Every finding on record at Hildebrand Care Center

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for four of four medication storage carts.Specifically, the facility failed to:-Date residents' insulin pens and inhalers with the date they were opened;-Label residents' medications the resident's name; -Discard insulin vials and epinephrine (used to treat life threatening conditions, including allergic reactions) medication that had expired; and,-Ensure loose pills in a medication cart were discarded.Findings include:I. Professional referenceAccording to the manufacturer, Viatris, How to Use a Wixela Inhub (inhaler used to treat asthma and lung disease), 2021, retrieved on [DATE] from https://www.wixelahcp.com/-/media/Project/Common/WixelahcpCom/PDF/[NAME]-2020-0047_V4_US_How-to-Use_PDF.pdf, Take Wixela Inhub out of the foil pouch just before you use it for the first time. Write the pouch opened and use by dates on the label. The use by date is one month from the date you opened the pouch for your first dose.According to the manufacturer, GlaxoSmithKline (inhaler used to treat lung disease) [DATE], Patient Information Incruse Ellipta, retrieved on [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Incruse_Ellipta/pdf/INCRUSE-ELLIPTA-PI-PIL-IFU.PDF#nameddest=PIL, Safely throw away Incruse Ellipta in the trash six weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler.According to the manufacturer Biocon Biologics, 2023, Patient Information-Storing the Insulin Glargine yfgn pen, retrieved on [DATE] from, https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=3ac85ebb-5594-59c8-77fd-df254329d151&type=display#section-18m, Only use your pen for up to 28 days after its first use. Throw away the Insulin Glargine yfgn pen you are using after 28 days, even if it still has insulin left in it.According to the manufacturer [NAME] Lilly and Company, 2023, Instructions for Use Humalog Insulin Lispro injection, retrieved on [DATE] from, https://pi.lilly.com/us/humalog-vial-ifu.pdf, Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.II. Facility policy and procedureThe Storage of Medications policy, undated, was provided by the nursing home administrator (NHA) on [DATE] at 12:53 p.m. It read in pertinent part, The nursing staff shall be responsible for maintaining medication storage and preparation in a clean, safe and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.III. Observations and interviewsOn [DATE] at 2:15 p.m., the River Walk medication cart was observed with licensed practical nurse (LPN) #1. The following medications were found:-The second drawer of the medication cart contained 35 loose pills at the bottom of the drawer. LPN #1 said the drawer should have been cleaned and should not contain a large amount of loose pills. -A used Wixela 250/50 micrograms (mcg) inhaler for Resident #64 was not labeled with the date it was opened. LPN #1 said inhalers should be labeled with the date opened.-A used Incruse Ellipta inhaler 62.5 mcg for Resident #64 was not labeled with the date it was opened.-A used Wixela inhaler 500/50 mcg for Resident # 52 was not labeled with the date it was opened.-A used Umeclidinizam/Vilanterol Ellipta inhaler 62.5/25 mcg for Resident #22 was not labeled with the date it was opened.-An unopened Epinephrine 0.3 milligram (mg) per 0.3 milliliters (ml) auto injector labeled with Resident #11's name, with an expiration date of [DATE]. LPN #1 removed the medication from the cart and said it should have been discarded in [DATE].-An used vial of insulin glargine pen for Resident #28 was not labeled with the date it was opened. LPN #1 said insulin should always be labeled with the date opened.On [DATE] at 2:52 p.m. the Aspen medication cart was observed with LPN #2. A used Ayr saline nasal gel was not labeled with a resident's name. LPN #2 said the nasal gel should be labeled with the resident's name. On [DATE] at 3:16 p.m. the Pikes Peak medication cart was observed with LPN #3. The following medications were found:-A used Trelegy Ellipta inhaler 100/62.5 mcg for Resident #9 was not labeled with the date it was opened. -Two used Trelegy Ellipta inhalers 200/62.5/25 mcg for Resident #56 were not labeled with the date they were opened. LPN #3 said the inhalers should be labeled with the date they were opened.On [DATE] at 3:43 p.m. the Mystic Mountain medication cart was observed with LPN #4. The following medications were found:-A used insulin lispro kwik pen 100 units per ml did not have a resident label attached. LPN #4 said the insulin pen should have a resident's label attached. -A used insulin lispro vial 100 units per ml for Resident #20 which was labeled with a date opened [DATE]. LPN #4 said the insulin should have been discarded on [DATE].IV. Staff interviewsThe director of nursing (DON) was interviewed on [DATE] at 4:05 p.m. The DON said the medication cart which contained 35 loose pills should have been cleaned more frequently and there never should be that many loose pills in a medication cart. The DON said the insulin and inhalers without dates opened should have been labeled with the date they were opened. The DON said the epinephrine should have been discarded in [DATE] and the insulin pen opened on [DATE] should have been discarded 28 days after it was opened. The DON said the nasal gel and the insulin pen should have had resident identification labels.The pharmacist was interviewed on [DATE] at 12:10 p.m. The pharmacist said that dry inhalers (such as the Wixela and Ellipta inhalers) should have been labeled with the date they were opened. The pharmacist said if the epinephrine and inhalers were used beyond manufacturer's recommendations, they could be less effective.

Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#7) of five residents reviewed for use of psychotropic medication out of 51 sample residents. Specifically, the facility failed to ensure the physician's order for Resident #7's as needed (PRN) lorazepam (antianxiety medication) was reevaluated and a rationale was provided by the physician to justify the continued use of the psychotropic medication beyond the 14-day limit.Findings include:I. Facility policy and procedureThe Antipsychotic Medication Use policy was provided by the director of nursing (DON) on 9/25/25 at approximately 10:00 a.m. The policy read in pertinent part, All antipsychotic medications will be used within the regulation guidelines for psychotropic medications or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.II. Resident statusResident #7, age greater than 80, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), the resident's diagnoses included dementia, anxiety and depression.The 9/9/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15.The MDS assessment indicated the resident was receiving antianxiety medications.III. Record reviewReview of Resident #7's September 2025 CPO revealed the following physician's order:Lorazepam 0.5 milligrams (mg), give 0.5 mg by mouth every two hours as needed for anxiety or shortness of breath, ordered 8/18/25.-The physician's order for the PRN lorazepam was prescribed indefinitely instead of for 14 days as required and did not include a rationale for extending the medication usage beyond 14 days. Review of Resident #7's psychotropic medication care plan, revised 9/4/25, revealed the resident received psychotropic medications for depression, anxiety, hallucinations, and insomnia. Interventions included giving medications as ordered by the physician and monitoring for side effects (sleepiness or fatigue, dizziness, dry mouth, nausea, tremors, headaches, constipation) and effectiveness, alerting the physician if side effects and/or ineffectiveness developed, monitoring for the need for the continued use of psychotropic medications or the potential for alternate approaches, reporting changes in mood/behavior to the nurse, monitoring for target behaviors, including distressing expressions that caused the resident mental anguish, unamendable impulsivity that interfered with delivery of care and/or impacts physical/mental health and saddened/apathetic expressions and utilizing non-pharmacological interventions, such as pain management modalities, assuring the resident she was safe and her needs would be met, distraction and redirection.Review of Resident #7's September 2025 medication administration record (MAR) revealed the resident received a dose of PRN lorazepam on 9/13/25 at 8:00 p.m. -However, the physician's order for the PRN lorazepam should have been reevaluated by the physician on 9/1/25 (14 days after it was initially ordered on 8/18/25) and a new physician's order obtained for the medication or a rationale documented by the physician for the continued use of the medication beyond 14 days.A review of Resident #7's progress notes revealed no documentation to indicate the physician had reevaluated the resident's PRN lorazepam in order to justify the use of the medication beyond the 14-day limit for PRN psychotropic medications. IV. Staff interviewsThe DON was interviewed on 9/25/25 at 5:00 p.m. The DON said she was not aware that PRN psychotropic medications should only be prescribed for 14 days and then reevaluated for continued use unless the physician documented a rationale for ordering the medication for longer than 14 days. The DON said she was new to the facility and had just begun in her current role approximately two weeks prior to the survey. The pharmacist was interviewed on 9/25/25 at 12:15 p.m. The pharmacist said she was aware of the regulation that PRN antianxiety medications could only be prescribed for 14 days. The pharmacist agreed that the physician should have documented a note which indicated a rationale for why Resident #7 was receiving the PRN lorazepam beyond 14 days. She confirmed there was no physician rationale for the use of the medication beyond 14 days documented in Resident #7's medical record.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#10 and #39) of five residents reviewed for accidents out of 51 sample residents.Specifically, the facility failed to ensure Resident #10 and #39 were transferred appropriately and according to their plan of care.Findings include: I. Facility policy and procedure The Safe Lifting and Movement of Residents policy, revised July 2017, was received from the director of nursing (DON) on 9/24/25. It read in pertinent part, ln order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: -Resident's preferences for assistance; -Resident's mobility (degree of dependency); -Resident's size; -Weight-bearing ability; -Cognitive status; Whether the resident is usually cooperative with staff; and, -The resident's goals for rehabilitation, including restoring or maintaining functional abilities. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Safe lifting and movement of residents is part of an overall facility employee health and safety. II. Resident # 10 A. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, hypertension and muscle weakness. The 8/5/25 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 resident required substantial assistance with activities of daily living (ADL). B. Observations On 9/24/25 at 9:10 a.m. there was a sign observed hanging on the wall in Resident #10's room. The sign indicated Resident #10 was a two-person transfer using the transfer pole. The sign indicated staff were to use a safety gait belt during the resident's transfers. C. Resident interview Resident #10 was interviewed on 9/24/25 at 9:10 a.m. Resident # 10 said approximately a month prior (August 2025) she was sitting in her lounge chair. She said that the certified nurse aide (CNA) transferred her from the chair without a gait belt. She said she was transferred incorrectly as the CNA transferred her alone. She said when the CNA transferred her, she twisted and hurt her knee. She said she went to the hospital for an Xray which did not reveal an injury. She said she had to take pain medications to help with the discomfort in her knee. Resident #10 said it was a new agency staff CNA who did not know what she was doing. The resident said since the incident, there were extra gait belts in her dresser drawer and there was a sign on the wall to describe how she was to be transferred. D. Record review Review of Resident #10's fall care plan, revised 7/29/25, identified the resident had a potential for falls/injury related to cognitive deficit, decreased mobility, poor safety awareness and weakness. Pertinent interventions included assisting the resident with a transfer pole (at bed and recliner) and using a gait belt with transfers. The physician's order, dated 7/31/25, revealed the resident was a two-person assistance with a pivot disc (mobility device that rotates to assist with twisting/turning) for transfers. The nurse progress note, dated 8/9/25, documented Resident #10 stated she was not feeling well. She reported increased left knee pain. Voltaren gel (topical ointment used to treat pain) was applied to her left knee A new physician's order, dated 8/11/25, revealed the resident was a two-person assistance for transfers and indicated staff were not to use the pivot disc. The facility investigation, dated 8/11/25, revealed that on 8/8/25 Resident #10 was transferred with one person with a gait belt when the resident's transfer status and physician's order indicated the resident was a two-person assistance transfer with a gait belt. The CNA failed to follow the transfer procedures for the resident which was a pivot disc. The investigation documented the CNA said she did the transfer alone, as other staff were busy and the resident was ready for bed. The investigation revealed staff were educated on how to transfer the resident properly and to use gait belts during the transfer. E. Staff interviews The physical therapist (PT) was interviewed on 9/24/25 at 3:10 p.m. The PT said the rehabilitation department completed assessments on the residents for proper transfer techniques. She said Resident #10 was a two-person transfer with a pivot disc before the incident on 8/8/25, but she had not liked the pivot disc. She said the resident was now a two-person transfer with a gait belt and the transfer pole. The DON was interviewed on 9/24/25 at approximately 5:00 p.m. The DON said staff were trained on proper transfer techniques. She said the agency staff the facility used at times received information on each resident when they worked, including resident transfer statuses. The DON said Resident #10 should not have been transferred with only one CNA. She said the CNA should have waited until another CNA or nurse was located to assist with the transfer. She said if a CNA or nurse needed help with a transfer, there was support from administration nurses and therapists who could assist. II. Resident #39 A. Resident status Resident #39, age greater than 65, was admitted on [DATE]. According to the September 2025 CPO, diagnoses included dementia, muscle weakness and chronic kidney disease. The 7/7/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. She required substantial/maximal assistance with toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene, sitting to lying and lying to sitting on the side of the bed. She was dependent on staff assistance with sitting to standing and chair/bed to chair transfers. B. Record review The mobility care plan, revised 6/27/25, documented Resident #39 had impaired functional mobility related to decreased cognition and weakness. Interventions included an orange name plate and banner to alert staff of the resident's high fall risk status, utilizing bed bars for bed mobility/transfers with sheep skin over the bed bars to reduce risk of injury and padded flooring in the resident's room to prevent injury. The functional care plan, initiated 7/9/25, documented Resident #39 would have opportunities to participate in her functional abilities tasks to her highest functional level over the next three months. Interventions included the resident needed two-person staff assistance with a gait belt for transfers. The 9/4/25 facility investigation was provided by the nursing home administrator (NHA) on 9/24/25 at 9:30 a.m. The report revealed that on 9/4/25 Resident #39 was transferred with one-person assistance with a gait belt by CNA #2, when the resident's transfer status and physician's order indicated the resident was a two-person assistance transfer with a gait belt. The investigation documented a second staff person was present in the room during the transfer, however, CNA #2 did not wait for assistance. Resident #39 was assessed by registered nurse (RN) #1 and no injuries were noted. CNA #2 was interviewed by the facility on 9/4/25 and stated that she transferred Resident #39 by herself using a gait belt. She said she did not follow the proper procedure of using two-person assistance. Resident #39 was interviewed by the facility on 9/5/25 and said she did not recall the incident and stated everyone took good care of her. She recalled no issues with her transfers. The conclusion of the facility's investigation revealed CNA #2 displayed a lack of professionalism and did not follow facility transfer procedures. The nursing progress note, dated 9/5/25 at 1:51 p.m., documented Resident #39's representative was called and notified that Resident #39 had been transferred by one-person staff assistance instead of two-person staff assistance by an agency CNA. The representative was notified the resident had no injuries. C. Staff interviews CNA #3 was interviewed on 9/25/25 at 3:24 p.m. CNA #3 said Resident #39 was a two-person assistance transfer with a gait belt. CNA #3 said Resident #39 had a sign posted in her room that instructed staff that she was a two-person assistance transfer with a gait belt. CNA #3 said if she was the only person in the room of a resident who required two people for transfers, she would pull the call light until another staff member came in to assist her with the resident transfer.RN #2 was interviewed on 9/25/25 at 4:51 p.m. RN #2 said Resident #39 was a two-person assistance for all transfers. RN #2 said one person should not try to assist the resident. RN #2 said two-person assistance was for Resident #39's safety and the safety of staff. RN #2 said agency staff had a binder that they had to review when working. RN #2 said the binder included residents who were a two-person assistance for transfers. RN #2 said if CNAs were not familiar with a resident, all they had to do was just ask another staff member. RN #2 said the incident of the one-person transfer for Resident #39 could have been prevented. The DON and the assistant director of nursing (ADON) were interviewed together on 9/25/25 at 5:23 p.m. The ADON said Resident #39 was a two-person assistance transfer with a gait belt. The ADON said an agency CNA was assigned to provide care for Resident #39 on 9/4/25 The ADON said Resident #39 was getting back into bed after breakfast and the second CNA who was in the room to assist with the transfer went to shut the door. She said while the second CNA was shutting the door, the agency CNA lifted Resident #39 using the gait belt and moved her to the bed by herself. The ADON said the agency CNA knew Resident #39 was a two-person assistance for transfers. The ADON said the agency CNA did not indicate why she decided to do the transfer by herself. The ADON said the agency CNA was pulled into her office for questioning and then was sent home and had not been allowed to return to the facility. The ADON said Resident #39 did not fall or sustain any injuries on 9/4/25. The ADON said she did not provide any new education to the staff on the floor regarding transfers following the improper transfer with Resident #39.

Based on record review and interviews, the facility failed to ensure one (#1) out of three sample residents received the care and services necessary to maintain her highest practicable level of well-being. Specifically, the facility failed to serve Resident #1 the correct physician-ordered mechanical soft texture diet which contributed to her mental and physical decline. Resident #1, who had a history of dysphagia (difficulty swallowing) and dementia, had a physician-ordered texture diet of mechanical soft. On [DATE], Resident #1 was served large pieces of steak, mashed potatoes, and a bread roll for dinner. The resident began choking in the dining room, the Heimlich maneuver (a first aid procedure utilized to dislodge an obstruction from the throat) was performed and emergency services were called. In the emergency room , a large piece of meat was dislodged from her trachea (the airway that leads from the vocal box to the lungs). The resident was admitted to the hospital for acute hypoxic (low levels of oxygen in the body's tissues) respiratory failure due to choking. The resident's mental status did not recover and she was unresponsive to verbal stimuli. She was diagnosed with severe acute hypoxic encephalopathy (a type of brain damage from lack of oxygen in the brain). Resident #1 returned to the facility under hospice care on [DATE] and passed away on [DATE] at the facility, seven days after the choking incident. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on [DATE] to [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE]. I. Situation of serious harm The facility failed to ensure Resident #1, who had a history of swallowing difficulties, was served the appropriate physician-ordered mechanical soft texture diet, which included ensuring food was chopped in small pieces and soft. This resulted in Resident #1 experiencing a choking episode in the dining room on [DATE]. The facility's failure to serve the resident the physician-ordered diet led to the resident being sent to the hospital where a large piece of meat was removed from her trachea in the emergency room . The resident was admitted to the hospital for acute hypoxic respiratory failure due to choking; however, she was unable to recover and was readmitted to the facility on [DATE] with hospice services. Resident #1 passed away at the facility on [DATE], seven days after the choking incident. Record review and interviews during the complaint investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from [DATE] to [DATE]. II. Facility plan of correction A. Immediate action The corrective action plan the facility implemented in response to Resident #1's choking incident on [DATE] was provided by the nursing home administrator (NHA) on [DATE] at 2:00 p.m. On [DATE], a huddle was conducted with the dietary staff to discuss the incident of Resident #1's choking. On [DATE], an educational in-service was conducted for all dietary staff regarding the importance of ensuring residents received the correct physician-ordered diet texture. The education included a review of all diet textures. B. Systemic changes On [DATE], the facility implemented a new system of diet cards for all residents. The facility implemented one card (instead of two pieces of paper) that included the diet texture, resident preferences, resident allergies, and the resident's food order for each meal. Education was provided to all staff, including dietary and nursing staff, on the new system put in place to ensure residents received the correct diet texture. On [DATE], an education write-up was completed for a dietary staff member. On [DATE] and [DATE], annual skills testing was conducted for all staff on diet textures, modified liquids and the importance of following physician-ordered diet textures. The facility conducted direct observations of staff serving meals with the correct diet tickets following the skills testing. C. Monitoring On [DATE], meal service audits were started and continued daily at different meals. Audits would be continued indefinitely. All audits were to be reviewed daily by the dietary manager, discussed weekly in the interdisciplinary team meetings (IDT), and reviewed during monthly QAPI (quality assurance and performance improvement) meetings. Interviews and record review during the complaint investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Facility policy and procedure The NHA provided the Mechanical Soft Diet policy and procedure, dated 2011, on [DATE] at 1:30 p.m. It revealed in pertinent part, A mechanical soft diet is used for individuals who have difficulty chewing regular textured foods. Foods that are difficult to chew are chopped, ground, shredded and/or soft cooked to facilitate chewing and ease of swallowing. Protein foods (fish, seafood, lean meat, poultry, eggs, cooked dry beans/peas/lentils as tolerated, soy products, etc): soft, tender, ground, shredded or chopped. IV. Incident of choking A. Resident status Resident #1, age greater than 65, was admitted on [DATE], readmitted on [DATE], and expired at the facility on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, interstitial pulmonary disease, and dysphagia. The [DATE] minimum data set (MDS) assessment revealed the resident had short-term memory impairment with modified independence in making decisions regarding tasks of daily life. She required set-up assistance with eating. B. Record review The cognition care plan, initiated on [DATE], documented the resident had a cognitive deficit with signs and symptoms of memory loss and dementia. The interventions included allowing the resident to participate in daily decisions to the best of her ability, contacting the resident's family to assist in major decision-making, encouraging the resident to share memories past and present, explaining procedures to the resident, and allowing her time to process and respond. The nutrition care plan, initiated on [DATE], documented the resident's diet was changed on [DATE] due to a previous choking incident from a regular texture to a mechanical soft texture. The interventions indicated the resident should be served the mechanical soft texture diet as ordered by the physician. The [DATE] CPO documented the following physician order: Regular diet, mechanical soft texture, chin tuck with swallowing, and no straws for diet. Order date [DATE]. The [DATE] nutrition/dietary progress note documented the resident was ordered by the physician to be served a mechanical soft texture diet. The [DATE] nursing progress note documented Resident #1 was observed choking in the dining room during dinner. The resident was not breathing, was unable to communicate verbally and her skin was noted to be severely cyanotic (bluish or purplish discoloration of the skin due to deficient oxygenation of the blood). The Heimlich maneuver was performed without success. Oral suction was performed with an output of a thick tan-colored substance, possibly bread, after several minutes. Resident #1 was taking slow and shallow breaths when emergency services arrived at the facility. The resident's oxygen saturation was 67% (percent) on 6 L (liters) of oxygen with a non-rebreather mask (oxygen mask that delivers high concentrations of oxygen). The resident was transferred to the emergency room . On [DATE] at 6:28 p.m., the facility nurse contacted the emergency room for an update on Resident #1's condition. Resident #1 was intubated (a tube inserted into the airway to assist with breathing) and moved to the intensive care unit (ICU). The [DATE] emergency room physician's progress note documented in pertinent part, Presented with respiratory distress in the setting of a possible foreign body aspiration. The resident arrived in respiratory distress with marked inspiratory stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway) while on 100 % oxygen via a non-rebreather mask. EMS (emergency medical services) reported that she was at a local nursing facility eating dinner and possibly choked on a dinner roll. On arrival, she has an oxygen saturation of 84% while on the non-rebreather mask. Her tongue was depressed, which revealed a foreign body in the oropharynx (middle part of the throat, behind the mouth). At the time of direct visualization, a large piece of meat was visualized with complete occlusion (blocking) of the trachea at the level of the vocal cords. Forceps were used to remove this piece of meat. After successful removal of this large piece of meat obstructing the patient's airway, it was collectively decided that the patient needed to be intubated for airway protection. She remained hypoxic on a 100% non-rebreather mask. The [DATE] nursing progress note documented Resident #1 remained in the ICU and intubated. It indicated the resident was still intubated due to the physical trauma to her airway. Resident #1 was readmitted to the facility on [DATE] with hospice services. The [DATE] facility physician progress note, written after the resident's readmission to the facility on [DATE], documented that on [DATE], Resident #1 had a choking episode in the dining hall. The progress note read in pertinent part: Nursing staff state efforts were made to dislodge a large piece of meat from her throat. At the same time, other staff were alerting emergency services to take her to the hospital. Staff indicated she was becoming cyanotic as she left the facility and was transported to the hospital. She was brought to the hospital emergency roiagnom on a non-rebreather mask and was gasping for air per the emergency room report. A large piece of meat was dislodged from the trachea in the emergency room . She was admitted for acute hypoxic respiratory failure secondary to choking. After being intubated in the emergency room for airway protection, she was admitted to the ICU. A ventilator bundle with lung protective ventilation was implemented and her respiratory status improved. The patient did pass spontaneous breathing trials and was extubated (the tube for breathing was removed). However, her mental status did not recover and she remained obtunded (slowed response to stimulation). The physician diagnosed her with severe acute hypoxic encephalopathy in the setting of multiple comorbidities. Prognosis for recovery to baseline function was deemed very poor. Just prior to her hospital discharge, the resident's family decided to place her on comfort care. The [DATE] nursing progress note documented the resident was unresponsive and unable to swallow. All of the resident's medications were discontinued except for medications used for comfort. The [DATE] nursing progress note documented one of the certified nurse aides (CNA) went to check on the resident and found her cold. The CNA said she could not see the resident breathing. The nurse checked on the resident and found her with no respirations, heartbeat and eyes were fixed. The physician and family were notified of the resident's death. V. Staff interviews The NHA, director of nursing (DON), and the dietary manager (DM) were interviewed on [DATE] at 1:44 p.m. The DON said on [DATE], Resident #1 had a choking episode during the dinner meal. She said the nurse who was in the dining room passing medications attended to the resident. She said the nurse called out for assistance, grabbed the crash cart and started the Heimlich maneuver. She said the nurse attempted oral suctioning of the resident for several minutes before dislodging a bit of food from the resident's airway. The DON said while the resident was being assisted, another nurse had called for emergency services. She said Resident #1 was blue on her lips, face and arms. The DON said after the suctioning dislodged a little bit of food, the resident was able to breathe. She said the nurse placed the resident on high-flow oxygen and then EMS arrived and transported the resident to the hospital. The DON said the assistant director of nursing (ADON) was working the day of the incident. She said the ADON immediately began an investigation and it was determined that the resident must have been served the wrong diet texture or the wrong plate of food. She said all dietary staff were interviewed and no one admitted to serving the resident. The DM said a dietary staff member was provided a formal written education. She said the investigation showed that the old system of tray cards was ineffective. The DM said the old system had a paper that showed the residents'physician-ordered diet and then another paper that had their order for each meal. She said the two different papers were confusing to the staff and easily got mixed up on the tray serving line. The DM said the dietary aides delivered the food to the residents in the dining room. She said the cook was responsible for checking the meal ticket, ensuring the correct diet texture and the residents' order, plating the food and placing it on the tray line. The DM said the dietary aide was responsible for checking the meal against the meal ticket to ensure it was correct and then serving the meal to the resident. The DM said she created a new tray card system that streamlined the resident's diet texture, likes and dislikes, allergies and their orders for each meal. The DM said education was provided to all dietary and nursing staff immediately following the incident. She said education was provided to all staff as well as during the orientation of all new staff working at the facility. She said the facility added the situation and process to the skills fair completed in [DATE] and it would be included during every skill fair going forward. The DM said she thought one of the dietary staff members grabbed the wrong plate and served it to Resident #1. She said the new card system had been successful so far and thought it would prevent incidents such as that which occurred with Resident #1 from happening again. The DM said audits of the meal service were being conducted every day during a meal to ensure residents were being provided with the appropriate diet textures. She said the audits were reviewed daily, weekly in the IDT meeting and then during QAPI monthly. She said the audits would continue indefinitely. The DM said the new process was added to the skills fair and competency checklist. She said she observed staff at meal times to ensure the process was working appropriately. The NHA said a blue binder was placed in the kitchen with every resident's diet texture, assistance level and any assistive devices. The DON said all dietary staff and nursing staff had been educated on the binder and had access to the binder. The DON said the binder was checked every morning to ensure any diet changes were implemented.

