a scratch across the resident's left cheek. The resident stated it was from when his roommate, resident #111, hit him. Observation, on 10/19/11 at 7:30 a.m., revealed resident #51 and resident #111 were both asleep in their room with a sitter present. Observation, on 10/19/11 at 10:37 a.m., revealed that in order to assist resident #51 to the restroom, the CNA demonstrated that the privacy curtain for resident #111 would have to be opened. At the same time, resident #111's wheelchair would have to be moved away from the bathroom to open the bathroom door completely. 4. Interviews/Additional Information Resident #51 stated in an interview, on 10/11/11 at 2:30 p.m., that he had issues with his roommate, resident #111. He said his roommate kicked him in the knees and shins when they were sitting next to each other. Moreover, he reported that resident #111's spouse would come in and yell at him. On 10/12/11 at 11:34 a.m., the spouse of resident #111 was interviewed. She voiced her concerns about the conflict between her, and her husband and the roommate (sample resident #51). She stated that her husband and his roommate did not get along and had been involved in several verbal altercations. She further stated that she had been in contact with the social services and expressed her concerns both verbally and in writing via e-mail. She stated that she had witnessed the verbal altercation and reported it to the facility staff. She stated she was told resident #51, her husband's roommate, had the right not to have to change rooms. She further stated that her husband had been in the room first and she did want to move him as he was subject to [MEDICAL CONDITION] and having a consistent room and staff helped with her husband's quality of life. The above e-mail documentation dated 8/16/11, provided to the survey team, documented the spouse had informed the facility social worker of a verbal altercation where she stated resident #51 had yelled and threatened to beat up her husband, resident #111. The response was dated 8/19/11. The social services person responsible for the hall where residents #111 and #51 resided, responded, "It is a person's right to choose not to move rooms." The social services person further stated that resident #111 could change rooms and this was the only resolution the facility had to offer." On 10/18/11 at 1:03 p.m., an interview with resident #51 revealed the resident was not afraid of resident #111, however he was, "Tired of being beaten up." He stated that if the facility did not do something about it he would not be held responsible for his actions. He stated that he did not want to change rooms just because they wanted him to. Resident #51 further stated he did feel safe in his room, however, he was tired of his roommate hitting him. An interview, on 10/18/11 at 2:03 p.m., with the nursing home administrator (NHA) and the director of social services (DSS) revealed that resident #51 had reported that resident #111 had struck resident #51 in the face "last night." They reported the residents were allowed to remain in the same room with 15-minute checks. The NHA stated their policy was to monitor the residents, and then was shown the policy provided by the director of nursing (DON). The policy read, in pertinent part, "If resident-to-resident abuse is suspected or substantiated, the Charge Nurse/Director of Nursing will immediately separate the two residents during the abuse investigation and ensure all other residents are protected from potential abuse." When asked if the residents were separated at the time, the NHA stated they were not. Interview with the DSS, on 10/18/11 at 3:06 p.m., revealed there were 15-minute checks from the 10/11/11 incident resident #51 had reported. Review of the 15-minute checks revealed large holes (blanks) in the documentation. The DSS stated that it did not look like anyone had signed off to show the residents were checked at those times. When asked about any checks or monitoring of documentation following the 10/16/11 reported resident to resident altercation between resident #51 and #111, she stated there were no checks. However, the unit nurse had met with the staff to discuss monitoring the residents. When asked if there was documentation on this the DSS stated, "No." An interview with a certified nurse aide (CNA), on 10/19/11 at 10:35 a.m., revealed the CNA working with residents #51 and #111 did not know the reason why resident #51 had a sitter in the room. The CNA also stated that she had heard different stories about the residents arguing with each other. An interview with a CNA working with residents #51 and #111 on 10/19/11 at 10:40 a.m., revealed the CNA did not know why resident #51 had a sitter and said she did not know what had happened between the residents. She added that a couple of months ago resident #51 had turned on his call light, and when she answered it, she witnessed resident #111 yelling at resident #51. The CNA stated she had reported the issue to the DSS. She further reported that frequently, when they placed resident #111 in bed he would kick or grab at them with his right hand and foot. On 10/19/11 at 2:35 p.m., an interview was conducted with the social services (SS) person responsible for residents #51 and #111. She stated that resident #111 and his spouse had both expressed concern about the roommate (resident #51) not being compatible as roommates on more than one occasion. When asked about the process for choosing roommates for compatibility, the SS stated residents were introduced and given some time to spend together to see if they were compatible. If the residents got along in this initial meeting they may be considered a good match. She stated the initial meeting would be in the range of 15 to 30 minutes. She stated she was aware of incidents between the two residents and said the residents had the right not to have to change rooms. The SS stated it was the responsibility of the facility to ensure that residents remained free from abuse. She stated that the facility was now planning on moving resident #51 to a new room. The facility was aware there were issues between the two residents, however, did not ensure resident #51 and resident #111 were protected from altercations that resulted in injury.