Based on observations, record review and interviews, the facility failed to ensure one (#121) of three out of 31 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to agency staff were aware of Resident #121 ' s history and risk of elopement. Findings include: I. Facility policy and procedure The Wandering and Elopement policy and procedure, reviewed May 2019, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It revealed, in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety. II. Resident #121 status Resident #121, age 53, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, dementia without behavioral disturbance, cognitive communication deficit and paraplegia. The 11/6/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. He required total assistance with all activities of daily living. It indicated the resident did not wander during the assessment period. A. Observations On 11/13/23 at 2:48 p.m. Resident #121 wheeled himself down the hallway toward the common area. In the common area, Resident #121 went toward the door that led outside and pushed it. An alarm sounded and certified nurse aide (CNA) #2 stood in the hallway, approximately 20 feet away from the resident. She said to Resident #121 that she did not know the code to make the alarm stop sounding. Resident #121 asked if there was another door that he could leave through. CNA #2 said she was not sure and asked him if he was allowed to leave. He said, I don ' t see why not. Another staff member was observed walking down the hallway. She used a code to disable the alarm. She told Resident #121 that he could go and sit outside on the patio outside of the dining room. CNA #2 said she would take him there and wheeled him down the hallway. B. Record review The November 2023 CPOs documented the following physician orders: -Code alert to notify staff of unsupervised exit attempts - ordered 10/26/23; and -Check placement of the code alert every shift - ordered 10/26/23. A review of the baseline care plan documented that the resident had a history of exit seeking behavior. The 10/26/23 elopement evaluation documented the resident had a history of exit seeking at home and a previous facility. It indicated the resident verbally expressed the desire to go home, packed his belongings to go home or stayed near an exit door. III. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 11/13/23 at 2:50 p.m. She said she was an agency staff member and it was her first day working at the facility. She said she was provided information on each resident ' s level of care during a report from the previous shift CNA. She said she did not know if Resident #121 worse glasses, hearing aids or dentures. She said she was only provided information on each resident ' s physical level of care. She said she did not have access to each residents ' plan of care. She said she was not aware if the resident had cognitive impairment or was at risk for exit seeking. She said she was not told the resident had a code alert that sounded an alarm when he was near an exit. She said she would be aware of it from then on out. The DON was interviewed on 11/16/23 at 11:48 a.m. She said dentures, hearing aids and dentures were documented on the CNA tasks for each resident and the plan of care. She said each CNA had access to the tasks for each resident to be able to see if the resident was at risk for exit seeking. She confirmed Resident #121 was at risk for exit seeking. She said each nursing station had a binder of residents that were at risk along with the front desk at the facility. She said the facility had the code alert system that sounded whenever someone who was at risk got close to an exit door. She said the outside patio also was armed so residents could still go outside but could not exit through the gate. She said she was aware the facility had communication concerns with agency staff. She said the facility was currently working on a solution, but did not have a plan finalized and in place. She said the agency CNA should have been informed verbally in report that the resident was at risk for exit seeking. She said she provided information to the agency on the facility policies, which included the code alert system and where to find the binder of the residents who were at risk for exit seeking.

Based on observations, record review and interviews, the facility failed to honor resident choices for one (#37) of one out of 31 sample residents. Specifically, the facility failed to ensure Resident #37 received anti-nausea medication in a timely manner upon request. Findings include: I. Facility policy and procedure The Resident Self Determination and Participation policy and procedure, revised August 2022, was provided by the director of nursing (DON) on 11/16/22 at 2:00 p.m. It read, in pertinent part, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: daily routine, such as sleeping and waking, eating, exercise and bathing schedules; personal care needs, such as bathing methods, grooming styles and dress; and health care scheduling, such as times of day for therapies and certain treatments. II. Resident #37 status Resident #37, age 78, was admitted on [DATE]. According to the November 2023 computerized physician's orders (CPO) diagnoses included alcoholic cirrhosis of the liver with ascites, depression, chronic obstructive pulmonary disease and panic disorder. According to the 5/10/23 minimum data set (MDS) assessment, the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident required extensive assistance with bed mobility, dressing and personal hygiene and was totally dependent on staff with toileting. It indicated that the resident was bed bound. It indicated that it was important to the resident to choose what clothes to wear, choose the type of bath received, have snacks available between meals and have family involved in discussions about care. B. Observations On 11/15/23 at 10:50 a.m. Resident #37 activated her call light. Certified nurse aide (CNA) #1 responded to the call light. Resident #37 requested Zofran (anti-nausea) medication. CNA #1 informed registered nurse (RN) #1 that Resident #37 complained of feeling nauseous and requested Zofran. RN #1 said she would assist the resident in a few minutes. At 11:03 a.m. Resident #37 activated her call light again. CNA #1 responded and told the resident that she notified the nurse of her request and the nurse said it would be a few minutes before she could get the medication for her. At 12:08 p.m. RN #1 administered Zofran to Resident #37, over an hour after Resident #27 had requested the medication C. Resident interview Resident #37 was interviewed on 11/15/22 at 12:18 p.m. Resident #37 said she did not like it when she had to wait such a long time for anti nausea medication. D. Record review The November 2023 CPOs documented the physician had ordered Ondansetron (Zofran) HCI 4 milligrams (mg) to be given every six hours as needed for nausea. The November 2023 medication administration record (MAR) documented that the resident had not received Zofran within the previous six hours and was within the parameters of being able to receive the medication at the time it was requested. III. Staff interviews CNA #1 was interviewed on 11/15/23 at 11:58 a.m. She said when a resident requested medication, she would inform the nurse first, the second time the resident requested she would let the resident know what the nurse said, and the third time the call light was activated she would tell the nurse again. CNA #1 said the nurse said it would be a little bit to administer the medication to Resident #37. She said she relayed the message to the resident. RN #2 was interviewed on 11/15/23 at 12:00 p.m. RN #2 said he should have administered the anti nausea medication within 15 minutes of being notified of the request. He said an hour was too long for Resident #37 to have to wait for requested medication. The DON was interviewed on 11/16/23 at 10:12 a.m. She said when a resident requested medication, the resident should be medicated within 15 minutes of the request. She said it was not appropriate for a resident to wait an hour for a requested medication.

Based on interviews and record review, the facility failed to ensure one (#6) out of 31 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to document and provide a resolution to Resident #6's missing item. Findings include: I. Facility policy and procedure The Resident Grievance Policy, revised April 2018, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It revealed, in pertinent part, It is the policy of the facility to help residents, their representatives (sponsors), and other interested family members, or resident advocates file grievances or complaints when such requests are made. Any resident, his/her representative, family member, or advocate may file a grievance or complaint concerning his/her treatment, medical care, behavior of other residents, or staff members, and theft of property without fear of threat of reprisal in any form. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Social Services Director. Grievance and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. The Grievance Investigation Report must be filed with the administrator within two working days of the receipt of the grievance or complaint form. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such a report will be made orally by the administrator or his/her designee within three working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident, and a copy will be filed in the business office. II. Resident #6 A. Resident status Resident #6, age 89, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included vascular dementia, unspecified depression, insomnia, and chronic kidney disease. The 7/11/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She required extensive assistance for bed mobility, transfers, dressing, and personal hygiene, and was independent with eating. She had no behavioral symptoms. B. Resident interview Resident #6 was interviewed on 11/13/23 at 11:02 a.m. The resident said she often had items missing from her room. She said the most recent item was a beauty facial cream her sister purchased for her on her birthday. She said her sister purchased two of the same facial creams and one of them had been missing for over a month. Resident #6 said those facial creams were very important to her since they were a gift given to her on her birthday. Resident #6 said she reported the missing item to all staff members who had entered her room. She said she reported it several times to registered nurse (RN) #3. She said she was told by the facility staff that the social services director, who was the grievance official, was too busy. Resident #6 said the facility had not located her missing item or found a resolution for it. She said no one had come to talk to her about her complaint and whenever she asked RN #3 for an update, she would tell her that the SSD was busy. Resident #6 said the situation made her upset and she wanted her facial cream back. C. Record review The facility ' s grievance log from September 2023 through November 2023 was reviewed on 11/16/23 at 10:30 a.m. It did not reveal documentation that a grievance had been filed on behalf of Resident #6 for her missing facial cream. III. Staff interviews RN #3 was interviewed on 11/16/23 at 9:32 a.m. She said Resident #6 had reported a missing facial cream that the resident had received for her birthday over two weeks ago. She said she felt that the resident had used the facial cream and it was not actually missing since her birthday was in March. RN #3 said she verbally reported it to the SSD. RN #3 said she assisted residents in filing grievances based on the circumstances of the complaint, but she did not feel that all complaints should be filed as a grievance. RN #3 said she did not complete a grievance form for Resident #6 ' s missing facial cream The assistant social services director (ASSD) was interviewed on 11/16/23 at 9:24 a.m. The ASSD said a grievance form should be completed for all missing items. She said the staff member who received the report should assist the resident in completing the grievance form and searching for the item. She said if the staff member was unable to find the item, then the facility would either replace the item or refund the cost of the item to the resident. The SSD was interviewed on 11/16/23 at 9:50 a.m. He said he did not receive a verbal or written notification that Resident #6 was missing facial cream. He said he was unaware of Resident #6 ' s complaint. He said all complaints and missing items reported to staff should be treated seriously, a grievance form completed and investigated. The SSD said he would provide education for all staff members regarding the grievance process. The DON was interviewed on 11/16/23 at 12:00 p.m. The DON said staff should report all concerns and missing items to the grievance official. She said the facility's goal was to resolve all grievances within 72 hours of the report. She said it was not up to the staff member to determine if a grievance form should be completed. She said she would provide education to all facility staff on the grievance process.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#121) of one resident reviewed for visual problems out of 31 sample residents. Specifically, the facility failed to ensure Resident #121 was assisted to wear his glasses. Findings include: I. Resident #121 status Resident #121, age 53, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, dementia without behavioral disturbance, cognitive communication deficit and paraplegia. The 11/6/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. He required total assistance with all activities of daily living. It indicated the resident had impaired vision with the use of corrective lenses. A. Observations On 11/13/23 at 2:48 p.m. Resident #121 was observed sitting in his wheelchair. He did not have his glasses on. Resident #121 said he usually wore glasses but was not sure where they were. On 11/14/23 at 12:15 a.m. Resident #121 was observed sitting in the dining room. He did not have his glasses on. On 11/15/23 at 10:00 a.m. Resident #121 was observed sitting in his wheelchair at the nursing station. He did not have his glasses on. B. Record review The cognitive deficit care plan, initiated 11/9/23, documented that the resident had a cognitive deficit and a cognitive communication deficit due to a diagnosis of dementia. The interventions included allowing the resident to participate in daily decision making to the best of his ability, encouraging the resident to share memories, explaining procedures to the resident and allowing him time to process and respond. The 10/26/23 baseline care plan documented that Resident #121 wore glasses. II. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 11/13/23 at 2:50 p.m. She said she was an agency staff member and it was her first day working at the facility. She said she was provided information on each resident's level of care during a verbal report from the previous shift CNA. She said she did not know if Resident #121 worse glasses, hearing aids or dentures. She said she was only provided information on each resident's physical level of care. She said she did not have access to each residents' plan of care. CNA #3 was interviewed on 11/15/23 at 2:00 p.m. She said she worked on Saturday, 11/11/23, and Resident #121 was wearing his glasses. She said she was aware that he was not wearing them today. She said was not able to find his glasses. She said she had not reported his missing glasses to social services yet. She said she would do that immediately. The director of nursing (DON) was interviewed on 11/16/23 at 11:48 a.m. She said dentures, hearing aids and dentures were documented on the CNA tasks for each resident and the plan of care. She said each CNA had access to the tasks for each resident to be able to see if the resident wore glasses. She confirmed Resident #121 was admitted to the facility wearing glasses. She said the facility had been able to locate his glasses in the laundry. She said they were broken and were working on getting an appointment for him to see an optometrist. She said she was aware the facility had communication concerns with agency staff. She said the facility was currently working on a solution, but did not have a plan finalized and in place. She said the agency CNA should have had access to the resident's tasks which should have indicated he wore glasses.

Based on observations and interviews the facility failed to ensure two out of two medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to: -Ensure the treatment cart and medication cart was locked when left unattended; and -Ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised April 2007, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It read in the pertinent part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. II. Observations On 11/13/23 at 9:00 a.m. the treatment cart on the west hall was unlocked and unattended. Several residents were returning from breakfast and walked past the cart to go to their rooms. One resident with a traumatic brain injury (TBI) also walked past the cart. The treatment cart contained prescription creams, ointments, over-the-counter creams and supplies for wound care. At 12:37 p.m. the treatment cart on the east hall was unlocked and unattended. Several residents were near the cart including two residents who had a diagnosis of dementia and had a historying of wandering. The treatment cart contained prescription creams, ointments, over-the-counter creams and supplies for wound care. Licensed practical nurse (LPN) #3 was notified and she locked the cart. On 11/15/23 at 10:36 a.m. the medication refrigerator on the east hall was observed. There was a controlled medication lock box in the refrigerator that was not permanently affixed to the refrigerator and it contained three bottles of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat agitation that tranquilizes the patient) and two vials of Ativan for emergency use. At 10:39 a.m. the medication refrigerator on the west hall was observed. There was a controlled medication lock box in the refrigerator that was not permanently affixed to the refrigerator. It did not have any controlled medications in it at the time of observation but LPN #1 said it normally contained Ativan. At 11:49 a.m. the medication cart on the east hall was unlocked and unattended. The nurse was not in direct line of sight. Registered nurse (RN) #1 exited a resident's room and returned to the cart. She immediately noticed she had left it unlocked. III. Staff interviews LPN #3 was interviewed on 11/13/23 at 12:38 p.m. She said the treatment cart should always be locked. She said residents could get into treatments that were not safe. RN #1 was interviewed on 11/15/23 at 10:37 a.m. She said the controlled medication box in the refrigerator should be permanently affixed to the refrigerator. She said anyone with access to the refrigerator could just take the box of controlled medications out of the refrigerator. The DON was interviewed on 11/16/23 at 10:14 a.m. The DON said medication carts and the medication rooms should be locked at all times when not attended by a licensed nurse. She said the controlled medication boxes should be permanently affixed to the refrigerators. She said if they are not permanently affixed they could be carried out of the facility by anyone with access to the refrigerator.

Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#20 and #64) of two residents reviewed for supplemental oxygen use out of 31 sample residents. Specifically, the facility failed to ensure Resident #20 and Resident #64 received oxygen at the liter flow prescribed by the physician. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, revised October 2021, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It read, 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 and review the physician orders or the facility protocol for oxygen administration. II. Resident #20 status Resident #20, age 94, was admitted on [DATE]. According to the November 2023 computerized physician ' s orders (CPO), diagnoses included unspecified dementia, chronic diastolic congestive heart failure, chronic respiratory failure and chronic obstructive pulmonary disease (COPD). According to the 8/29/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistance from one person for bed mobility, grooming, and toileting and one person set up assistance with eating. It indicated that the resident received oxygen therapy. A. Observations On 11/13/23 at 2:01 p.m. Resident #20 was observed sitting down in her wheelchair with an oxygen nasal cannula in her nostril. The resident's oxygen concentrator was set to 1.5 liters per minute (LPM). On 11/14/23 at 11:13 a.m., Resident #20 was sitting in the dining room area with her cannula on. The portable oxygen concentrator was set at 2 LPM. On 11/16/23 at 11:05 a.m., Resident #20 was seen in her room wearing a nasal cannula connected to a portable oxygen tank set at 2 LPM. B. Record review The respiratory care plan, initiated on 9/7/23, identified that the resident had an alteration in respiratory status with a physician ' s order for the use of supplementary oxygen at 4 liters via nasal cannula. The interventions included providing oxygen as ordered by the physician. The November 2023 CPOs documented for the resident to receive oxygen therapy at 4 LPM continuously via nasal cannula - ordered 8/17/23. III. Resident #64 status Resident #64, age 81, was admitted on [DATE]. According to the November 2023 CPOs, diagnoses included unspecified schizophrenia, unspecified pulmonary fibrosis, anxiety disorder, depression, and dependence on supplemental oxygen. According to the 8/14/23 MDS assessment, Resident #64 was cognitively intact with a BIMS score of 13 out of 15. She required supervision for bed mobility, transfers, grooming, and toileting. It indicated that the resident received oxygen therapy. A. Observations On 11/13/23 at 3:21 p.m., Resident #64 was observed walking down the hallway without oxygen. There was no portable oxygen tank observed in the resident ' s room. On 11/14/23 at 11:24 a.m. Resident #64 was observed sitting in the dining room waiting for her lunch to be served. The resident was not wearing oxygen. The facility staff observed in the dining room did not get oxygen for the resident. On 11/15/23 at 3:15 p.m., Resident #64 was observed walking down the hallway to the dining room without oxygen. The resident went to the dining room and sat by the dining table waiting for dinner. The facility staff did not get oxygen for the resident. B. Record review The respiratory care plan, initiated on 8/17/23, identified that the resident had the potential alteration in respiratory status. The interventions included checking the portable oxygen tank often to make sure it has oxygen and working properly and refilling it as needed. The November 2023 CPOs documented a physician ' s order for the resident to receive oxygen therapy at 2 LPM, continuously via nasal cannula for pulmonary fibrosis - ordered on 8/9/23. IV. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 11/16/23 at 11:09 a.m. CNA #4 said Resident #20 used oxygen continuously. She said she did not know how many liters the physician had ordered for the resident. CNA #4 confirmed the portable oxygen tank indicated the resident was receiving 2 LPM. Upon verifying from the unit nurse, CNA #4 confirmed that Resident #20 should have been receiving 4 LPM. CNA #4 said Resident #64 used oxygen continuously. She confirmed Resident #64 did not have a portable oxygen tank in her room. Licensed practical nurse (LPN) #4 was interviewed on 11/16/23 at 11:20 a.m. LPN #4 said Resident #20 received oxygen therapy due to her diagnosis of COPD. She said Resident #20 required continuous oxygen at 4 LPM. She said the resident could suffer medical emergencies such as dizziness, and lightheadedness due to low oxygenation. LPN #4 said Resident #64 refused to wear oxygen when she left her room, however confirmed the resident ' s medical record did not reflect those refusals. She confirmed that there was no portable oxygen tank in the resident ' s room. She said Resident #64 required continuous oxygen at 2 LPM continuously for pulmonary fibrosis. The director of nursing (DON) was interviewed on 11/16/23 at 12:00 p.m. The DON said oxygen therapy required a physician's order in order to be administered. She said Resident #20's oxygen should have been administered as ordered by the physician. She said Resident #20 could have experienced respiratory distress from not receiving the appropriate amount of oxygen therapy. The DON said Resident #64 should have her oxygen on at all times. She said the nursing staff should have ensured oxygen orders were followed according to physician orders She said the nursing staff should document all refusals, notify the provider of the refusal, and offer education to the resident.

Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#1) of three residents reviewed out of three sample residents. Resident #1 fell on [DATE] in the bathroom. He had increased pain, at the facility, for two days until 2/3/23, when an x-ray confirmed he had a fracture of the left hip. Two resident representatives were interviewed. Both representatives said Resident #1 had called them all night long on 2/1/23 and 2/2/23 complaining of being in pain and being unable to move his left leg. The representatives said they had requested the resident be sent to the emergency room (ER) on 2/2/23 for an x-ray of the left hip. However, the facility had an x-ray at the facility, without results until 2/3/23. Resident #1 was interviewed on 7/6/23. He said he had severe stabbing pain and had been unable to move his leg for two days after falling in the bathroom on 2/1/23. He said he was then sent to the ER, from the facility, after a couple days of being in pain and had surgery related to injuries from the fall. There was no additional documentation of facility staff monitoring the resident's condition for pain or evaluation of the resident's change of condition after the initial fall evaluation on 2/1/23, between 2/1/23 to 2/3/23. Resident #1 was given only one tablet of 325mg (milligrams) of acetaminophen (Tylenol) for pain three times as needed from 2/1/23 to 2/3/23 for an undocumented (unknown) pain level. On 2/2/23 and 2/3/23 the Tylenol was documented as not effective. There was no documentation of what was done for the resident when the one tablet of Tylenol was not effective. The resident had an order for Norco pain medication as needed on admission 8/23/22; however, the facility staff said it had never been ordered from the facility pharmacy and therefore was not available to administer for the resident's unresolved pain, during the 2/1/23 to 2/3/23 time period. The 2/3/23 emergency room assessment notes documented the resident was in pain with any motion and his leg was externally rotated and shortened. The resident had surgery to repair the fracture and returned to the facility on [DATE]. Resident #1 continued to complain of daily pain and difficulty placing weight on the left leg during the survey period. Cross-reference F689 accident hazards for the facility's failure to implement effective fall interventions that caused a fall with major injury and subsequent falls after he returned to the facility. Findings include: I. Facility policy and procedure The Pain Clinical Protocol, revised March 2018, was received from medical records (MR) on 7/5/23 at 5:50 p.m. The policy documented in pertinent part, The nursing staff will assess each individual for pain whenever there is a significant change in condition. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. II. Resident #1 A. Resident status Resident #1, age 88, admitted on [DATE], and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnosis included, history of left femur fracture and left hip pain, neuropathy (nerve pain), chronic low back pain and repeat falls. The 5/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive one person assistance with bed mobility, dressing and personal hygiene; and required extensive two person assistance with transfers, and toileting. The assessment documented the resident reported his worst pain level on a 0 to 10 scale (with 10 being the worst pain on the scale); was 4 out of 10. The assessment further documented that the resident said he had almost constant pain that limited his daily activity. B. Resident and resident representative interviews Two of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night complaining of being in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on [DATE]. The representative said she had asked the nurses on the phone about pain medication and they said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol for his pain. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times requesting alternative treatment for the resident, as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available, and was told the results were not back yet. The representative said she received a call, a short time later that morning (2/3/23) from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview with the first resident representative. The second resident representative said Resident #1 had also called her all night on 2/1/23 and 2/2/23 complaining of stabbing pain to his left leg. She said he told her his leg was out to the side and he could not move the leg. The second representative was getting ready in the morning to head to the facility on [DATE], while the first resident representative kept calling the facility. The second representative said that while on the way to the facility she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 layed in bed for two days in pain, even after being asked by the first representative that the resident be sent to the hospital. The second representative said the facility only gave the resident Tylenol which was ineffective for pain from a fractured hip. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record review The pain care plan, initiated 8/26/22, documented in pertinent part, potential for alteration in comfort related to chronic back low back pain, osteoarthritis, peripheral neuropathy, and history hip surgery which was added on 5/17/23. Interventions included: -Monitoring for side effects of Tylenol, dated 8/26/23. Monitoring for side effects of narcotic pain medications, dated 8/26/22. -Give medications as ordered, dated 8/26/22, and monitor for side effects, and effectiveness. -Notify the physician if there were side effects or if medication were consistently ineffective. -Report to nurse vocal and non verbal indication of pain. Pain assessment quarterly and as indicated. It documented the resident's acceptable level of pain was extreme. Use dementia face scale if needed. Try alternate methods of pain relief such as repositioning rest, stretching, ambulating, warmth, coolness, and distraction. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom, and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted (cross-reference F689). On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after laying around for two to three days post fall. The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed. -There were no pain assessments documented for the resident. The MAR documented the resident was on routine acetaminophen (Tylenol) 325 mg one tablet three times per day. The MAR documented the resident had an order for as needed (PRN) Tylenol 325 mg every four hours as needed for pain, dated 10/25/22. The MAR documented the resident had an order for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10), ordered 8/23/22. On 2/1/23 the resident did not receive any PRN Tylenol. On 2/2/23 at 12:33 a.m. the resident received as needed Tylenol for pain.It documented the Tylenol was effective. -There was no pain level documented. On 2/2/23 at 12:54 p.m. the resident received PRN Tylenol. The pain medication was documented as not effective. -No pain levels were documented and here was no follow up on the resident's pain. On 2/3/23 at 7:34 a.m., the resident received Tylenol and the pain medication was documented as not effective. -The was no pain level documented. The nursing notes documented at 7:55 a.m. the physician would be called about getting the resident's Norco (hydrocodone and acetaminophen 5-325 mg, opioid narcotic analgesic) refilled. -However, the resident was admitted to the facility with the order for Norco. The interviews (see below) revealed the facility had never sent the Norco order to the pharmacy and therefore it had never been filled or available for the resident. An Interview for Pain Assessment, dated 2/13/23, after the resident's hip fracture, was reviewed. The assessment documented the resident had a history of neuropathy, chronic low back pain and pain in the left hip due to a history of fracture. The pain assessment documented Resident #1 was on schedule pain medication and had received PRN pain medication. It documented he had received non-medication interventions. The interview documented the pain was occasional and made sleeping difficult. On a scale of 1 to 10, Resident #1 rated his pain at a 10 for the worst it had been. -There was no information on what exacerbated the pain or made it better. There was no information on what an acceptable level of pain was or pain goal. There was no description of the pain, characteristics of the pain or the location of the pain. There were no listed non-medication interventions listed on the pain assessment. -The May 2023 Interview for Pain Assessment was requested from the DON and not received by the end of the survey on 7/6/23. The MDS assessment, dated 5/23/23, documented the resident had constant pain which affected his activities of daily living. Weekly nursing charting in the progress notes was reviewed for the last 90 days. There was a weekly summary twice in April 2023, once in May 2023 and four times in June 2023. -The weekly charting, when it was done weekly, did not contain documentation regarding pain. It did not document whether the resident had pain or not. The June and July 2023 medication administration records revealed the following: -Resident #1 received Tylenol 325mg (milligrams), by mouth, three times daily routinely, order date 2/6/23 for June and July 2023. -Resident #1 received gabapentin (antiseizure medication used for nerve pain) 600 mg three times per day routinely for neuropathy, order date 2/6/23, for June and July 2023. Additionally, the resident had as needed (PRN) orders started on 5/1/23 for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10). Tylenol (acetaminophen) capsule 325 mg, one tablet by mouth every four hours as needed for pain. The June 2023 MAR documented Resident #1 received Norco 6/11/23, 6/15/23 two times, 6/23/23, 6/24/23 and 6/25/23 for pain of 8 out of 10. Pain included the lower extremities, lower back, and reddened buttocks. On 6/16/23, there was no Norco signed out as administered. However, on 6/16/23 at 11:46 p.m, the nurse documented that the Norco was documented as somewhat effective. However, there was no time documented for when it was given or what pain level. Resident #1 received PRN Tylenol for an undocumented pain level on 6/10/23 and 6/30/23. The MAR from 7/1/23 to 7/5/23, documented Resident #1 received Tylenol for pain of 4 out of 10 on 7/3/23. -However, the orders were to give Norco for pain levels of 4 to 10. On 6/12/23 at 12:14 p.m., the nursing progress notes documented the resident had pain to the buttocks on 6/12/23 at 12:14 p.m. The buttocks were documented as red, shiney and sore. -There were no pain levels and no PRN Tylenol or Norco given per the nursing notes and MAR. On 6/16/23 at 1:58 p.m., the nursing progress notes documented the resident complained of pain to his buttocks and coccyx. The area was documented as red and the resident requested to go to the hospital due to the pain. -There was no pain level documented and no PRN Tylenol or Norco documented as given. The nursing notes documented again at 6:22 p.m. that the resident complained of pain to the reddened buttocks. -It is unknown if Norco was given, or at what time and for what level of pain on 6/16/23 (see above). There was no pain level. III. Staff interviews Registered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain level after the fall. He said there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23 due to the resident being in pain. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been documentation on the resident's condition. RN #1 said he did not know why the resident was given one tablet of Tylenol for pain after his fall 2/1/23, instead of the Norco ordered on admission. The controlled drug count sheet was requested for the Norco for January and February 2023. RN #1 said he did not have one. He said to check with the director of nursing (DON). RN #2 was interviewed on 7/6/25 at 9:20 a.m. He said he knew Resident #1. RN #2 said Resident #1 was on Trazadone (antidepressant) for pain. -However, the resident was not on Trazodone for pain, but for depression. RN #2 said the Resident #1 had an order for Norco which he said the resident received for pain. RN #2 said the licensed nurses did not currently document a routine pain level. He said a pain level was only assessed and documented if the resident or someone else came and reported pain. He said he heard the facility was going to start doing pain assessments routinely, but he did not know when that was to start, and could not remember who told him this. The DON and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell , there should be an assessment completed by the RN, and an event was initiated in the electronic medical record (EMR). She said the nurses should document in the progress notes for the next 72 hours, and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. The DON said pain was assessed quarterly and as needed. She said pain was documented in the resident's weekly summary in the progress notes. -However, the weekly summaries reviewed for the last 90 days, when done weekly, did not contain information about pain. The ADON said pain should be assessed every shift and documented on the resident's MAR and when any pain medication was given. The DON said there was no count sheet for the Resident #1's Norco during the time prior to the resident's transfer to the hospital on 2/3/23. The DON said she had spoken to the pharmacy and the Norco had not been ordered. The ADON said the Norco was ordered and administered as needed after the resident returned form the hospital on 2/6/23. The ADON said she had started a performance improvement plan (PIP) for pain management yesterday (7/5/23) and would provide a copy. IV. Facility follow-up A document titled Performance Improvement Plan, Project Name: Pain Assessment and Management, initiated 7/5/23, was received from medical records on 7/6/23 at 5:58 p.m The plan documented the goal was to have a complete record of the resident's pain levels with a start date of 7/5/23. Action items initiated were, add pain question to daily Grand Rounds 7/7/23, no responsible person was listed, electronic health record will prompt nurses for basic pain assessment every shift as well as during administration of medications and treatments start 8/1/23, no responsible person was listed. Educate nurses on regular pain documentation every shift especially 72 hours after a fall or when new orders obtained with diagnosis of pain example, new order for tylenol or x-ray, no date or responsible person was listed, all medications for pain will have associated pain scales initiated on approved by medical director no date or responsible person was listed, policy update to reflect changes 7/6/23, final approval with medical director and interdisciplinary team 7/24/23, no responsible person listed. Indicators and Measures documented there would be electronic medical record documentation audits, it was unclear what would be audited, there was no start date, frequency, or responsible person identified. The PIP documented incidents would be audited for complete documentation by ADON weekly, and quarterly comprehensive pain assessments by the MDS coordinator.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents remained as free from accident hazards as possible. The facility failed to ensure interventions were implemented to prevent major injury from falls for Resident #1. Interviews during the survey revealed the facility still was not implementing interventions for toileting per the care plan. Furthermore, interviews and documentation revealed the staff did not provide transfer assistance to the resident with two person assistance as ordered. Due to the facility's failures to implement effective interventions, Resident #1 sustained a fracture of the left hip from a fall on 2/1/23. Additionally, the facility delayed assessing and monitoring Resident #1's injuries and related pain after the fall on 2/1/23, when the resident complained of having severe pain in his leg for two days after the fall (cross-reference F697). The facility failed to implement effective interventions when Resident #1 returned from the hospital on 2/6/23 which caused him to sustain additional falls. Finding include: I. Facility policy and procedure The Falls and Fall Risk Management policy, revised March 2018, was received from the director of nursing (DON) on 7/6/23 at 12:15 p.m. The policy documented in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls, incontinence. The nurse shall assess and document/report the following when a fall has occurred: Vital signs, the condition in which the resident was found-resident found lying on the floor between bed and chair, any injury, especially fracture or head injury, subsequent first aid administered, musculoskeletal function, observing for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred, pertinent medication, especially those associated with dizziness or lethargy. Nursing staff will observe for delayed complications of a witnessed fall for 72 hours. Vital signs will be taken at the time of the fall and then every shift for the first 24 hours, then everyday on day shift for two subsequent days, Nursing staff will follow the fall, neurological record frequency for obtaining vital signs and neurological checks if a fall is unwitnessed and or head trauma is suspected. The staff, with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out. II. Resident #1 A. Resident status Resident #1, age 88, admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnosis included history of left femur fracture and left hip pain, neuropathy (weakness, numbness from nerve damage) and repeat falls. The 5/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive two person assistance with transfers and toileting; and extensive one person assistance with bed mobility, dressing and personal hygiene, The resident had almost constant pain which limited daily activity. The assessment documented he had no falls since his prior assessment. -However, the resident fell on [DATE], 2/1/23 and 2/10/23; then again on 4/1/23 just before the above MDS assessment was completed (see below). B. Resident and resident representative interviews Two of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on [DATE]. The representative said she had also asked the nurse about pain medication and the nurse said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available and was told the results were not back. The first representative said she received a call, a short time later that morning from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview. The second resident representative said Resident #1 had called her all night on 2/1/23 and 2/2/23 with stabbing pain to his left leg. She said the resident told her his leg was displaced out to the side and he could not move the leg. The second representative was getting ready in the morning to head to the facility, while the first resident representative kept calling the facility to get the resident help. While on the way the representative said she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 laid in bed for two days in pain, even after the first representative requested that the facility send Resident #1 to the hospital. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record review The fall care plan, initiated 8/29/22, documented potential for falls and injury related to osteoarthritis, history of falls, cognitive impairment, balance issues, unsteady gait, activity intolerance, bilateral lower extremity weakness, history of hip fracture from fall. Interventions included: physical therapy (PT) evaluation and treatment for transfer safety 8/29/22, 2/2/23 and 6/5/23, Dycem (anti slip material) in recliner 5/15/23, walker for short distance, transfers and wheelchair for long distance 5/15/23, two assist for transfers 2/14/23, urinal to be given at bedtime for night usage 2/13/23, visual aide to close footrest on recliner before getting up 11/22/22, resident forgets to lock brakes on wheelchair, anti roll backs in place 11/21/22, reacher, grabber encourage resident to use it to reach out of reach items 11/14/22, non skid strips in bathroom, gripper socks 10/3/22, toilet riser 9/26/22, education provided on proper footwear and ensuring shoes are on correctly, and how to use grabber reacher 9/21/22, bed bars to aide in bed mobility 8/31/22, orange nameplate alert placed to increase staff awareness of increase fall frequency 8/30/22, grab bars in bathroom [ROOM NUMBER]/29/22, call light in reach 8/29/22, keep personal items in reach maintain clean clutter free environment 8/29/22, observe resident and room frequently for any safety needs 8/29/22. The urinary incontinence care plan, initiated 8/29/23 documented the resident needed assistance with toileting, offer and aide in bathroom or use of urinal before and after meals, approximately every two hours while awake and as indicated. Fall history On 1/18/23 at 6:10 a.m., the nursing progress notes documented the resident was observed on the floor in the bathroom with a gash to his head and left arm. He was seen to the ER. The progress note documented the day shift would notify the physician. The resident returned to the facility in approximately two hours, with no new orders. -There were no progress notes indicating the physician was notified. The hospital transfer form documented the resident was alert and oriented and was independent with transfers, toileting and dressing. -However, the urinary care plan, dated 8/31/22, documented Resident #1 needed to be offered and assisted to the bathroom before and after meals, and every two hours while awake. The care plan documented the resident had an overactive bladder and would attempt to toilet himself. On 1/19/23 at 11:34 a.m. the nursing progress notes documented the resident sustained a skin tear to the left forehead one centimeter (cm) by 0.9 cm and a skin tear to the left arm three cm by 2.8 cm. -There were no new interventions documented in the progress notes or the care plan (see above). On 1/23/23 at 11:17 a.m. the nursing progress notes documented the resident was on a bowel and bladder program and should be encouraged, offered and assisted to the bathroom every two hours from 2:00 p.m. to 10:00 p.m. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted. The family and physician were notified. -However, the resident did develop pain by midnight and was administered Tylenol (see below). On 2/2/23 at 7:55 a.m., a restorative progress note documented restorative was held due to recent fall and the resident was in bed. The certified nursing aide (CNA) documentation for 2/1/23 to 2/3/23 was reviewed. -There was no documentation after the fall on 2/1/23 until 2/2/23. On 2/2/23 under transfers, the CNA documented that it did not occur. -There was no documentation for 2/3/23. On 2/2/21 at 1:31 p.m. the nursing notes documented PT evaluation and treatment due to fall. On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. There was no further assessment of his left leg or hip. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The x-ray report documented the x-ray was done on 2/2/23 at 3:26 p.m. -There were no records in the facility progress notes regarding an x-ray having been done. On 2/3/23 at 12:53 a.m. (after the resident is sent to the hospital) a late entry was added to the progress notes for 2/2/23. The note documented the resident had an unwitnessed fall in his restroom. The resident was in the restroom and was attempting to pull up his pants, the resident lost his balance and fell resulting in a skin tear to his left wrist and an abrasion to his low back. The resident has had two falls in the last 90 days and eight total falls since his admission. Current interventions that were in place at the time of the fall and that remain to be deemed appropriate include: visual aide in room to remind resident to put the feet of his recliner down, anti-roll backs added to w/c (wheelchair), time pattern of falls reviewed with no time pattern noted, non-skid strips placed in bathroom, gripper socks were offered and provided, orange name plate (used to identify resident as high fall risk) and bed bars to aide in independent bed mobility. New intervention, PT to eval. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after laying around for two to three days post fall. The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23. -However, the investigation did not identify that the last two falls occurred in the bathroom and there were no new interventions on 1/18/23. In addition, no new interventions related to toileting the resident for the fall on 2/1/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed there were no pain assessments for Resident #1. Resident #1 received Tylenol 325 mg one tablet as needed, on 2/2/23 at 12:33 a.m., 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. for undocumented pain levels. The Tylenol was documented as not effective 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. There was no follow up documented for the residents pain (cross-reference F697, pain management) The February 2023 TAR had an order dated 2/1/23, Monitor status for 72 hours for bruising, change in mental status or condition, pain or other injuries. However, the resident was in pain, with an externally rotated and shortened left leg as documented in the ER report. The facility nurses gave Resident #1 Tylenol and documented it was not effective. Despite initially the TAR, the licensed nurses did not follow up timely on the resident's change of condition, pain, or injury to the left hip. The July 2023 CPO documented to transfer with assistance of two persons, dated 2/14/23. The weekly summaries in the nursing progress notes were reviewed for May 2023 through 7/5/23. The progress notes revealed the following: On 5/3/23 at 1:26 a.m. the weekly summary documented the resident was ambulatory (ability to get around) with his wheelchair. -There was no documentation regarding the level of transfer assistance. There were no further weekly summaries for May 2023. On 5/23/23 at 10:47 a.m., the interdisciplinary (IDT) note documented Resident #1 required two person assistance with transfers. On 6/7/23 at 12:59 a.m., the weekly summary documented the resident requiring one person assistance with transfers. On 6/14/23 there were two weekly summaries. The one at 12:59 a.m., documented the resident was a one person assist with transfers. The weekly summary at 11:19 a.m. documented the resident was independent with a cane and wheelchair. On 6/21/23 at 12:36 a.m., the weekly summary documented the resident required two person assistance with transfers. On 6/28/23 at 1:19 a.m., the weekly summary documented the resident required two person assistance with transfers. On 7/5/23 at 12:55 a.m., the weekly summary documented the resident required two person assistance with transfers. III. Staff interviews Registered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain after the fall; but there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been follow up documentation on the resident's condition. He said the resident was independent with toileting and ambulation in his room at the time. RN #1 said he was not supposed to be independent, but he was. RN #1 said Resident #1 now required the assistance of one person when using the bathroom. -However, the resident's medical record documented that prior to the fall Resident #1 was a two person assist with transfers (see above). Certified nurse aide (CNA) #1 was interviewed on 7/6/23 at 9:10 a.m. CNA #1 had been working at the facility for five months and had started at the end of February 2023. CNA #1 said she was not working at the facility when the resident fell and broke his hip. CNA #1 said she was familiar with Resident #1 and was usually assigned to the hall he lived on. CNA #1 said Resident #1 would call if he needed to use the toilet. She said he did not need to be prompted or cued. She said he also had a urinal that he used. While in the resident's room she looked around for the resident's urinal but could not find it near the resident; but found the urinal in the resident's bathroom. CNA #1 said maybe the resident only used the urinal at night. CNA #1 said the resident required extensive one person assistance to transfer. She then said she thought maybe it was supposed to be two persons to assist with transfers, after looking on his wall (where his transfer status was posted) and seeing it indicated he needed two people. There were two apples on the resident's wall. The CNA said this meant he needed two person assistance. She then said he could transfer with one person's assistance. -However, the resident care plan and MDS assessment documented that the resident required two person assistance. RN #2 was interviewed on 7/6/25 at 9:20 a.m. RN #2 said he was familiar with Resident #1. RN #2 said he was not the resident's nurse when he fell and broke his hip. RN #2 said the resident required one person assistance ambulating to the bathroom. RN #2 said if a resident had a fall the process was for the RN to assess the resident, call the physician and notify the family. If the fall was unwitnessed or witnessed and the resident hit their head, the nurse would do neurological checks. He said he did not know if there was any follow up documentation that needed to be in the nursing progress notes. He said sometimes there was a place on the resident's TAR where the nurse signed off that they monitored the resident for 72 hours. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell , there should be an assessment completed by the RN, and an event was initiated in the resident's electronic medical record (EMR). She said the nurse should notify the physician and family. The DON said neurological checks should be done for an unwitnessed fall or a fall with head injury. She said the nurses should document in the progress notes for the next 72 hours and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. IV. Additional falls A. Record review On 2/10/23 at 2:15 a.m. the nursing progress notes documented Resident #1 had a fall from bed. The Resident's brief was wet, but not soaked. There was no injury. A urinal was provided on 2/13/23 for use at night. On 4/1/23 at 9:05 p.m. the nursing progress notes documented the resident was found on the floor near his bed. He was on his back fully dressed. He stated he had pushed the call light and was trying to get into the bed. His wheelchair was about two feet from where he was found on the floor. The nurse documented his vital signs and neurological checks were normal. On 4/1/23 at 2:51 a.m. the same nurse documented the resident had been sleeping most of the night. No further complaints of pain. Vital signs were stable at this time. Neuro (neurological) checks were within normal limits. -However, there were no vital signs or neurological checks in the record. There were no interventions implemented. There was no further documentation or update to the care plan. On 7/5/23 at 12:55 a.m. the nursing progress notes documented Resident #1 had a fall on 7/3/23, no injuries were noted. -There was no documentation before the 7/5/23 note that the resident had fallen on 7/3/23. There was no assessment, notifications or further information. B. Staff interview The DON and ADON were interviewed on 7/6/23 at 9:34 a.m. The DON said she did not know why there was no follow up from the 4/1/23 fall. She said she did not have any neurological checks or vital signs. She said there had been no new interventions added to the care plan for that fall. The DON said the resident's care plan told the staff how a resident should be transferred; gave bowel and bladder information; and information for toileting and incontinence care. Additionally, the information was put on the resident's room wall. The DON said if the resident had one apple posted on the wall in their room, the resident required a one person transfer assist, if two apples they were two person assist. The DON said she thought it had been an agency nurse who documented the 4/1/23 fall but he had not returned to the facility since that night. The DON reviewed the nursing notes dated 7/5/23 regarding a fall 7/3/23. The DON said she did not remember a fall in the past week for Resident #1. The DON thought the note might have been an error. The DON said he would investigate -No further information was provided by the end of the survey on 7/6/23. V. Facility follow-up A Performance improvement Project Guide, Reduce number of falls, dated 3/30/23, with review date set for 7/30/23, was received from medical records (MR) on 7//23 at 6:25 p.m. The form documented three items under plan, 1. Educating on orange nameplate and banner (used to identify resident as a high fall risk); Check In program for high reported to staff on floor at that time, the start date was listed as ongoing 2. Weekly rounds with Restorative RN, Director of Rehabilitation (DOR) and MDS, start date 4/6/23. 3. All staff inservice: Removing clutter/trip hazards Examples to avoid falls. Reporting decline or concerns. Day. Answering call lights, started 4/17/23, completed 4/17/23. -There was no further documentation on the plan indicating when it was reviewed for effectiveness, since it was written three months prior to the survey. A copy of a text sent 2/2/23 at 3:50 p.m. to the physician for Resident #1, was received from MR on 7/6/23 at 8:30 a.m. The text documented, Resident #1 was stating his left hip was hurting after a fall, may we get in house x-ray. The physician responded at 3:53 p.m., yes. -However, the x-ray results documented the x-ray was done at 3:26 p.m.

Based on record review and interviews, the facility failed to ensure professional staff was licensed, certified, or registered in accordance with applicable State laws. Specifically, the facility failed to ensure the acting nursing home administrator's license was valid. Findings include: I. Entrance interview On 11/29/22 at 10:45 a.m. the entrance conference was conducted with the director of nursing (DON). The DON was acting as the nursing facility's administrator (NHA) at the time of the survey and the facility had active job listings posted for a permanent licensed nursing home administrator. II. Record review On 11/29/22 at 10:50 a.m. a review was conducted on the State licensing website. The website showed the director of nursing (DON) had not applied for a temporary NHA license for emergency situations. II. Interviews The DON was interviewed on 11/22/22 at 11:00 a.m. She stated she had not applied for a temporary NHA license because she was told she did not need the license since she had a registered nurse license. The information technology/health information manager (IT/HIM) was interviewed on 11/22/22 at 1:45 p.m. She stated that she had pulled the State/Federal regulations for nursing home administrators, and had interpreted the regulations incorrectly. She stated she would assist the DON in completing the temporary license application to ensure she was licensed as the NHA by the end of the day. The DON was interviewed again on 11/22/22 at 2:30 p.m. She stated she had applied for the temporary NHA license and provided the invoice for the license. The invoice was reviewed and showed application and payment for the temporary license.

Based on record review and interviews, the facility's governing body failed to appoint an administrator who was licensed by the State. Specifically, the facility failed to ensure the temporary nursing home administrator license was valid and did not expire. Findings include: I. Entrance interview On 11/29/22 at 10:45 a.m. the entrance conference was conducted with the director of nursing (DON). The DON was acting as the nursing facility's administrator (NHA) at the time of the survey and the facility had active job listings posted for a permanent licensed nursing home administrator. II. Record review On 11/29/22 at 10:50 a.m. a review was conducted on the State licensing website. The website showed the DON had not applied for a temporary NHA license for emergency situations. III. Interviews The DON was interviewed on 11/22/22 at 11:00 a.m. She had not applied for a temporary NHA license because she was told she did not need the license since she had a registered nurse license. A member of the governing body was interviewed on 11/22/22 at 2:04 p.m. He stated he was unaware of the need for the DON to apply for a temporary NHA license, but he would make sure it was completed by the close of business on 11/22/22. The board member stated the facility had interviews for the permanent NHA position scheduled for December 2022, and would have the NHA position filled by year end. The DON was interviewed again on 11/22/22 at 2:30 p.m. She stated she had applied for the temporary NHA license and provided the invoice for the license. The invoice was reviewed and showed application and payment for the temporary license.

Based on observation, record review and interview, the facility failed to ensure that residents had reasonable access to send and receive mail during the routine United States Postal Service hours of operation. Specifically, the facility failed to ensure residents' personal mail was delivered timely on Saturday. Findings include: I. Facility policy and procedure The resident's handbook and admission packet, dated March 2021, page eight, item number 17, was received from the director of IT (DIT) on 7/28/22 at 12:33 p.m. It read in pertinent part, the facility and its staff are committed to total compliance with all State and Federal regulations. Mail will be delivered unopened to the resident. Mail delivery is Monday through Friday. II. Resident interview and observation The resident council president, Resident #64 was interviewed on 7/26/22 at 3:00 p.m. He said the mail was not delivered on the weekend. Resident #4, #52, #63, and #46 were interviewed on 7/26/22 at 3:05 p.m. The residents were a part of the resident council. The residents said the mail was not delivered on Saturdays. They said they did not know why and thought it was related to not having a weekend receptionist. III. Staff interview and observation The front desk (FD) receptionist was interviewed on 7/26/22 at 3:58 p.m. She said they were hiring for a weekend receptionist and did not currently have one. She said the United States postal service (USPS) did not deliver mail to the facility on Saturdays. The local USPS representative was interviewed 7/27/22 at 3:39 p.m. He confirmed it was correct that there was no mail delivery to the facility on Saturdays. He said there were quite a few residents living there that could be receiving mail on Saturdays. The USPS representative said it was at the facility's discretion if they wanted to receive mail on Saturday but the mail carrier had been instructed to not deliver on Saturdays by the facility. The FD receptionist was interviewed on 7/26/22 at 4:23 p.m. She said she had worked in the business office for the last nine months and there had been no Saturday mail delivery during that time. The nursing home administrator (NHA) was interviewed on 7/26/22 at 4:35 p.m. He said he was not aware that there was no mail delivery to the facility on Saturdays. The NHA went and spoke with the payroll clerk and she confirmed that the mail had not been delivered on Saturdays for quite some time. The payroll clerk was interviewed on 7/28/22 at 8:27 a.m. She said the FD receptionist gets the mail Monday-Friday, in front of the facility there is a mailbox. The payroll clerk said she had worked at the facility since 1999. The mail had not been delivered on Saturday all these years. She was not sure why and said she thought it started because there was no FD receptionist on the weekends. She said she did not know if anyone had reached out to the post office to resolve the issue. The business office manager (BOM) was interviewed on 7/28/22 at 8:45 a.m. She said she had worked at the facility since 2018 and for those years the mail had not been delivered on the weekend. She was not sure when that started, it had always just been that way. She said they explained to the residents upon admission so they were aware. The NHA was interviewed on 7/28/22 at 8:52 a.m. He said he did not know the mail had not been running on the weekend. He said he had worked at the facility for over four years. He said he did not know if anyone had spoken to or reached out to the post office to inquire about why the mail was not delivered on Saturdays. The NHA said to his knowledge no one had reached out to the post office but he would now since it was brought to his attention. The director of admissions and activities (DAA) was interviewed on 7/28/22 at 12:50 p.m. She said she had worked at the facility for over [AGE] years. She said back in the 1990's there was another NHA and he had asked the post office to hold the mail on Saturdays and not deliver it because when it arrived there were too many hands in the pot. The DAA said the facility weekend staff had not sorted the mail properly and some things may have been distributed that should not have been so the NHA handled the problem by canceling the mail on Saturdays.

Based on observations, record review, and interviews, the facility failed to honor the bathing preferences for four residents (#61, #47, #21, #23) of five residents reviewed for choices out of 37 sample residents. Specifically, the facility failed to provide routine bathing consistent with the residents' preferences for Resident #61, #47, #21 and #23. Findings include I. Facility policy The Nursing Home Residents ' Rights ' policy, not dated, was provided via email by the director of nursing (DON) on 7/28/22 at 12:15 p.m. It was revealed in pertinent part;, It is the policy of our facility to promote and protect your rights as a resident. We believe that you have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Therefore, as a resident, you have: The right to choose activities, schedules, and care consistent with your interests, assessments, and plan of care. The facility will allow you to make choices about what you wear, how you are groomed, with whom you eat, etc. The right to receive services with reasonable accommodation of individual needs and preferences. II. Resident #61 A. Resident status Resident #61, age over 80, was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/13/22 minimum data set (MDS) assessment revealed the resident had short and long term memory problems, the resident had continuous disorganized thinking, and difficulty with focused attention. The resident did not reject care provided by staff. She required extensive assistance with locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident had total dependence on staff for bathing. B. Interview Resident #61 was interviewed on 7/25/22 at 2:07 p.m. She said it was very important to her that she received her showers on the days that she prefered. She said she liked her showers to be done on Monday and Thursday. She said she did not like when staff skipped her showers or moved her showers to another day. C. Record review The shower log documentation for the facility was provided on 7/28/22 at 8:21 a.m. by the director of nursing (DON). It was revealed in pertinent part, Resident #61 requested to have her showers provided on Monday and Thursday each week. -The week of 5/15/22-5/21/22 the resident only received a shower on Monday 5/16/22. The resident did not receive a second shower on Thursday or any other day that week. -The week of 5/22/22-5/28/22 the resident received a shower on Monday 5/23/22. The resident did not receive a second shower on Thursday or any other day that week. -The week of 5/29/22-6/4/22 the resident received only a shower on Sunday 5/29/22 and did not receive any showers on Monday or Thursday or the rest of the week. -The week of 6/5/22-6/11/22 the resident only received a shower on Thursday 6/9/22. She had no shower on Monday nor any documentation of refusals. -The shower documentation for the week of 6/12/22-6/18/22 was not provided by the facility. -The shower documentation for the week of 6/26/22-7/2/22 was not provided by the facility. -The week of 7/3/22-7/9/22 the resident received her shower on Sunday 7/3/22 and not on her preferred day of Monday. III. Resident #47 A. Resident status Resident #47, age over 80, was admitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/2/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required substantial maximum assistance with showering and bathing. The resident did not reject care provided by staff. B. Interview Resident #47 was interviewed on 7/25/22 at 2:05 p.m. He said he and his wife Resident #61, liked their showers on Monday and Thursday. He said it was important to have showers twice per week. He said he felt when the facility was short-staffed, his showers did not happen. He said it was okay if the staff let him know that his shower was rescheduled for the following day if they were short staffed. He said for his wife that he lived with it was never okay to change her shower days or to miss a shower day. He said he wanted showers twice per week and his wife needed her showers twice per week on the days that she wanted or it upset her. C. Record review The shower log documentation for the facility was provided on 7/28/22 at 8:21 a.m. by the director of nursing (DON). It was revealed in pertinent part, Resident #47 requested to have his showers provided on Monday and Thursday each week. -The week of 5/15/22-5/21/22 the resident only received a shower on Monday 5/16/22. The resident did not receive a second shower on Thursday or any other day that week. -The week of 5/22/22-5/28/22 the resident received a shower on Monday 5/23/22. The resident did not receive a second shower on Thursday or any other day that week. -The week of 5/29/22-6/4/22 the resident received a shower on Sunday 5/29/22 and did not receive any showers on Monday or Thursday. The resident received a shower on Saturday 6/4/22. -The week of 6/5/22-6/11/22 the resident received a shower on Monday 6/6/22 and Friday 6/10/22. -The shower documentation for the week of 6/12/22-6/18/22 was not provided by the facility. -The week of 6/19/22-6/25/22 the resident received a shower on Monday 6/20/22 and Friday 6/24/22. -The shower documentation for the week of 6/26/22-7/2/22 was not provided by the facility. -The week of 7/3/22-7/9/22 the resident received his shower on Friday 7/8/22 and not on his preferred day of Thursday. -The week of 7/10/22-7/16/22 the resident received his shower on Tuesday 7/12/22. He did not receive any other showers that week. -The week of 7/17/22-7/23/22 the resident received his shower on Friday 7/22/22 instead of his preferred day of Thursday. IV. Resident #21 A. Resident status Resident #21, age 79, was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/18/22 minimum data set (MDS) assessment revealed the resident requested staff do not do a brief interview for mental status score (BIM). He was independent with his cognitive decision making skills. He was totally dependent on staff for bathing, dressing, eating, toilet use, eating, and locomotion on and off the unit. He required extensive assistance with transfers. The resident did not reject care provided by staff. B. Interview Resident #21 was interviewed on 7/25/22 at 10:09 a.m. He said he had not had a shower in nine days. He said he was a quadraplegic and needed staff to give him a shower. He said he only wanted a shower one time per week and that staff did not give it to him every week. He said, Look at how greasy my hair is, this bothers me. This is just awful. And my nails are dirty and need to be trimmed. He said showers were an ongoing problem over his nine years living in the facility. I've complained but I am not sure who listens to me. Resident #21 was interviewed again on 7/26/22 at 11:00 a.m. He said after he spoke with a surveyor Monday morning a staff person came in Monday afternoon and gave him a shower. He said he was happy now that he had his shower and his nails were trimmed and cleaned. He said nine days was too long in between showers. He said he was glad he had a shower yesterday. C. Observations On 7/25/22 at 10:09 a.m. Resident #21 was observed to have very greasy hair, and long fingernails with dirt under his nails. D. Record review The shower log documentation for Resident #21 was retrieved from the electronic medical records (EMR) on 7/27/22 at 3:40 p.m. It revealed in pertinent part, -The resident received a shower on 5/4/22 and eight days later on 5/12/22. -The resident received a shower on 6/4/22 and eight days later on 6/12/22. -The resident received a shower on 6/26/22 and eight days later on 7/3/22. -The resident received a shower on 7/16/22 and nine days later on 7/25/22. V. Resident #23 A. Resident status Resident #23, age 90, was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/23/22 MDS assessment revealed Resident #23 was cognitively intact with a BIMS score of 15 out of 15. The resident exhibited physical, verbal and other behavioral symptoms directed toward others one to three days including rejection of care for the past seven days. She required extensive to total assistance and one to two-person physical assistance with all activities of daily living (ADLs) and totally dependent upon staff for showering. B. Resident interview Resident #23 was interviewed on 7/25/22 at 2:17 p.m. She said there was not enough staff, she said she only received a shower once a week and her preference was to have a shower every night. C. Record review The ADL care plan, initiated 11/24/09 and revised on 5/24/22 revealed Resident #23's preference was to shower twice a week. Review of the shower book with shower schedule located on the unit revealed a schedule for the week during survey dated 7/24/22 to 7/30/22 it revealed Resident #23 had a shower on Sunday 7/24/22. On 7/26/22 at 12:02 p.m. shower records were requested from the director of nursing (DON) for the months of May, June and July 2022; she said she started a performance improvement plan (PIP) for showers (see record review and interview below). On 7/27/22 at 3:25 p.m. additional shower schedules were provided it revealed the following: -For 5/1/22 to 5/7/22 documentation for the resident was not available; -For 5/8/22 to 5/14/22 the resident had one shower for the week on 5/9/22; -For 5/15/22 to 5/21/22 the resident did not have a shower for the week; -For 5/22/22 to 5/28/22 documentation for the resident was not available; -For 5/29/22 to 6/4/22 the resident refused on 5/29/22 and received a shower on 6/4/22; -For 6/5/22 to 6/11/22 the resident did not have a shower for the week; -For 6/12/22 to 6/18/22 the resident had one shower for the week on 6/12/22; -For 6/19/22 to 6/25/22 the resident had a shower 6/19/22 and on 6/22/22 -For 6/26/22 to 7/2/22 the resident received a shower on 6/26/22 and on 7/1/22; -For 7/3/22 to 7/9/22 the resident received a shower on 7/3/22 and 7/9/22; -For 7/10/22 to 7/16/22 the resident had a shower on 7/11/22, 7/15/22 and 7/16/22; and, -For 7/17/22 to 7/23/22 the resident had one shower for the week on 7/17/22. For the first four weeks 5/1/22 to 5/28/22 Resident #23 received one shower out of eight opportunities. For the following four weeks from 5/29/22 to 6/25/22 Resident #23 received four showers out of eight opportunities with one refusal. For the following four weeks from 6/26/22 to 7/23/22 Resident #23 received a shower eight times out of eight opportunities; however Resident #23 only had one shower for the week of 7/17/22 to 7/23/22. VI. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 7/25/22 at 12:54 p.m. He said at the nurses stations there were shower documentation books. He said each resident's name was listed in the shower book and their preferred shower days were designated with an asterisk. He said Resident #61 and Resident #47 had asterisks on Monday and Thursday because those were their preferred days to receive their showers. He said it was very important for Resident #61 to receive her showers on Monday and Thursday. He said Resident #47 would prefer his showers on Monday and Thursday but if he did not receive his showers on those days he was okay to receive his showers the next day if the staff communicated with him about the change. He said both Resident #61 and #47 did not refuse when they were offered showers. He said staff were to document showers on the shower sheets at the nurses station. He said then after the week was over a staff member would put that documentation into the electronic medical record (EMR) for each resident. He said it was part of the CNAs responsibilities to give the residents their showers. He said the facility did not have a bath aide who only worked to give the residents showers. He said sometimes a CNA did not come to work when they were scheduled and then staff may need to rearrange showers for the residents due to missing staff. The social service director (SSD) was interviewed on 7/28/22 at 11:00 a.m. He said when a resident was admitted into the facility he was responsible to conduct an interview with the resident and ask them what their preferred days for showers were. He said he would then communicate that information to the nurses and the nurses would then write the information on the shower documentation logs. He said he received a complaint from Resident #21 last Monday on 7/25/22 during the survey. He said Resident #21 was a quadraplegic and was unable to write. He said Resident #21 asked a CNA to write a complaint for him to be turned into the SSD. He said the CNA wrote a complaint on a napkin for Resident #21. He said the complaint was that Resident #21 had not received a shower in nine days and he wanted one. He said he rewrote the complaint on the napkin onto a grievance form. He said he then went to the director of nursing (DON) and spoke to her about Resident #21's complaint. He said when he brought the complaint to the DON during the survey a performance improvement plan (PIP) was written up to handle not only the shower for Resident #21 but for the entire facility. The DON was interviewed on 7/28/22 at 12:00 p.m. She said the SSD had brought to her attention the grievance filed by Resident #21 on Monday 7/25/22 during the survey. The SSD told her that Resident #21 had not had a shower in nine days. She said Resident #21 was given a shower on Monday after he filed a complaint. She said she immediately began a PIP and had management sign it. She said she also educat the nursing staff about showers. She said the shower plan would begin fully after the survey was completed. She said a resident's preferred shower days were important for the facility to honor. VII. Record review of the PIP for showers The quality improvement and performance plan was emailed by the DON on 7/28/22 at 3:37 p.m. It was revealed in pertinent part, Nursing department PIP Observations: Showers have been given inconsistently. Refusals not being documented. General concerns. Action: Daily audit by RN (registered nurse) /charge (charge nurse). Weekly audit conducted by DON/designee. Ensure documentation. Alternatives are being offered. Goal or measure of success and date: 90 days from 7/25/22. Action plan completed on 7/25/22. (during the survey) The action planned was signed by the DON, SSD, and the nursing home administrator (NHA).

Based on record review and interviews, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for four (#51, #6, #59, #23) of six residents reviewed for unnecessary medications out of 37 sample residents. Specifically, the facility failed to complete a monthly drug review by a licensed pharmacist for April 2022 for five Residents. Findings include: I. Facility policy and procedure The Medication Regimen Reviews policy revised May 2019, was emailed by the director of nursing (DON) on 7/27/22 at 3:37 p.m. It revealed in pertinent part: The consultant pharmacist reviews the medication regimen of each resident at least monthly. Policy Interpretation and Implementation The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: A. Medications ordered in excessive doses or without clinical indication; B. Medication regimens that appear inconsistent with the resident's stated preferences; C. Duplicative therapies or omissions of ordered medications; D. Inadequate monitoring for adverse consequences; E. Potentially significant drug-drug or drug-food interactions; F. Potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences; G. Incorrect medications, administration times or dosage forms; or H. Other medication errors, including those related to documentation. The medication regimen and associated treatment goals involve collaboration with the resident (or representative), family members, and the interdisciplinary team (IDT). As such, the MRR includes a review of the resident's (or representative's) stated preferences, the comprehensive care plans and information provided about the risks and benefits of the medication regime. The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. Copies of medication regime reports, including physician responses, are maintained as part of the resident permanent record. II. Resident #51 A. Resident status Resident #51, age 74, was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 computerized physician orders (CPO), the diagnoses included type 2 diabetes mellitus, [CONDITION(S)], dysphagia (difficulty swallowing), anxiety disorder, [CONDITION(S)], depression, [CONDITION(S)], and hypertension (high blood pressure). The 6/28/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required supervision with toilet use and personal hygiene. She was independent with bed mobility, transfers, eating, and dressing. B. Record review Review of the record revealed the resident did not have an MRR done for April 2022 conducted by the facility pharmacist. According to the July 2022 CPO the resident started the following medications in April 2022: -On 4/1/22 alum-mag hydroxide simeth suspension, 400-400-40 mg (milligram)/ 5mL (milliliter) and 30 ml (milliliter) oral every four hours PRN (as needed) for indigestion heartburn. -On 4/11/22 Zolofot 50 mg (milligrams) one time per day for depression. -On 4/11/22 chiropractic to evaluate and treat back pain. III. Resident #6 A. Resident status Resident #6, age under 70, was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), the diagnoses included [CONDITION(S)] (MS), pressure ulcers, gastro [CONDITION(S)] reflux disease (GERD), [CONDITION(S)] C, and dysphagia (difficulty swallowing). The resident was admitted to the facility with a hospice provider with a diagnosis of heart failure. The 7/19/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of five out of 15. She required extensive assistance with bed mobility, eating, dressing, and personal hygiene. She required total dependence on staff for toilet use. B. Record review Review of the record revealed the resident did not have an MRR done for April 2022 conducted by the facility pharmacist. On 4/28/22 the hospice provider ordered [MEDICATION(S)] 20 mg/mL oral concentrate, .25 ml orally every four hours. IV. Resident #23 A. Resident status Resident #23, age 90, was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 CPO, diagnoses included depression, anxiety, hypertension, gastroesophageal reflux disease (GERD), long-term use of antibiotics, history of urinary tract infections, [CONDITION(S)] and chronic pain. The 5/23/22 MDS assessment revealed Resident #23 was cognitively intact with a BIMS score of 15 out of 15. The resident exhibited physical, verbal and other behavioral symptoms directed toward others one to three days including rejection of care for the past seven days. B. Record review Review of the July 2022 CPO revealed Resident #23 received the following medications were added on 3/31/22 and the month April 2022: -Biofreeze 5% topically three times daily as needed for pain, (the site for application was not documented), ordered on 3/31/22; -[MEDICATION(S)] 5-325 mg by mouth three times daily for pain, ordered on 4/4/21; and, -Fiber lax tablets give two tablets by mouth every morning with eight ounces of water for constipation, ordered on 4/29/21. Review of Resident #23's clinical record revealed the medication regimen review was not completed for the month of April 2022. V. Resident #59 A. Resident status Resident #59, age 80, was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, Chronic obstructive pulmonary disease, and anxiety disorder. The 7/6/22 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) was not conducted. The staff assessment for mental status was completed and revealed short term and long term memory problems. He required extensive assistance with one person for dressing, toilet use, bathing and personal hygiene. Limited assistance with one person for transfers, and walking in the room. Supervision with one person for bed mobility. The resident received antipsychotic medication, antidepressant, and anticoagulant medications. B. Record review Review of the July 2022 CPO revealed resident # 59 received the following medications: -Lubricant eye drops ([MEDICATION(S)] sodium) OTC drops, 0.5 %. Two gtts ophthalmic (eye), PRN for dry eyes. Started 4/26/22. -Senna OTC tablet, 8.6 mg, two tablets by mouth PRN. Give two tablets daily as needed for constipation. Start date 4/16/22. Review of Resident #59's clinical record revealed the medication regimen review was not completed for the month of April 2022. VI. Interviews The director of nursing (DON) was interviewed on 7/27/22 at 10:00 a.m. She said the pharmacist was out ill the month of April 2022. She said the facility had done their due diligence to keep up with the resident's medical records but the pharmacy reviews were not done for the month of April 2022. She said the pharmacist did not complete several resident MRR's. The DON said she knew it was a regulation that pharmacy reviews were to be completed every month. She said she understood that it was very important for a pharmacist to review every medication a resident received. She said the pharmacy reviews were monthly sent to the four different facility physicians. She said the doctors would review the pharmacist's medication reviews and the doctor might make recommendations. She said the physician would either accept, decline, or change an order upon a pharmacist's medication review. She said when a physician's review of a pharmacy review was completed, she would let the nurses in the facility know of any changes, and she would put any changes into the resident's medical record. She said there was no April 2022 MRR for many residents in the facility. She said the MRR was not done and it should have been completed. She said she did not realize that it had not been done for the month of April 2022. She said she would correct the situation so that it did not happen again. The facility pharmacist (PH) was interviewed on 7/27/22 via the phone at 4:05 p.m. She said she was not working the month of April 2022. She said typically the pharmacy had a backup pharmacist to cover when she was sick and not working who would complete resident MRRs for her. She said it is ultimately on me that this happened. She said her company must have had a missed communication because an entire month of pharmacy reviews were not done. She said there was no documentation of any MRR being done for the month of April 2022 for several residents in the facility. She said she would fix the situation so that it would not happen again.

Based on observations, record review, and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#52) of three residents reviewed for nutrition out of 22 total sample residents. Resident #52 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to document, track and monitor weight records consistently. The facility failed to provide the appropriate level of assistance with eating. The facility failed to update the resident's care plan with nutritional risks and interventions. Due to the facility failures, Resident #52 sustained a 13 pound avoidable weight loss considered significant in six months. Findings include: I. Facility policy and procedures The Nutrition policy, revised October 2017, was received from the health information manager (HIM) on 5/19/21 at 10:50 a.m. It read in pertinent part: As part of the resident assessment, a nutritional assessment should be conducted including nutritional status and risks for impaired nutritional status for each resident upon admission. The registered dietician along with the nursing staff and other administration staff shall conduct the nutrition assessment. The assessment team shall identify risk factors for impaired nutritional status such as cognitive decline, pain and increased need for calories or protein. Once conditions and risk factors are identified, individualized care plans will be developed to help minimize those risk factors such as to identify the causes of impaired nutritional status along with the residents' personal preferences and benchmarks for improvement. II Resident #52 A. Resident status Resident #52, age 88,was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/7/21 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) revealed the resident was severely cognitively impaired with non-traumatic [CONDITION(S)].The MDS indicated the resident had a five percent or more weight loss in the last 30 days. According to the MDS the resident was not on a physician prescribed weight loss program. Her weight and height were not indicated on the MDS. She required maximal two-person assistance with dressing, bathing and transferring, and one person assistance with eating. B. Observations of meals On 5/5/21 at 11:20 a.m. Resident #52 was seated in her wheelchair at a table in the dining room. An unidentified certified nurse aide (CNA) accompanied her. -At 11:25 a.m. the resident received her meal. The meal was chili dogs and potato salad. The food was chopped up in small pieces. -At 11:27 a.m. the CNA proceeded to give Resident #52 a bite of food. The resident chewed the food and swallowed it. -At 11:28 a.m. the CNA gave the resident a drink of juice through a straw. She swallowed the juice. -At 11:30 a.m. the CNA gave the resident another bite of food. She would not open her mouth to take the bite. No alternative was offered to the resident. One bite of the food was eaten which left 99% of the food on the plate. -At 11:32 a.m. the CNA tried again to give the resident a bite of food. She again did not open her mouth to take the food. -At 11:34 a.m.the CNA offered the resident a drink of the health shake which she drank. The resident took six more drinks of the shake and then refused to take anymore. -At 11:36 a.m. the CNA offered the resident another drink of the health shake. The resident did not open her mouth to take a drink. On 5/6/21 at 9:00 a.m CNA #2 sat with Resident # 52 at the nurses station. -At 9:05 a.m. to 9:30 a.m. CNA #2 assisted Resident #52 to eat oatmeal and drink her health shake. The CNA took a health shake from the fridge in the nurses station. She offered the shake in between bites of oatmeal. The resident consumed approximately 25% of the oatmeal. She was not offered an alternative. She drank 50% of the health shake. She refused to take any more after that. On 5/10/21 at 11:00 a.m Resident #52 sat at the table at the nurses station in her wheelchair. Registered nurse (RN) #2 was sitting at the table with her. This was thirty minutes before lunch started. -At 11:05 a.m. the RN gave the resident a drink of her health shake. -At 11:07 a.m. the resident took a drink of the shake assisted by RN#2. -At 11:09 a.m. the RN offered the resident a drink of the shake and she did not open her mouth. -At 11:12 a.m. the resident fell asleep in her chair. The nurse got up from the table and went to the medication cart.The cup of shake was half empty. The RN#2 threw the cup away. -At 11:16 a.m. the assistant director of nursing (ADON) came to the nurses station and assisted the resident to her room. C. Record Review The nutrition care plan initiated upon admission on 4/23/18 indicated Resident #52 had potential for weight loss due to dementia and major depressive disorder. The interventions included in the care plan on admission were to monitor the resident for change in nutritional status, intake, and her ability to feed herself. The care plan was updated on 2/11/21 to include the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -There was no other nutrition care plan for the resident.The care plan failed to show any update on new interventions until 2/10/21 after the resident had lost weight (see below). Review of the resident's documented weights from January 2021 through May 2021 were as follows: 1/12/21= 112 pounds (lbs) 2/3/21= 106 lbs, 6 lbs weight loss in one month, 5.4% considered significant; 3/4/21= 104 lbs 4/7/21= 100.5 lbs 5/6/21= 99lbs, 13 lbs weight loss in six months, 11.6% considered significant. The resident experienced significant weight loss at 11.6% with a 13 lbs weight loss. -The medical record failed to show the registered dietitian (RD) did a complete and thorough assessment which included calorie needs and assessments of the current interventions, as the resident had experienced a significant weight loss and was not completed until 5/11/21 (see below, five days after the weight was recorded on 5/6/21). Review of the May 2021 CPO revealed the following physician orders -Regular diet, texture solids and thin liquids with a start date of 6/20/2020; -House supplement shake eight ounces to be administered with meals for continued weight loss. Give her as many shakes as she wants with a start date of 7/30/2020; -Ensure clear eight ounces twice daily with a start date of 2/10/21. -The Ensure clear was not implemented until 2/10/21 which was seven days after the resident had a recorded weight loss on 2/3/21 (see above). Review of the medication administration records (MAR) for 4/28/21 to 5/11/21 revealed the resident drank Ensure clear 100% on three of the days. The record indicates that the resident drank 50% to 75 % on the rest of the days. The intake record for the house shake dated 4/28/21 to 5/11/21 indicates that the resident drank 50% to 100% on six of those days. The record indicates the resident consumed 0% to 50% on eight of those days. Review of the resident's food and fluid intakes beginning 3/1/21 to 5/6/21 showed the resident consistently ate on an average of up to 25% per meal. The average fluid intake varied from 180 ml to 300ml per day. Snacks were taken on 10% of the days. A nutrition note dated 4/8/21 the RD documented, the resident did not feed herself and she ate her meals at the assisted medical dining room (MDR). The 5/11/21 registered dietitian (RD) note indicated that Resident #52 was prescribed a maximum of 1920 calories per day along with 76 grams of protein with nutritional supplements. She indicated Resident #52 needed a minimum of 1350 calories per day to maintain her current weight of 99 pounds.She said the intervention would be for staff to notify her if the resident did not meet the minimum requirements of 1350 calories per day. She included she would then notify the doctor and the family. -However, based on observations and record review (see above) the resident was not meeting the minimum calories per day. No additional interventions were added after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Interviews Certified nurse aide (CNA) #8 was interviewed on 5/10/21 at 10:31 a.m. She said Resident #52 sometimes ate 80% of her breakfast. She indicated that the resident's intake fluctuated on a daily basis. She said the resident experienced no weight loss lately. She indicated that the resident was a total assist with feeding. CNA #8 said the resident would not open her mouth if she did not want to eat. She indicated that there were foods Resident #52 liked in the nursing refrigerator like pudding, applesauce and yogurt to offer if she refused to eat her meal. She said she did not document anywhere if the resident ate those foods. She indicated that the resident would sometimes eat her meals in bed. The registered dietitian (RD) was interviewed on 5/10/21 at 11:00 a.m. The RD said she was aware Resident #52 had experienced a severe weight loss. The RD said she was aware of the resident's daily intake of food. A meal alternative was not suggested if the resident had not eaten the meal. She included the resident was prescribed meal shakes and Ensure clear as a supplement if she did not eat. She stated that the CNAs weighed the resident on a weekly basis. -However, the vital record above indicated the resident was weighed monthly (see above). CNA #2 was interviewed on 5/11/21 at 9:11 a.m. She said Resident #52 food intake was documented in the resident's medical record. She said the CNAs did not document what food was offered to the resident. She indicated the staff assisted the resident with what they could get her to eat. She included Resident #52 liked cottage cheese, yogurt and pudding. She said the resident's intake was hit or miss meaning that some days she would eat and some days she would not. CNA #2 said the resident would close her mouth when she did not want to eat. She included Resident #52 refused snacks most of the time. The director of rehab (DOR) was interviewed on 5/11/21 at 9:15 a.m. She said Resident#52 did not have swallowing issues. She said the restorative aides assisted the resident with eating three times per week. She said the aides did not document what the resident ate. She included that the resident would shut down sometimes when staff tried to help her eat.The DOR acknowledged the incidents of the resident declining to eat should be recorded and reported to the IDT. The RD was interviewed again on 5/11/21 at 10:30 a.m. She said the staff were to notify her and the nursing staff if Resident #52 did not meet the minimum daily intake requirements of 1350 calories per day. She stated that she would then alert the resident's physician and the family to inform them of the decline in the resident's intake. The RD acknowledged she did not provide any interventions for the resident when she did not meet the minimum intake requirements of 1350 calories per day.

Based on observation, record review and interviews the facility failed to provide appropriate treatment and services to a resident with depression to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (#16) of four out of 22 sampled residents. Resident #16, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On several occasions, it was documented and staff interviews revealed the resident was persistently depressed and had feelings of anxiety. The facility failed to provide the appropriate treatment and services to the resident to attain the highest practical mental and psychosocial well-being. Cross-reference F745 provision of social services. Findings include: I. Facility policy and procedure The Behavior Assessment, Intervention, and Monitoring policy, updated in December 2016, was provided by the health information manager (HIM) on 5/10/21 at 3:00 p.m. It read in pertinent part Residents who do not display symptoms of or have not been diagnosed with, a mental, psychiatric psychosocial adjustment or post-traumatic stress disorder will not develop a pattern of decreased social interaction or increased withdrawn, angry or depressive behaviors from baseline or historical status of, that cannot be explained or attributed to a specific clinical condition that makes the pattern unavoidable. Residents will have minimal complications associated with the management of altered or impaired behavior. Appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Resident #16 Resident #16, aged 78, was admitted to the facility on [DATE]. The May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/19/21 minimum data set (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident's depression assessment, patient health questionnaire-9 (PHQ-9, depression questionnaire), revealed the resident had moderately severe depression with a score of 15 of 27. The resident required extensive two-person assistance with bed mobility, extensive one-person assistance with dressing, toileting, and hygiene, supervision and one-person assistance with eating, and one-person physical assistance while bathing. III. Resident interview and observation The resident was interviewed on 5/5/21 at 9:45 a.m. She said she hates this whole thing. She said she could not walk, could barely hold her head up, or feed herself. She said her tremors (shakes) were so bad it interfered with her ability to feed herself. She said she prayed all the time (visible tears began running down the resident's face). She said she wished there was something the facility could do to help her feel better about her situation that did not have so many side effects (medication). She said she was on some funny pills that gave her hallucinations and nightmares. The resident was interviewed on 5/6/21 at 10:45 a.m. She said she was ready to go to heaven and be with Jesus. She said she did not wish to be a burden to her children and was ready to leave this world. The resident was interviewed again at 3:40 p.m. She said God needed her in heaven and it was her time to go. The resident was interviewed on 5/10/21 at 10:44 a.m. She said she still felt like she needed to go to heaven. She said she had talked with multiple facility staff about her feelings of wanting to go to heaven. She said a priest came to visit her on Sunday and they discussed her feelings of wanting to die and if it would be a sin to choose to die. She said she was not sure if she wanted to try other medications for her depression or anxiety. She said the certified nurse aides (CNA) and nurses talked with her, held her hand, and validated her feelings when she talked about going to heaven. She said if she was not all crippled up she would be trying harder. She said she knew she was not going to get better so she did not feel like trying. She said she preferred to stay in her room and enjoyed independent activities. She did not like using the mechanical lift for transfers because of the pain she experienced. IV. Record review A PASRR (Preadmission Screening and Resident Review) note, dated 2/16/21, documented the resident was receiving scheduled [MEDICATION(S)] 25 mg for depression and as needed (PRN) [MEDICATION(S)] (anti-anxiety medication). The medications were to be tracked and monitored for two weeks to determine effectiveness. Staff reported on several occasions that the resident expressed being miserable and not caring about anything. While the nurse was completing a blood draw the resident had a flat affect and expressed little joy. A nursing note, dated 2/18/21, documented the resident reported not feeling well and wished to see her family. Staff informed her that while she was in isolation she could not receive visitors. The resident stated that she did not think she would be alive at the end of her isolation. Staff tried to reassure the resident but she seemed pretty down. Social services were notified and were in the room talking with the resident. The care plan, dated 2/23/21, documented psychosocial well-being related to (R/T) recent hospital stay and recent nursing home admission. The resident was not oriented to the facility, the resident's BIMS was completed 2/15/21 with a score of 8/15, and PHQ9 (depression scale) was 15/27. Her strengths included strong family support. Documented interventions included allowing the resident to voice concerns and validate, encourage meals in the main dining room and join out of room activities of choice to encourage socialization, encourage participation in activities of daily living (ADL) to the best of her ability and assist as needed, encourage family visits often for support, explain procedures to the resident and allow time to process and respond, reassure the resident that she is safe and her needs are being met, and social service (SS) visits one-to-one (1:1) as needed. A 2/23/21 PASRR note documented the physician recommendations for a gradual dose reduction to the residents PRN [MEDICATION(S)] medication from 0.5 milligrams (mg) to 0.25 mg and was to continue for the remainder of the two weeks. The physician increased the resident's [MEDICATION(S)] from 25 mg to 50 mg each day. The medication changes were made due to the resident's change in overall condition, the resident's power of attorney (POA) was notified and gave verbal consent. A 2/24/21 nursing note documented the resident received her first increased dose of [MEDICATION(S)] this morning. Monitoring for effectiveness and side effects initiated. No side effects were noted and the resident was cooperative and pleasant. Will continue to monitor. A nursing note, dated 2/25/21, documented the resident was crying and refusing care from CNAs. The resident stated that she did not want to do this anymore. Staff provided reassurance and support to the resident. Monitoring for an increase in [MEDICATION(S)] medication in progress. A 2/26/21 PASRR note documented the facility being out of 0.25 mg [MEDICATION(S)]. The PRN 0.5 mg [MEDICATION(S)] order was reactivated due to the resident being in great mental distress related to changes in her routine. A nursing note, dated 2/26/21, documented the resident was teary-eyed and refusing a bath before her transfer out of isolation. The resident stated that she did not want to be there and that she just wanted to die. A 2/27/21 nursing note documented the resident requested her PRN [MEDICATION(S)] related to her room change. She said she was feeling anxious and needed to get some sleep. The resident slept through the night following the medication. The resident did not appear in distress or discomfort. The resident was being monitored for the increase in [MEDICATION(S)] with no apparent side effects. A 2/27/21 activity note documented the resident did not feel up to having a visit from activity staff that day. A 3/1/21 nursing note documented the resident experienced one episode of anxiety and reported feeling like the walls were closing in on her. The writer spoke with the resident and reassured her she was safe and upon exiting the room, left the door open so the resident could see into the hallway. PRN medication was given and no other behaviors noted. A nursing note, dated 3/2/21, documented the resident expressed she felt the walls were coming in on her around 12:45 p.m. Staff talked with the resident and reassured her safety, and offered her as needed (PRN) antianxiety medication. She accepted and rested well the rest of the night. A 3/5/21 nursing note documented the resident was on behavioral charting for an increase in [MEDICATION(S)] medication. No signs or symptoms of an adverse reaction and no unusual behaviors displayed or reported. The resident was compliant with medications and provided care. The resident reported a low appetite this evening and declined to eat dinner. A 3/11/21 nursing note documented the resident continued on behavior monitoring for an increase in [MEDICATION(S)]. No adverse effects noted. The resident requested PRN [MEDICATION(S)] last night while experiencing a panic attack. Medication was effective and the resident rested peacefully after receiving medication. A 3/12/21 nursing note documented the discontinuation of the resident PRN [MEDICATION(S)]. The resident continues on an increased dose of [MEDICATION(S)] at the hour of sleep for depression and anxiety. The resident's generalized anxiety disorder scale evaluation, dated 3/25/21, revealed the resident had moderate anxiety with a score of 10 out of 21. The evaluation indicated the resident's anxiety made it somewhat difficult to work, take care of things at home, or get along with other people. A nursing note dated 4/12/21 documented a one-week hold of the resident's antidepressant ([MEDICATION(S)]) medication was completed and the resident was to resume the medication that day. The resident was teary-eyed and expressing she did not want to be home, she did not want to be at the facility, and that she just wanted to go to heaven. The resident complied with getting out of bed for the breakfast meal but requested to go immediately back to bed after she finished. A 4/17/21 nursing note documented the resident refused her [MEDICATION(S)] during medication pass. The resident asked the nurse if she was still receiving those funny pills and the nurse said yes. The resident stated she did not ever want those pills again. This nurse assured the resident that she would not receive any medications she did not want and provided education about why she was taking [MEDICATION(S)]. When asked why the resident did not want to take the medication she said she thought they made her see things that were not there. The physician was notified and approved the discontinuation of the medication until further notice. The care plan, updated 4/23/21, documented the resident was taking antidepressant medication for depression and an as-needed antianxiety medication for anxiety. Target behaviors included expressions of sadness and apathy. The care plan documented an increase in antidepressant medication on 2/23/21 and the discontinuation of the antidepressant medication on 4/17/21. Documented interventions included give medication as ordered and monitor effectiveness, monitor and report side effects of sleepiness or fatigue, dizziness, dry mouth, nausea, tremors, headaches, and constipation, monitor need for continued use or potential for an alternate approach, non-pharmacological interventions included refocus on functional progress and encourage spirituality, and to report changes in mood and behavior to the nurse. A dietary note dated 5/6/21 documented that while the registered dietitian (RD) was visiting with the resident, the resident expressed that she did not wish to get up for meals, only for family visits. The resident voiced that she wanted to go to heaven and did not have an appetite. A nursing note dated 5/11/21 documented that while the activity assistant was visiting with the resident, the resident asked that if she stopped taking her meds (medication) would she still go to heaven. The activity assistant explained to her the only God decides how long we live. The activity assistant also discussed with her the benefit of medication and how they affect her wellbeing while she was alive. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/10/21 at 11:46 a.m. She said person-centered care to her was getting to know the resident's preferences, encouraging residence independence, encouraging residents to do their best, and reassuring the safety and security of the residents. She said some residents did express a wish to die, and she struggled with this. She said when residents expressed this to her she reassured the resident that they were not alone and she was here to help them and make their day better. She said when residents express a desire to die she notified the nurse. She said she informed the nurse if the resident appeared depressed or was displaying behaviors of any kind. She said she had not received behavior training regarding depression or anxiety from the facility but had from other facilities she worked at. She said some residents with depression will not eat much or at all, they want to stay in their room in bed or brought up going to heaven. She said the staff did use the resident care plans for care preferences and programs the resident was involved in. She said she was not sure if behaviors or emotional problems were included in the care plan. She said the nurse knew and told her most of the behavioral information she needed to know about residents. She said it could be hard to help new residents acclimate to the facility. She said she tried to get to know the residents and their needs and helped them acclimate by meeting those needs and orienting them to their environment. She said she worked with Resident #16 when she first arrived at the facility and after she moved out of isolation. She said they would talk and pray together. She said Resident #16 told her often that she wanted to go to heaven. She said when the resident expressed this she would reassure the resident that she was safe and would pray with her. She said the last time the resident told her she wanted to go to heaven was five days ago (5/5/21) on her last shift. She said she tried to advocate for the residents when they expressed wishes to die. Licensed practical nurse (LPN) #1 was interviewed on 5/10/21 at 12:08 p.m. She said person-centered care to her was meeting the resident's medical needs, talking with them about their families, and listening to them so they felt heard. She said when a resident expressed a wish to die she discussed with them why they felt that way, encouraged them to talk about their families, and focused on the good things in their life. She said if it was a serious expression and talking with them does not help she reports their feelings to the charge nurse and their physician. She said the behavior was tracked after the physician was informed and medication changes were made. She said new medications or medication changes were tracked daily for two weeks and the resident was monitored for side effects, improvements, and behavior changes. She said she received in-service training from the facility about depression and anxiety. She said signs and symptoms of depression and anxiety included isolating in their room, not wanting to get out of bed, and expressing concern for family members. She said signs and symptoms of depression and anxiety were resident-specific. She said non-pharmacological interventions for depression and anxiety included family phone calls and visits, offering preferred activities, staff visits, putting on their favorite movie or television show, offering favorite snacks or beverages, and encouraging safe socialization. She said she did use the resident's care plans and included routine preferences, favored activities, and interventions. She said Resident #16 frequently expressed wanting to go to heaven. She said Resident #16 expressed to her yesterday (5/9/21) that she wished to go to heaven, had no will to live, and a desire to unburden her family. She said the resident had been on antidepressant medications and refused them. She said the facility had been working medically and spiritually to meet her needs and it was not effective. She said social services (SS) notified the family of the residents ' expressions and maintained the families ' involvement in care. She said both of the social workers (SW) from the facility go in and talk with her about her feelings. The activity director (AD) was interviewed on 5/10/21 at 12:56 p.m. She said resident activity preferences were discovered through the initial activity preference interview and through reports from staff members. She said activity staff provided one-to-one sessions with residents who prefer to stay in their rooms. She said residents who had depression received one-to-one visits regularly from activity staff. She said if residents expressed a desire to die, the activity staff talked with them and informed the nurse and the social workers. She said Resident #16 received three one-to-one visits a week from activity staff. She said the resident expressed wanting to be out of bed only for family visits which she received often. The social service director (SSD) and the social service assistant (SSA) were interviewed on 5/10/21 at 1:34 p.m. They said they completed training with staff members about redirection and intervention for resident behaviors but did not keep in-service records or log-in sheets of the staff who attended. The SSD said when residents express feelings of wanting to die to staff, they often come to social services for tips and advice about how to discuss this with the residents. He said he or the SSA would also go talk with the resident about their feelings. He said they should be documenting these encounters with residents. He said he conducted annual training with staff about emotional issues the residents could face. He said when he was on the floor he would provide on-the-spot training to staff if he saw something that warranted it. He said staff informed himself or the SSA if resident behavior was out of the normal. He said non-pharmacological interventions for residents could be found in the care plan and progress notes. The SSA said he checked in with Resident #16 often to make sure she was doing alright. He said he felt she was having a hard time adjusting to life at the facility. He said she chooses to stay in her room except when she has visitors. He said a big part of acclimating to the facility was communal dining and socialization, which she declined. He said he met with the resident frequently to help her adjust to the facility. He said he should have documented his one-to-one sessions with the resident and what he assisted her with during the session. He said she frequently expressed her desire to die and go to heaven to him. He said she had no plan and did not express suicidal ideation. He said these expressions did not evoke concern because he had experienced this with other residents. He said when she expressed these feelings he would sit and talk with her about her family and the good times she had in her life and that usually helped her feel better. He said she mentioned going to heaven and dying twice to him that week. He said he should have documented these expressions, and had been asked to document his sessions with residents. He said he should have included her feelings and expressions of wanting to die in her care plan with intervention options for staff to use. He said a resident with a PHQ9 (depression scale) score of six or more, should be referred to senior counseling services. He said Resident #16 had a score of 15/27 and should have been referred to counseling, but he did not follow up on the recommendation. He said he should have offered her senior counseling services and that they could benefit her wellbeing. He said he had not offered or discussed senior counseling services with the resident. The DON and assistant director of nursing (ADON) were interviewed on 5/10/21 at 2:37 p.m. They said staff should offer reassurance and validate the resident's feelings when a resident expressed feelings of wanting to die. They said if the expression was odd or unusual for the resident the CNAs should tell the nurse who should inform social services (SS). They said a mood care plan should be included for residents who experience depression or anxiety and that is completed and updated by SS. They said SS conducts behavior, trauma-informed care (TIC), and dementia training annually with all floor staff members, and the annual training was scheduled for 7/26/21. The activity assistant (AA) was interviewed on 5/11/21 at 9:11 a.m. She said the facility and activities department specifically provided depression and anxiety training all the time. She said the training covered the general signs and symptoms of depression and anxiety, and how to maintain and establish the well-being of the residents. She said she learns more about the residents ' specific presentation of depression and anxiety by spending time and talking with them. She said she visited with Resident #16 three times a week. She said they typically pray, read scripture and sing during their visits. She said the resident asked her if she stopped taking her medications if God would be ok with that and she would still go to heaven. She said she reassured the resident that medications made her time on earth more comfortable and God would take her when he was ready for her. She said Resident #16 expresses her desire to go to heaven every time she meets with her. She said she informs the nurse for the hall when the resident expresses this. The registered dietitian (RD) was interviewed on 5/11/21 at 1:34 p.m. She said if a resident expressed a desire to go to heaven while she was talking with them she informs the SW. She said the emotional state of residents can have an impact on appetite. She said when Resident #16 told her she wanted to go to heaven, she was concerned and informed social services on 5/6/21. She said she called the family and informed them of the resident's lack of appetite. She said the family informed her that the resident did not have an appetite and had issues eating before being admitted to the facility. She said she continued to offer preferred food choices and the resident was not interested. She said the family brought her food often when they came to visit. VI. Follow-up A social service note dated 5/11/21 documented the resident's depression scale, PHQ9, results were forwarded to the psychiatric nurse for a referral to senior counseling services. The physician signed and approved the referral. A new order for [MEDICATION(S)] 30 mg once a day was requested and approved by the resident physician on 5/11/21 for the resident's depression. The resident agreed to the medication and the POA was notified and gave verbal consent.

Based on record review and staff interviews, the facility failed to ensure one (#16) of four out of 22 sample residents reviewed for pressure ulcers were free of neglect. Specifically, the facility failed to remove a bed pan placed under Resident #16 timely resulting in a deep tissue injury. The resident was left on the bed pan for 11.5 hours overnight. The evening shift placed the bed pan under the resident at the end of her shift and failed to report the bedpan placement to the oncoming night shift. The night shift did not check the resident therefore did not discover the bedpan during the night shift. The day shift aide did not discover the bedpan when her shift started. The physical therapy assistant (PTA) and the certified occupational therapy assistant (COTA) discovered the bedpan the [MEDICATION(S)] placement while providing treatment. The resident had been identified as a risk for developing a pressure ulcer. This failure to remove the bed pan timely resulted in a soft deep tissue injury (SDTI) to bilateral buttocks measuring 20 centimeters (cm) by 2 cm in the shape of the bed pan. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/5/21 to 5/11/21, resulting in the deficiency being cited at past non-compliance with a correction date of 3/9/21. I. Facility policy The policy titled Resident Saftey and Abuse Prevention provided by the health information manager (HIM) on 5/12/21 at 11:34 a.m. included, Policy Statement: It is the policy of this facility to maintain a work and living environment that is professional and free from threat and/or occurance of harassment, abuse (verbal, physical, mental, or sexual) neglect, corporal punishment, involuntary seclusion, and misappropriation of property. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. II. Resident status Resident #16, age 78, was admitted on [DATE]. According to the May 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/19/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident needed extensive two person assistance with bed mobility. She had not displayed any behaviors or resisted care during the look back period. III. Record review The care plan, initiated on 2/18/21 and revised on 5/11/21, identified the resident was admitted with a possible deep tissue injury, with an update on 2/25/21 of bilateral buttocks wounds. Interventions included: -Use a draw sheet as tolerated to aid in bed mobility. -Encourage me to drink my dietary supplement to aid hydration and protein in my diet for wound healing. -Education given and encouragement to turn off of my back. Help me with turning and repositioning frequently when in bed. Educate me on the importance of repositioning when I decline. Updated 2/24/21. -I have a pressure relieving mattress on my bed and a cushion in my wheelchair. I now have an alternating air mattress. Updated 2/24/21. The progress note dated 2/24/21 at 10:56 a.m. written by the assistant director of nursing (ADON) documented, I was requested by wound nurse this am around 9:30 a.m. to aid in assessing wound formation. Therapy repositioned the resident and removed a bedpan from underneath her. There is a gray, semi-hardened non-blanching bilateral linear SDTI to bilateral buttocks, measuring approximately 20 cm in length by 2 cm in width. Site does not blanch, [CONDITION(S)] noted to peri-wound with purple linear lines near the gray discolored area. There is an impression of what appears to be a handle of a bedpan next to the discolored area. Resident denies pain at site. When asked, the resident stated she asked to be placed on the bed pan last night and fell asleep. During this statement she seemed to be questioning her own statement so this nurse asked to seek clarification if it was in the a.m. or last night that she asked for the bedpan, she states she believes it was last (evening) but she fell asleep. Direct care staff being interviewed. Starting skin prep to site to aid in hardening of skin to prevent damage. Work order placed for alternating air mattress to aid in off loading pressure. Physical therapy (PT), who already is working with residents, alerted and will provide additional measures to promote wound healing. Alert to MD (medical doctor). The progress note dated 2/24/21 at 10:01 a.m. licensed practical nurse (LPN) #3 documented, This nurse visited with resident at approximately 0815 this morning. Resident covered with sheet. Resident conversed with this nurse. Took medications. This nurse took time to clean the resident's bedside table. Asked if she needed anything further. Resident stated that she did not. At no time during this visit was this nurse alerted that the resident was on a bedpan. IV. Resident interview Resident #16 was interviewed on 5/5/21 at 10:20 a.m. She said the night of the incident she had requested a bedpan. She said after placement on the bed pan she had fallen asleep and no one had checked on her until the therapist arrived the following morning for therapy. She said that was when the staff had discovered the bedpan had been there overnight. She said she did not recall a staff member checking on her throughout the night. V. Investigation by the facility The bedpan was discovered by the therapy department during treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The statement written by the PTA and the COTA documented, 2/24/21 Between 9:00 a.m. and 9:30 a.m. Treatment Session During treatment session, (we) went to roll (the) resident for changing (her) incontinence pad and noticed (a) bed pan underneath (the) resident's buttocks. When asked how long she had been on the bed pan, the resident could not remember as she reports falling asleep with it underneath her. After resident was rolled to her right, off of the bed pan, and the bedpan removed, there was noted indentations on her buttocks outlining the shape of the bed pan. Immediately notified wound nurse who was present during treatment session. Wound nurse (LPN #3) observed and ADON notified. The facility began an investigation that included interviews with the assigned aides to Resident #16 for the past 11.5 hours. CNA #1's written statement said, I, CNA #1, went into Resident #16's room at 10:00 p.m. She asked for a bed pan so she could try to go so I told her to call when she was done. I went in there about 10 mins later to get her vitals and asked if she was ready and she said no not quite. I responded after getting her vitals to call when she was done and proceeded to walk out. I was in a rush to go get all the Med A/weights/fall vitals I forgot to get, and overnights (night shift) arrived. I got (went over) the right side (of the hall) with CNA #4 and NA (nurse aide) #1. I forgot to report to CNA #3 about Resident #16 being on the bedpan. Signed CNA #1 2/24/21. CNA #3's written statement said, To whom it may concern: On 2/23/21 upon coming onto my shift I completed rounds at 10:30 p.m. with the current shift, being CNA #1 on (assigned hall). Upon getting to Resident #16's room we peeked in on her and I asked her if she was ok and did she need anything. She replied telling me no. During rounds I was informed that Resident #16 was ok and had just recently been checked on and her foley emptied. We continued with rounds. At 1:00 a.m. I entered Resident #16's room on rounds and emptied her trash and asked her if she needed anything and did she want to be repositioned, to which she replied no. Again on 5:00 a.m. rounds I entered Resident #16's room and checked to see if she needed anything. Again she replied with no. I also asked her if I could reposition her and again she refused. Around 5:45 a.m. she put on her call light, when I entered her room she told me she wanted to get up since she was awake, and she wanted to get dressed and around, I told her to let me find out from day shift the routine with her and that she might have to wait until day shift comes on to get up because I don't know her routine. I reported this to CNA #2 during rounds so that she was aware of it. Also the day shift nurse LPN #3 asked whom I was talking about and when I told her she said Resident #16 was on isolation and could not come out until Friday. I told her yes I was aware if that and Resident #16 just wanted up. Signed CNA #3 dated 2/24/21. CNA #2's written statement said, To whom it may concern, On February 24, myself along with (night shift) CNA's started morning rounds down (assigned hall). I proceeded with aides to do visual checks on residents. During rounds (night shift) aides informed me that Resident #16 wanted to get up out of bed. At that point we continued rounds. Around 8:00 a.m. I coordinated with therapy for assistance getting the resident out of bed. Around 8:30 a.m. - 9:00 a.m., I noticed the resident's call light was on, so I went to answer the light to be informed that the therapist/wound nurse requested the ADON or DON. I went to report to ADON. Signed CNA #2. CNA #4 was interviewed on 2/24/21 at 9:50 a.m. She stated she did not go into the room at all during the night. States she only goes in if the other aide who is assigned her needs help. CNA #4 stated that Resident #16 call light did not go off last night until the morning shift change. CNA #4 said she saw CNA #3 gown up and go into Resident #16's room right before day shift came in. CNA #1 was interviewed and said she placed the bed pan under Resident #16 before she left at 10:00 p.m. She said she had forgotten to pass it on. VI. Conclusion to investigation The facility determined that CNA #1 placed the bedpan under Resident #16 at the end of her shift and forgot to report it to the oncoming shift. CNA #1 had NA #1 help with rounds that were not familiar with working in that group. It was determined that physical rounds (going into the room physically checking) were not done by either night or day shift but both day and night shifts checked in with residents verbally. It was determined that the resident did fall asleep and even when staff went in to check on her she did not report bedpan being under her. VII. Corrections implemented by the facility Resident #16 was provided with an alternating air mattress. PT performed ultrasound and diathermy therapy on Resident #16's wounds. Resident #16 was placed on ensure clear. Resident #16 was referred to the inhouse wound physician. Skin prep was utilized for deep tissue injury to help [NAME] the fragile skin. The care plan was updated to reflect new interventions. The staff were strongly encouraged to reposition and education was provided on the importance of repositioning. CNA #1, #3, and #2 were provided education immediately and were given an individual performance improvement plan. All residents were assessed for neglect on 2/24/21. Investigation was completed 2/26/21. The facility reported the incident to the survey state agency on 2/24/21. The facility continued to monitor repositioning with random audits that consisted of the charge nurse placing a card near/under a resident. The time the placement of the card would be documented and the time the card was returned to the nurse would also be recorded to ensure the staff continued to reposition timely. The monitoring was ongoing. All staff re-educated on the importance of checking residents timely and repositioning. The training was completed 3/9/21. Date of compliance was 3/9/21. VIII. Outcome Resident #16's SDTI was determined resolved on 4/27/21.

Based on observation, record review, and interview, the facility failed to ensure a resident (#1), who entered the facility without a pressure ulcer, did not develop a pressure ulcer, unless the individual's clinical condition demonstrated that it was unavoidable. Specifically: -The facility failed to ensure the wheelchair of the resident, who spent most of the day in the wheelchair, was properly adjusted and fitted with effective pressure relieving devices, to prevent the development of a pressure ulcer. -The facility failed to ensure the resident's wound was evaluated after each change in status, as it progressed through four stages over a 37-day period, from a Stage 1 pressure ulcer to an unstageable pressure ulcer. -The facility failed to identify and remove underlying risk factors contributing to the development and progression of the pressure ulcer. The findings include: 1. Facility Policy The facility's Prevention of Pressure Ulcers policy, dated 3/2005, included the following "general preventive measures" in pertinent part: " ...3. For a person in a chair: change position at least every hour; use foam, get, or air cushion as indicated to relieve pressure; ...6. Refer resident to a rehabilitation program, or a restorative program, as indicated; ...9. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown; 10. Immediately report any signs of a developing pressure ulcer to the supervisor; 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate ..." 2. Record Review a. Resident Status Resident #1 was admitted to the facility on [DATE], with diagnoses, including [MEDICAL CONDITION], convulsions, [MEDICAL CONDITIONS], anxiety, and behaviors. The resident had an external Texas catheter. The quarterly minimum data set (MDS) assessment, dated 2/25/15, indicated the resident had severely impaired cognitive skills for decision-making. The assessment indicated the resident did not have a pressure ulcer. The resident required extensive assistance for all activities of daily living, except for eating, for which he required supervision. Two of the resident's family members were his co-guardians. A quarterly social services assessment, dated 2/24/15, read, in pertinent part: "Resident noted to have behavior issues this quarter; medications adjusted. (Resident) is most often pleasant and cooperative with care but does have occasional outbursts ...Short and long-term memory loss, impaired decision-making. Has legal guardian. Impaired vision; non-verbal but can communicate through sounds and a few words; can answer yes/no questions; supportive family; W/C (wheelchair) bound; no plans for d/c (discharge)." b. Wheelchair Prior to 2/27/15, the resident used a wheelchair which had a scooped seat pan, designed to alleviate pressure to the buttocks. On 2/27/15, a family member brought in a new wheelchair for the resident. A nurse's note, dated 2/27/15, read, "Resident has new chair that (family member) bought him. Will monitor resident to see how he is adjusting to new chair. Resident pleasant this evening." The resident's Skin care plan, initiated on 11/18/08, indicated that the resident "gets a rash sometimes on his arms and legs and he scratches at them. I also don't move as much as I should." Approaches initiated at this time included: "Evaluate/Recommend and assist with obtaining effective relief devices; Nurse to do weekly skin assessment; reposition (Resident) frequently when in W/C and in bed at night." On 2/27/15, the following approach was added to this care plan: "Observe and check for pressure areas r/t (related to) new W/C." Record review revealed that the first evaluation made of the new wheelchair was on 3/26/15, 28 days after the resident started using it. The director of rehabilitation (DOR) services wrote the following report after evaluating the wheelchair: "The current wheelchair (a tilt-in-space style chair) the resident is in, provided independently from an outside vendor per family request, is not a proper fit. The set width appears adequate; however, the seat depth is too short by several inches, as (Resident) is a tall man. The chair is lacking approximately 4 inches of support to the resident's thighs, creating a potential for increased fall risk and for skin shearing, as (Resident) has been observed sacral sitting in the wheelchair. The headrest was not adjusted for proper fit, so that if the resident was tilted posterior, he would not have adequate head support. As well, the armrests, with the resident's left shoulder presenting elevated more than the right shoulder. (Resident's) sister was present while his current wheelchair was measured and was made aware of the recommendations for a longer seat depth to provide additional support to the resident. As well, the resident may benefit from a different style cushion to prevent potential for skin breakdown, as the resident reported to this PTA (physical therapy assistant)/DOR preference to stay in chair for majority of his days. This DOR recommended to the resident's sister, that since they are pursuing a private purchase wheelchair rather than a wheelchair provided in-house, she (family) contact the vendor to ensure proper fit to decrease risk of falls and skin breakdown." As of 4/16/15, when the resident was transferred to the wound clinic, the resident was still using this same wheelchair, which he received on 2/27/15. No adjustments were made to the wheelchair or the cushion after the 3/26/15 evaluation. c. Wound Progression On 2/27/15, when the resident first used the new wheelchair, the resident did not have any pressure areas. The record included the following nurses' notes: -3/4/15: "Resident with a red 5 x 5 area under left buttocks, area cleaned and [MEDICATION NAME] applied, to be changed every third day." -3/5/15: "Buttock dressing not intact, area cleansed with wound wash and new dressing applied." -3/7/15: "Dressing to left buttock missing, cleansed wound and applied new dressing." -3/10/15: "Resident in his wheelchair. Does mobilize self with his feet for short distances ..." -3/11/15: "New order received and noted for calcium alginate to left buttock area." -3/13/15: "Resident with a red open area 5 x 5 area under left buttocks, area cleaned and dressing applied to be changed daily, PRN (as needed)." -3/15/15: " ...Staff applied dressing to open wound on left gluteal fold and repositioned res. Will cont. to monitor." -3/28/15: "Resident has open area 3 x 4.5 cm and 2.5 cm deep to left lower buttocks. Open area cleaned with wound cleanser. Packed with silver calcium alginate. Borderfoam dressing applied over open area. zinc fixation tape tape applied over dressing. DON and ADON notified. MD notified. (Family member) of resident is getting new Roho ( a type of pressure reduction/re-distribution) cushion for chair, she has been experimenting with different products and parts of chair. Resident in bed. Will continue to monitor." -4/7/15: "Treatment to left buttock done per orders. Moderate amount of black drainage noted on removed bandages. Foul odor also noted. Area cleansed and santyl with calcium alginate with borderfoam 4 x 4 and inc tape applied. Resident tolerated procedure well." -4/8/15 (11:24): "New order received and noted to refer to wound clinic for debridement if okay with family. This nurse has called (family member) and messages left to please call facility. Call placed to ____ wound nurse specialist in regards to wound. New orders received and noted for treatment per standing orders, faxed placed to Dr. ___ in regards to change in wound." -4/8/15 (19:00): "Dressing on bottom intact. Foul odor coming from wound. (Wound nurse specialist) notified facility and will be in tomorrow morning." -4/9/15: "Dr. ___ in on rounds to see wound to buttock and culture sent over per Dr. ___ new orders ..." (This physician's report, dated 4/9/15, read, in pertinent part: exudates: heavy; wound bed: 100% black lysing necrotic tissue oozing BM - 3 cm tunnel at 3" - ...Santyl/TAO to expedite recovery of a viable wound bed...Report condition to PCP (primary care provider) ASAP ) as soon as possible for further treatment.") -4/10/15: " ...Resident over to ___ wound clinic and returned ..." (This wound clinic report, dated 4/10/15, read, in pertinent part: "Wound care consult, initial consult ...He is in clinic for evaluation and treatment plan regarding an ulcer that has developed within an uncertain time frame. Per his (family member) and care providers, he spends most of his waking time in his wheelchair and does not like to be in bed. Report is that he is up sometimes till 02:00 or 03:00 in his chair. (Resident is incontinent and skin in the area of the wound has a red inflamed appearance with possible fungal development at the borders of the wound ...Stage: unstageable; Length: 1.3 cm; Width: 3.8 cm; Depth: 4.30 cm; % Slough: 100%, yellow; ...Drainage: Serous ...Wound Debridement Method Comment: Loose and semi-attached slough remove using #15 blade, scissors and forceps without bleeding. Some of the deep necrotic tissue was removed as well short of getting into bleeding tissue. The firm thick deeper necrotic tissue was left in place, probable surgical sharp debridement for this tissue if OR (operating room) controlled environment ...(Resident) should be kept out of his chair for now and repositioned every 1 to 1 ½ hours...") -4/12/15: "PCP in on rounds, this nurse spoke with him and updated on resident's wound care status." -4/13/15: " ....received orders to give [MEDICATION NAME] ...before CT (scan).." -4/16/15: "Resident transferred to ____ today for wound care ..." 3. Observations and Interviews a. Certified Nurse Aide (CNA#1) On 4/22/15 at 11:50 a.m., CNA #1 verbalized that she often worked as the shower aide. With regard to resident #1, the CNA said, "It fluctuated in color depending on the day - sometimes pink and sometimes purplish. It was about this big (showing the size to be the size of a softball). I left on a Friday, and when I came back on Monday (March 16), it was open. We were surprised." b. Director of Nursing (DON) and CNA #2 During an interview with the DON and CNA #2 on 4/22/15 at 12:05 p.m., the following was reported: -(DON): When the new wheelchair came in on 2/27/15, the facility "put a ROHO cushion on it, but it didn't fit great - it was for another wheelchair ...The (family member) had one on order." -(DON): Approximately one week later the vendor put its own cushion in the wheelchair which was not a ROHO cushion. "The ROHO cushion was put on a non-used wheelchair." -(CNA #2): "He kept moving around in it - the seat part needed to be longer and the tilted back was too far back. We had to put a pillow." -(DON): "When I found out about it, I asked therapy to look at it." c. Observations of the Wheelchair On 4/22/15 at 12:15 p.m., an observation of the resident's wheelchair was made with the DON. The wheelchair did not have a sling-like bottom, like other wheelchairs in the facility. Rather, it had a flat, firm bottom, with a 3-inch cushion on it. The DON explained that the length of the wheelchair was too small for the resident. d. Director of Nursing and Director of Rehabilitation (DOR) Services During an interview with the DON and the DOR on 4/22/15 at 12:50 p.m., the following was verbalized: -(DOR): "The DON and ADON(assistant director of nursing) asked me to check the chair at the end of March. I went in and his (family member) was in the room. The width was fine. It was the depth. I spoke with the (family member) to contact family to get a better fitting chair since it wasn't an appropriate fit ...The (family member) said it was a trial ...He's (the resident) not on caseload ..." -(DON): "We told the (family member) to contact the company. The (family member) had a difficult time getting a hold of the company." e. Director of Nursing and Wound Care Nurse (WCN) During an interview with the DON and the WCN on 4/22/15 at 2:35 p.m., the following was communicated: -(WCN): On 3/13/15, when the status of the pressure ulcer changed from a stage 1 (closed) wound to a stage 2 (open) wound, "We sent a FYI fax (to the physician) but didn't hear back." The WCN verbalized that standing orders were used for treatment of [REDACTED]. -(WCN): The resident frequently had bouts of diarrhea. -(WCN): On 4/2/15, when the pressure ulcer now had a depth measurement, a FYI fax was sent to the physician and standing orders were used for treatment. -(DON): The resident's Texas external catheter leaked every day. "I brought this up to the family a couple weeks ago." The DON acknowledged that this conversation was not documented, and that the physician was not involved in this discussion with the family. -(DON): The DON indicated that the care plan approach to "evaluate/recommend and assist with obtaining effective pressure relief devices" was the responsibility of the wheelchair vendor. "If (the family member) hired a company, that's what they would do." -(DON and WCN): The wound care consultant normally came to the facility on ce a month. The first time the wound care consultant examined the resident's pressure ulcer was on 4/9/15, 28 days after the wound first opened (on 3/13/15). -(DON and WCN): The new wheelchair was a major contributing factor to the development of the resident's pressure ulcer, along with incontinence. f. Facility Failures The facility failed to ensure resident #1 was provided the care and services necessary to prevent the development of a pressure ulcer, as outlined below: -The facility failed to ensure the resident's wheelchair was properly adjusted and fitted with effective pressure relief devices from 2/27/15, when the resident started using the wheelchair, through 4/16/15, when the resident was transferred to the wound clinic. -The facility failed to ensure a therapy evaluation of the wheelchair was conducted in a timely manner. After the rehab specialist determined on 3/26/15 that the wheelchair "was not a proper fit" and that the resident could "benefit from a different style cushion to prevent potential for skin breakdown," no change was made to the resident's wheelchair. -The facility failed to ensure the resident's pressure ulcer was evaluated by pertinent interdisciplinary team members after each change of status of the wound. -The facility failed to ensure underlying risk factors contributing to the development and progression of the pressure ulcer were identified and removed, per facility policy. -The facility failed to ensure the wound care consultant was utilized in assessing the resident's wound from 3/4/15 through 4/8/15, when it progressed from a Stage 1 pressure ulcer to an unstageable pressure ulcer.

Based on observations, record review, and staff interviews, the facility failed to ensure one of 26 sample residents (#94) received the care and services necessary to maintain her highest practicable level of well-being. Resident #94 began complaining of right jaw pain on 5/5/14. On 5/7/14, the resident was observed holding the right side of her face which was swollen and red. She said her jaw "hurts so much" that she was not eating or drinking. Nursing staff failed to assess and communicate the resident's increasing symptoms to the physician and failed to manage her pain. The findings include: 1. Resident Status Sample resident #94, age 78, was admitted to the facility on [DATE] with diagnoses, according to the facility face sheet, of [MEDICAL CONDITION], [MEDICAL CONDITIONS], and acute kidney failure. The 4/16/14 minimum data set (MDS) assessment included a Brief Interview for Mental Status (BIMS) score of 14 out of 15, suggesting minimal cognitive impairment. The 4/22/14 care plan for pain documented the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] disc disease. She took [MEDICATION NAME] three times a day and had as needed (PRN) [MEDICATION NAME] or Tylenol on order. The goals were that the resident did not want to suffer any uncontrolled pain over the next three months and she wanted to be able to state pain relief within one hour from receiving pain medication or alternative methods offered over the next three months. The approaches included trying alternative methods for pain relief such as playing soft music, repositioning, warm compresses, notifying the medical doctor if pain medication was ineffective or had side effects, and report any signs or symptoms of pain to the nurse. Computerized Physician order [REDACTED]. -Order dated 1/14/14-[MEDICATION NAME]-[MEDICATION NAME] tablet ([MEDICATION NAME]) 37.7-325 milligram (mg) 1 tablet orally three times a day, 5:30-6:30 a.m., 11:00-2:00 p.m., and 7-11:30 p.m., for pain -Order dated 1/14/14-[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) - Schedule III tablet 5-325 mg 1 tablet orally, give every four hours/PRN for pain -Order dated 1/14/14- Tylenol 650 mg tablet; 325 mg 2 tablets orally PRN, give every four hours do not exceed 3 grams in 24 hour period for pain and temperature 2. Facility failure to recognize, assess, and communicate the resident's worsening symptoms of pain and signs of a red, swollen area near her jaw Observations/Resident Interviews: On 5/7/14 at 3:53 p.m. resident #94 was interviewed in her room. She stated she had pain on the right side of her face, cupping her right cheek and jaw. Her jaw line appeared red and swollen near her cheek and ear. At 4:00 p.m. resident #94, holding her hand to her jaw and grimacing, stated, " My jaw, it hurts. Some think it's my ear, it may be plugged up." She said her doctor was on vacation so she couldn't see him. Her eyes filled with tears and she said, " I'm skipping meals now because it hurts so much. I can't sleep either. " At approximately 4:15 p.m. resident #94 was in her wheelchair near her sink/vanity area. She was attempting to make a warm compress for her right jaw with a white washcloth. She stated that her jaw hurt and pointed to the area near her right ear and lower jaw. It was red and swollen. She repeated that she was not going to go eat dinner because it hurt and she hadn't been eating or drinking much the last couple of days because of the pain. Record Review: On 5/5/14 at 5:32 p.m., a progress note stated that the resident complained of soreness and swelling on the right side of her face and throat, especially around her ear. The resident did not have a fever at that time. The resident's physician was notified. On 5/6/1/4 at 1:52 p.m., Registered Nurse (RN) #10 documented in the progress notes that the resident had a red, painful, swollen area to right mandibular area. Resident reported that she had difficulty opening her mouth due to the pain. The RN noted there was no obvious injury to inside the resident's mouth, but the area was painful upon palpation. The resident also complained of difficulty hearing from right ear, and the RN noted there was ear wax in the ear canal. The Medical Director (MD) (and the resident's personal physician) was notified and gave an order to refer the resident to a specialist. An appointment was made for 5/12/14 (in six days time) and the resident's power of attorney (POA) was notified. The MD instructed the nurse that he was to be notified if the resident's condition worsened. No further progress notes were entered for 5/6/14 about the resident's red, painful, swollen right mandibular area; specifically, whether her pain was managed by her prn medications, whether alternative measures to relieve pain were implemented, and whether the resident was consuming sufficient food and/or fluids. On 5/7/14 at 4 p.m., progress notes for the day were reviewed. There were no progress notes indicating an assessment of the resident's right mandibular area and her pain, as expressed during resident interviews above on 5/7/14. Moreover, there was no indication of communication with the RN charge nurse or Director of Nurses (DON) or any further communication with the Medical Director. Staff Interviews: On 5/7/14 at approximately 4:20 p.m., the charge nurse (RN #7) said she had not observed the resident "recently", and had seen her the day prior but not that day. She then went to the resident's room, took resident's temperature and looked in the resident's ear. She noted the resident's right jaw was swollen and red and said, "She didn ' t look like this before, she didn't look like this yesterday; she is much more swollen." She stated she could see the resident's inner ear and the resident did not appear to have a fever. She stated that the resident had an appointment scheduled with a specialist on 5/12/14. She also stated that the doctor would be in the facility the next day and he would see her then. She did not call the Medical Director or notify the DON of the increased swelling she had observed. . On 5/7/14 at approximately 4:45 p.m., the DON said that she was not aware of resident #94's condition change of increased pain, jaw swelling and reddened jaw line area. Upon being informed of the condition of the resident's jaw (red, painful, and per RN increased swelling), the DON immediately called the Medical Director. The DON did not assess resident #94 prior to contacting the doctor for an order or contact the RN charge nurse for an assessment. She said the physician would be in the facility the next day and he would see the resident at that time. The physician ordered an antibiotic ([MEDICATION NAME]) and warm compresses by telephone order.) On 5/7/14 at 5:10 p.m., LPN #5 who was responsible for the resident's care on the day shift 5/7/14 said the resident's condition was worse than it had been previously as demonstrated by increased swelling and pain. She said she had not told the charge nurse or DON of the symptom changes and had not notified the Medical Director of the resident's increased symptoms. On 5/13/14 at approximately 2:30 p.m. the DON was interviewed again. She said: -When the resident's symptoms progressed and worsened on 5/7/14, the LPN should have notified the RN charge nurse or her (DON) of the condition change, as well as the Medical Director as set forth in his telephone order to monitor and notify of changes. -The resident had presented with increasing symptoms that constituted a change in condition. (On 5/8/14 at morning report, the night nurse had noted that the resident had developed a fever overnight but had not contacted the physician.) She said that any time a nurse noted a resident's change of condition; it was her expectation the nurse would contact nursing administration or the physician. She said, in both instances, as soon as she was aware of the condition changes, she had immediately contacted the physician for instructions. On 5/15/14 at 8:33 a.m. the Medical Director was interviewed via telephone. He said he was aware of the resident's condition on 5/6/14 and had told the facility to make an appointment with an Ear, Nose and Throat Specialist. He had also told them to contact him if the resident's condition worsened. He said he had not heard back from the facility until 5/7/14 at approximately 5 p.m. when the DON called and said the resident's face was more swollen and her pain had increased. (see interview above). He said he started antibiotics at that time because he thought it was an infection of the parotid gland and when the resident spiked a temperature the next morning, he had her transferred to the hospital for care. 2. Facility failure to manage the resident's pain Resident Observation and Interview: See interview above with resident #94 on 5/7/14 at 3:53 p.m. The resident was tearful and holding her jaw, stating that her jaw "hurt so much" that she was not going to dinner. On 5/7/14 at 5:07 p.m. the resident said she did not know if she had received anything extra for pain that day. She said, "I don ' t think so because if I have, it hasn ' t helped at all." Record Review and Staff Interview 5/7/14: The resident's medication administration record (MAR) was reviewed on 5/7/14 at 4 p.m. According to the MAR, the resident had not received any prn medication that day. . Review of progress notes on 5/7/14 at 4 p.m. revealed no documentation regarding the resident's pain or pain management (pharmacological or non-pharmacological). And, as noted above, no documentation of an assessment of her jaw. On 5/7/14 at 5:10 p.m. LPN #5 was interviewed. She said she had given resident #94 her pain medication at 8:00 a.m., 12:00 p.m. and 4:00 p.m. However, see above; at 4:00 p.m., MAR for [MEDICATION NAME] administration was blank for 5/7/14, indicating the medication had not been given that day. In addition, the pain management flow sheet and the narcotic count sheet were likewise blank, indicating [MEDICATION NAME] had not been administered. LPN #5 stated, "I gave her medication three times today but I didn't record any of those meds because I'm really bad at that." She stated she had asked the resident if the medications were effective after administering them, but she had not documented those responses either. She stated, "The [MEDICATION NAME] did not help much." She said she hadn't talked to the RN charge nurse or the resident's physician about the resident's condition that day. Record Review 5/8/14 The resident's MAR and progress notes were reviewed again on 5/8/14 at 8:30 a.m. At this time: -The MAR reflected [MEDICATION NAME] had been administered on 5/7/14 at 8 a.m., 12 noon, 4 p.m. and 8 p.m. All entries on the pain management record stated the resident had rated her pain at 8 or 9 out of 10 on the pain scale. After administration, the resident had rated her pain as 4 out of 10 on each instance. All were documented by the same LPN (LPN #5). The progress notes revealed the following notes entered for 5/7/14 by LPN #5: --At 8:00 a.m. the resident complained of right jaw pain area. The area was noted as slightly swollen. The resident was given [MEDICATION NAME] as ordered for pain. --At 9:15 a.m. the resident said the [MEDICATION NAME] had helped some but she still had pain at a level 4 out of 10. The resident's appetite was noted to have diminished. LPN #5 noted she would continue to monitor the resident's condition. --At 12:00 p.m. the resident continued to complain of right jaw pain, saying her pain was then at a 9 out of 10 on a pain scale. [MEDICATION NAME] was again given to the resident. --At 1:00 p.m. the resident said she rated her pain as 4 out of 10. --At 3:15 p.m., resident's right jaw was noted as more swollen area and warm to touch. LPN #5 stated she informed the charge nurse of the resident's condition and that resident needed an appointment with doctor/specialist before 5/12. She said she was informed the resident's physician would be in to see her the next day. The resident requested another pain pill, and was told she could have another at 4:00 p.m. --4 p.m., [MEDICATION NAME] given for right jaw pain. The DON had told LPN #5 that the resident would be started on the ordered antibiotic as soon as it was delivered. --At 4:05 p.m. an order was received for [MEDICATION NAME] related to pain and swelling on right side of neck/ear. The order was called in to the pharmacy. --At 5:00 p.m. the resident was able to eat some sorbet and a fortified shake as well as some watermelon. The resident rated her pain (after [MEDICATION NAME] administration) as 4 out of a pain scale of 10. A progress note dated 5/8/14 at 8:15 a.m. noted the resident had presented with a fever of 100.3 degrees Fahrenheit and her pulse was 140 beats per minute. The resident was transferred to the emergency room and admitted for an infected parotid gland and dehydration. Interviews: On 5/13/14 at approximately 2:30 p.m. the DON was interviewed again. She said: --If pain medication was not effective in managing a resident's pain she expected the nurses to notify her or the charge nurse, so the resident's condition could be assessed and reported to the physician as needed, --She was not aware LPN #5 had not documented the three administrations of [MEDICATION NAME] on 5/7/14, and --It was her expectation for the nurses to document the medication promptly when it was administered and the effectiveness of the medication after each as-needed pain medication administration. On 5/15/14 at 8:33 a.m., the Medical Director stated he expected the facility to notify him promptly when a resident's pain level was not controlled with ordered medication.

Based on observations, record review, and interviews, the facility failed to ensure residents on the secure unit, including two of five sample residents (#1 and #2) were provided adequate supervision and assistance to prevent accidents. Specifically: Resident #1, who was admitted to the secure unit on [DATE], exhibited physical and verbal aggression toward residents shortly after her admission to the unit. The facility failed to implement measures to ensure resident #1's care was individualized and effective and her supervision adequate to protect residents on the secure unit, including resident #2, towards whom resident #1 was known to direct some of her aggression. On [DATE], resident #1 pushed resident #2 into a metal cart. Resident #2 sustained multiple fractures and expired at the hospital on [DATE]. The findings include: A. Residents and Resident Environment 1. Resident #1 Resident #1, an [AGE] year old female, was admitted to the facility on [DATE], discharged [DATE] and re-admitted [DATE]. According to her face sheet, her [DIAGNOSES REDACTED]. According to her most recent minimum data set (MDS), dated [DATE], the resident could not participate in a brief interview for mental status (BIMS) due to rarely or never being understood. She was noted as having physical behavioral symptoms directed toward others one to three days out of a seven day period, as well as verbal behavioral symptoms directed toward others, and more frequent (four to six days out of seven) symptoms not directed towards others. She needed supervision and oversight for ambulation on the unit, and was noted as wandering. 2. Resident #2 Resident #2, an [AGE] year old female, was admitted to the facility on [DATE]. She was discharged to the hospital [DATE] and expired there on [DATE]. According to her face sheet, her [DIAGNOSES REDACTED]. According to her most recent MDS, dated [DATE], she was unable to participate in the BIMS and her cognitive skills were severely impaired. She was noted as having physical and verbal behaviors directed towards others one to three days out of a seven day period. She was independent with ambulation and was noted as wandering. 3. Resident Environment Resident #1 and #2, along with six other residents, resided on the secure unit. By observation and staff interviews [DATE] and [DATE], all of the residents on the secure unit had impaired cognitive ability and most had impaired mobility. Residents were observed to wander the unit, entering resident rooms, and to approach visitors, staff, and other residents and begin to talk or touch the other person. B. Failure to protect residents on the secure unit from resident #1's aggressive behaviors 1. Resident #1's status on admission - Knowledge of inappropriate behaviors that put self and others at risk - Facility response. Record review revealed on [DATE], prior to resident #1's admission, the facility was faxed resident #1's long term care professional medical information. -The information included the resident had delusions, hallucinations and mood instability with supervision needed for agitation, impaired judgment, medication management and memory impairment. -The report also identified the resident had experienced depression and anxiety for years, angered easily and would yell at family members. She was noted as verbally aggressive toward family members and having a dementia diagnosis. -The report stated that the resident required supervision due to exhibiting inappropriate behaviors that put self, others at risk and required more than verbal redirection to interrupt inappropriate behaviors. The facility developed a care plan on [DATE], identifying resident #1 as having altered mood state related to depression [DIAGNOSES REDACTED]. Interventions included: one to one social service visits as needed, contact physician if increased signs or symptoms of depression or anxiety. On [DATE], a care plan addition read to refer to (psychiatrist) or a mental health facility. 2. Incidents of resident #1's aggressive behaviors after admission, culminating in harm to resident #2. [DATE]: A nursing note stated, "Staff reported resident found sitting on her roommate's bed, while her roommate was laying in bed yelling. Yelling at her to "shut up! Or I am going to kick your (expletive). "Resident immediately removed from room. Will sleep in (another) room for tonight. Staff instructed to do Q5 (every 5 minutes) check on resident to ensure safety of both residents. Will monitor." [DATE]: A nursing note stated in pertinent part, "In evening she was very accusatory of staff and residents. " [DATE]: A nursing note stated in pertinent part, "CNAs (certified nurse aides) report resident's disruptive behaviors. Needs one on one staff while she is awake." [DATE]: A nursing note at 10:00 p.m. stated, "Resident in reclined chair, (resident #2) sitting next to her in different chair. (Resident #2) leaned over in her chair toward (resident #1) and (resident #1) smacked her on the arm. No bruising, redness or swelling to (resident #2's) arm. CNAs reported that she has been hitting her on several occasions. This nurse reported to CNAs to try and keep them away from each other." [DATE]: A nursing note at 9:00 p.m. stated, "This nurse witnessed resident yelling at (resident #2) that she was "going to cut her up into to (sic) little pieces if she didn't stop looking at her." Res (resident #1) not easily redirected. Residents were separated to different parts of the room. On another occasion (resident #1) stated, "I'm going to slap her face if she doesn't stay away from me." Tried to redirect resident again but not effective. Resident continues to yell and cuss at staff throughout the shift. Will continue to attempt to redirect." [DATE]: A nursing note at 8:00 p.m. stated, "CNAs reported that (resident #1) slapped other resident x 3 this evening whenever she came near her while she was reading the paper." (The resident who was slapped was not identified.) [DATE]: Two nursing notes on this date indicated the resident was found pulling a resident out of their bed and, when redirected went across the hall, attempted to pull another resident out of her bed. [DATE]: A report was received from the facility, dated [DATE], which stated in pertinent part: -"At approximately (9:00 p.m.) resident (#1) pushed resident (#2) stating she told her if she walked by her again she would, "knock her out." Resident #2 complained of arm pain, upon assessment, RN (registered nurse) notified DON (director of nursing) at 9:10 p.m. DON requested to notify PCP (physician) and send resident to ER (emergency room ) for further evaluation." -ER phoned back to state resident had multiple broken ribs and scapula. DON notified and entered facility at 10:15 p.m. at which time administrator (NHA) and social services were notified. Staff on unit doing frequent rounding to monitor resident #1. (Behavioral health facility) contacted and resident information faxed at 10:30 p.m. Medical director notified and M1 (mental health hold) signed. (Behavioral health) stated they would review resident records to see if admission was possible related to primary [DIAGNOSES REDACTED]. Unit staff observing resident frequently to ensure other residents are safe, will await call back from (behavioral health). Review of resident #2's hospital report, dated [DATE], revealed it read, in pertinent part, the resident had been pushed into a metal food serving station and exhibited a fracture of multiple left ribs and left scapula. A subsequent note on [DATE] revealed the resident had expired at the hospital under end of life care. 3. Failure of the facility to respond timely and adequately to resident #1's aggression in order to ensure the safety of residents on the secure unit. a. Failures prior to [DATE] Record review (nursing notes, physician orders, and social service notes) revealed two interventions in response to resident #1's aggressive behaviors between [DATE] and [DATE]. Both interventions were dated [DATE]. One intervention was an order for [REDACTED]. (1) Failure of the facility to evaluate the resident's [DATE] medication change A nursing note, dated [DATE], read in pertinent part, "(Resident #1) is not having any adverse effect from Haldol but I don't think she is having a calming effect." There was no documentation in the resident's record after [DATE] and before the [DATE] incident that the effectiveness/ineffectiveness of Haldol in addressing the resident's behavior was communicated to the interdisciplinary team or the physician to discuss and consider whether alternative interventions should be considered in an effort to address the resident's aggressive behaviors. (2) Failure of the facility to follow up on the [DATE] referral to psychiatry The social services director (SSD) was interviewed on [DATE] at 3:48 p.m. When questioned about the [DATE] referral to psychiatry, the SSD stated she was aware the local psychiatrist was not accepting new patients. She said she would not be the one to follow up on the referral; she said that would be the nursing department. The DON was interviewed on [DATE] at 5:23 p.m. She stated resident #1 had not received an appointment with the psychiatrist since the referral date of [DATE]. Moreover, she said the resident had not received any psychiatric services since she returned to the facility on [DATE]. (3) Failure to develop an effective plan of care that included detailed information on resident #1's behaviors and information for staff on the supervision required to maintain the safety of residents on secure unit. Review of the resident's behavior care plan revealed the sole care plan update referred to the psychiatry/mental health referral which per record review and interview (see above) did not occur after [DATE] until the resident was discharged to a behavioral health facility on [DATE], after the incident involving resident #2. Absent from the care plan was any detailed information on the resident's aggressive behaviors, including what the resident might be trying to express, how the behaviors might be triggered, and how the behaviors could be managed. Staff interviews revealed some information was known to staff but not timely incorporated into resident #1's plan of care. Specifically: Information known to facility from documentation in nursing notes: -Although the nursing notes documented several incidents involving resident #1 and resident #2 and a need to keep these residents apart (see [DATE] note "CNAs reported (resident #1) has been hitting (resident #2) on several occasions ....reported to CNAs to try and keep them away from each other."), there was no reference to resident #2 on resident #1's care plan and no instruction to staff to keep the residents away from one another. -Although resident #1 was documented to need one to one staff supervision while awake (see note [DATE]), was found in other residents' rooms, pulling residents out of bed (see note [DATE]), found threatening serious harm to resident #2 (see [DATE] note), and found slapping a resident who came near her ([DATE]), there was no information on resident #1's care plan instructing staff on the level of supervision resident #1 required in order to keep other residents on the unit safe from harm. -Although the nursing notes documented resident #1 was not "easily redirected" or redirection was unsuccessful (see nursing notes [DATE] and [DATE]), there were no interventions identified on the care plan (or elsewhere in the resident's record) on how to manage the resident's behaviors. Information known to staff and revealed in interviews [DATE]: -On [DATE] at 9:30 a.m., the licensed practical nurse (LPN)/charge nurse for the secure unit who was familiar with resident #1, stated resident #1 usually showed aggression towards staff in the afternoons and the resident's behavior was markedly increased in the afternoons. She indicated residents at risk as a result of resident #1's aggression were those residents similar to resident #2 - small, frail, and a wanderer. -On [DATE] at 1:58 p.m., a secure unit CNA stated resident #1 had frequently hit or been verbally aggressive to other residents and she had informed nursing staff of all issues with the resident. She indicated residents at risk as a result of resident #1's aggression were those that wore a helmet (like resident #2) and wandered. -On [DATE] at 3:48 p.m., the SSD stated she was aware resident #1 had a history of [REDACTED]. See care plan above; none of this information was included in the resident's care plan in order to protect resident #2 and all other residents residing on the secure unit from harm. Interviews on [DATE] with the SSD at 3:48 p.m. and the DON at 5:23 p.m., confirmed no interventions had been developed and implemented prior to [DATE] to keep residents on the secure unit safe from resident #1's aggressive behaviors. -The SSD was unable to identify any interventions that had been attempted beyond separating and redirecting in times of conflict. -The DON, too, stated there were no identifiable attempted interventions prior to [DATE] to address the aggressive and threatening behaviors of resident #1 besides the addition of Haldol in ,[DATE]. The DON further stated she had not reviewed the resident's chart and identified the pattern of resident #1 having multiple issues with resident #2 until after the incident [DATE]. She said when the pattern was discovered, they re-educated staff on reporting and noting behavioral issues and patterns. She stated the incidents of resident #1 slapping resident #2 and saying she was going to cut resident #2 up should have been reported to her immediately; however, they had not been passed on appropriately. b. Failures in facility response [DATE] Staff interviews revealed that on [DATE] and before the incident at 9:00 p.m., licensed staff was aware of aggressive behaviors that day between resident #1 and #2. Licensed staff failed to alert all staff on the secure unit to order to ensure steps were taken, including adequate supervision, to keep them safe. The secure unit CNA who was present when resident #1 pushed resident #2 into the metal cart was interviewed on [DATE] at 3:01 p.m. -The CNA said she was the only staff present in the main room with resident #1, resident #2 and two other residents. She was sitting with a new resident at a dining table, who needed close attention, when resident #2 approached resident #1 who was sitting in a recliner and resident #1 pushed resident #2. The CNA said resident #2 fell on to a cart and started vomiting and she knew that 'something was broken.' -The CNA said she was not aware that resident #1 had made any comment earlier in the day about pushing resident #2. The licensed practical nurse (LPN) who wrote the [DATE] report of the incident was interviewed on [DATE] at 9:30 a.m. -The LPN said she was the charge nurse the night of the incident but not a witness to it as she was not on the secure unit when the incident occurred. She stated she had been on the secure unit earlier that day but nothing had been happening. However, she said she was aware that at one point on [DATE], the facility had separated residents #1 and #2 and she thought at the time that they were doing okay. -The LPN did not indicate additional supervision of the residents was considered or implemented on [DATE]. Another secure unit CNA was interviewed on [DATE] at 1:58 p.m. She was assigned to the unit the night of the incident and frequently worked with resident #1. -The CNA said she was assigned to the unit on the day of the incident and was aware that earlier in the day, resident #1 had taken issue with resident #2 and the residents had needed to be separated. She stated she had occupied resident #2 with a Christmas tree and resident #1 was in her chair watching television. She said she needed to put a resident to bed and that left one CNA in the main room with the residents. -The CNA did not indicate she informed the remaining CNA about the earlier incident involving resident #1 and #2. c. Failures after [DATE] In the interview with the secure unit LPN/charge nurse on [DATE] at 9:30 a.m., she stated resident #1 still posed a threat due to the fact that there were other residents in the secure unit who matched the profile of resident #2 - small, frail, and wandering into other residents' space. She further stated that although when the resident returned on [DATE], she seemed to have fewer behaviors, since that time her behaviors had seemed to increase back to the baseline of fixating on other, smaller residents and being hostile towards them. In the interview with the secure unit CNA on [DATE] at 1:58 p.m., she, too, stated that since the resident had returned from the behavioral health facility on [DATE], she had become focused on another resident who wandered and wore a helmet, like resident #2. See care plan above; resident #1 care plan revealed no updates after her return on [DATE] that alerted staff to the resident's focus on certain residents that matched resident #2's characteristics and to her hostility toward them. See also DON interview above; the resident had not received any mental health services since her return on [DATE]. Cross-reference F309 for further details regarding failures in resident #1's care and services.

Based on observations, record review and interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of eight sample residents (#2). Specifically: The facility failed to ensure the on-going safety of resident #2, who was assessed with [REDACTED]. The resident experienced 26 falls in less than six months, resulting in a subdural hematoma, before the resident was transferred to the secure unit for "increased supervision." The findings include: I. Facility Fall Prevention Program The facility's policies on prevention of falls ("Falls and Fall Risk, Managing", "Assessing Falls and Their Causes," and "Falls-Clinical Protocol") were received and reviewed on 4/21/11. The policies read, in pertinent parts: "The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls." . . . "1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes... 3. Fear of falling may limit an individual's participation in activities. 4. Falling may be related to underlying clinical conditions of functional decline, medication side effects, and/or environmental risk factors. 5. Residents must be assessed in a timely manner for potential causes of falls. 6. Relevant environmental issues should be addressed promptly"... "The staff, with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gate, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity intolerance, continence, and cognition. 7. The staff will seek to identify environmental factors that may contribute to falling such as lighting and room layout."... II. Resident Status Medical record review revealed [AGE] year-old resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with Alzheimer's disease, intracranial hemorrhage, chronic airway obstruction, abnormal loss of weight, mitral [DIAGNOSES REDACTED]. The 5/6/11 Minimum Data Set (MDS) revealed the resident had short-term memory impairment and was moderately impaired in the cognitive skills for daily decision-making. The resident required extensive assistance of a staff member with bed mobility, transferring, dressing, eating, and with toilet use, and was dependent upon staff for personal hygiene and locomotion on and off the unit. Resident #2 was frequently incontinent of bladder and occasionally incontinent of bowel. The resident was 64 inches tall and weighed 108 pounds and recently had weight loss. III. Record Review/Falls/Facility Failures The comprehensive care plan, last updated on 5/2/11, indicated the resident had an alteration in vision related to the [DIAGNOSES REDACTED]. The plan also indicated the resident was at risk for injuries related to a recent hospital stay and was weak. The care plan indicated the resident used a walker and could be unsteady at times, had numerous falls the last quarter, and often did not use the call light to ask for help. Some of the approaches listed were: -Keep the call light within reach and remind the resident to use the call light (11/9/10), -Maintain a clutter free and well lit environment (11/9/10), -Monitor the resident and the resident's room frequently for any safety needs (11/9/10), -Assist the resident in another bed, in another chair, and to walk (11/9/10), -Low bed with lip mattress (12/6/10), -Pad alarm by bed and chair (4/26/11), -Helmet to be fitted by occupational therapy to prevent possible further head injuries (4/26/11), -Front of releasing closure seatbelt when in the wheelchair (4/28/11), and -Secure unit (4/28/11). Further review of the medical record revealed the resident was at moderate risk for falling according to the fall risk evaluation completed on 5/10/11. The medical record also revealed the resident was on 10 mg of Celexa (an antidepressant) daily. Review of the nurses' notes and "Resident Incident Evaluations," requested and reviewed on 6/29/11, revealed the following entries related to the resident's 26 falls: 1. On 10/29/10 at 7:30 a.m., the resident was found on the floor, confused, and had a small bruise to the left upper quadrant of the abdomen and a small red area to the upper right forehead. Neuro checks were begun. According to the "Resident Incident Evaluation" form the potential factors that could have contributed to the fall were listed as "poor safety awareness and call light not utilized." The facility's description for "Further measures to be taken to prevent further falls" was listed as "resident educated about the need for call light use and the need to wear shoes when ambulating." 2. On 11/6/11 at 12:30 p.m., the resident was found in the middle of her room between the bathroom and the recliner. According to the "Resident Incident Evaluation" form, the resident was ambulating with bare feet to her recliner after using the bathroom and was found sitting on the floor with her legs straight in front of her. According to the form, the resident lost her balance and fell . A "pattern to resident falls" was described as "poor safety awareness, and does not call for assistance when needed." The resident's blood pressure at the time of the fall was documented as 96/44 and neuro checks were begun. According to this form, "Further measures to be taken to prevent further falls" was documented as a "Tab monitor needs to be instituted soon." 3. On 11/12/10 at 12:20 p.m., the resident was found on the floor with her face on the floor and had replied she was going to the bathroom. The resident's injuries included two skin tears to the right forearm, a skin tear to the right lip and a slit to the right lip, bruises to the right buttocks, the right forearm, the right shoulder and the right temporal area, a hematoma to the right upper eyelid and chin, and a small slit to the mid-nose. Potential factors that could have contributed to the fall" were listed as, "poor safety awareness." A "pattern to resident falls" was described as, "does not call for assistance when needed." Neuro checks were begun. According to this form, "Further measures to be taken to prevent further falls" was documented as a "Tab monitor obtained, will commence use now." 4. On 11/24/10 at 7:15 p.m., the resident was found sitting on the floor in front of the recliner. According to the reports the resident had taken the tab monitor off. A "pattern to resident falls" was described as, "trying to get up without assistance." Neuro checks were begun. Potential factors that could have contributed to the fall" were listed as, "the resident was confused and attempted to get out of the recliner without assistance. She had taken off the tab monitor." According to this form, "Further measures to be taken to prevent further falls," was documented as a "Resident should wear nonskid shoes." 5. On 11/25/10 at 1:15 p.m., the resident was found sitting on the floor in front of the mechanical recliner with the recliner seats up in the air. A "pattern to resident falls" was described as, "Confusion/poor safety awareness." "Potential factors that could have contributed to the fall" were listed as, "Confusion (mechanical recliner found all the way in 'assist to stand' position, has been trying to use chair remote to turn on television, education on controller reinforced on each contact." According to this form, "Further measures to be taken to prevent further falls," was documented as "Monitor often for tab monitor placement, reinforce education of remotes for television and chair often." 6. On 12/5/10 at 2 p.m., the resident was found outside of her room in the hallway with a laceration to the back of the head. A "pattern to resident falls" was described as, "Resident noncompliant with waiting for assistance or using call light." The resident was sent to the emergency room for emergency care. According to this form, "Further measures to be taken to prevent further falls," was documented as, "Monitor." 7. On 12/6/10 at 3:40 p.m., the resident was found in the doorway of her room and had appeared to pull the nightstand on top of herself. The resident had a skin tear to the right elbow and a bruise to the right scapula. A "pattern to resident falls" was described as, "Resident noncompliant with waiting for assistance or using call light for assistance." "Potential factors that could have contributed to the fall, "were listed as, "Poor safety awareness." According to this form, "Further measures to be taken to prevent further falls" was documented as, "Monitor closely, low bed, lip mattress." 8. On 12/10/10, the resident was found sitting on the floor in her room facing the recliner at 1:15 p.m. According to the report the resident, wearing socks, stated she had walked back from the bathroom and slipped. There was no documentation whether a tab alarm had sounded or even was in use. The report questioned if there was a pattern to the resident's falls and "resident in room" was documented. The resident's blood pressure was documented as 96/44. "Potential factors that could have contributed to the fall, "were listed as "Resident unsteady on his feet." According to this form, "Further measures to be taken to prevent further falls," was documented as, "Encourage resident to use call light." 9. On 12/14/10 at 6:15 p.m., the resident was observed on the floor in her room; "apparently the resident had gone over to the TV and raised up, bumped her head on the TV which is mounted on the wall and then falls striking her head on the floor." According to the report the resident received a laceration to the right side of the head and one to the back of the head, and possibly reopened old wounds on the right side of the head. The report also documented the resident had contusions on the front top of the head and on the right side of the head. The resident was sent to the emergency room for care. "Potential factors that could have contributed to the fall, "were listed as (the) "res (resident) did not use call light and wait for assist." "Further measures to be taken to prevent further falls," were documented as, "Remind resident to use call light and wait for assistance." 10. At 12:15 p.m. on 12/18/10, the resident was witnessed ambulating with a walker and tipped backwards sitting on the floor. The report documented the tab alarm had been taken off by the resident, "noncompliant." A description to the pattern of the resident's falls was documented as, "Residents frequently ambulating without utilizing call light, takes own the tab monitor off, education is reinforced at every contact . . .to use call light." "Potential factors that could have contributed to the fall," were listed as, "mental status is confused most of the time." 11. On 12/30/10 at 11 a.m., the resident was found on the floor on her back with her head wedged between the wall and the leg of a TV tray. The report indicated the resident was noncompliant with the call light and the tab monitor. "Poor safety awareness, noncompliance with call light and tab monitor, confusion" was the description of a pattern to the resident's falls. The resident's blood-pressure was documented as 107/66. "Further measures to be taken to prevent further falls," was documented as, "Continue to monitor often, reinforce education on need for assistance, use of call light, and tab monitor." 12. At 3:15 p.m. on 12/30/10, the resident was again found on the floor in her room near the recliner. According to the report, the resident misjudged the recliner and had no injuries from the fall. "Potential factors that could have contributed to the fall," were listed as "Resident's confusion." "Further measures to be taken to prevent further falls," was documented as, "call light within reach." 13. On 12/31/10 at 9 a.m., the resident was found with no apparent injuries on her back in the middle of her room. The report did not document whether the tab monitor was in use only that the resident was noncompliant. "Poor safety awareness, does not use call light, noncompliant with tab monitor use," was the description of a pattern to the resident's falls. "Further measures to be taken to prevent further falls" was documented as," Continue to monitor often, reinforce education on call light use, and tab monitor use." 14. At 6:15 p.m. on 12/31/10, the barefoot resident was found sitting on the floor in the middle of her room. No injuries were noted. The resident's blood pressure was documented as 100/60. The report did not document whether the tab alarm was in use only that the resident was noncompliant with and removes the alarm. A description to the pattern of the resident's falls was documented as, "not compliant with tab monitor and removes, doesn't use call light and has poor safety awareness." "Potential factors that could have contributed to the fall" were listed as "confusion, poor safety awareness." "Further measures to be taken to prevent further falls" was documented as "monitor frequently, reminding to use call light, and frequently check that tab (monitor) is in place." 15. On 1/7/11 at 10:30 a.m., the resident was found on the floor in her room between the wheelchair and the bed with her head facing the bottom of the bed. The resident received two 1.5 centimeters (cm) lacerations to the right posterior head. The report did not document whether the tab alarm was in use and/or sounded. The resident's blood pressure was documented as 98/56. "Potential factors that could have contributed to the fall" were listed as "poor safety awareness, unsteady gait, legally blind." "Further measures to be taken to prevent further falls" was documented as "we'll speak to family about removing extra furniture in room." 16. On 1/11/11 at 10 a.m., the "Resident Incident Evaluation" documented the resident was near her recliner and lost her balance resulting in a half inch skin tear to her mid-back. The report did not document whether the tab alarm was in use and/or sounded. The resident's blood-pressure was documented as 90/60. There were no documented potential factors that may have contributed to the fall. "Call light within reach" and "bed in low position" were listed as further measures to be taken to prevent further falls. 17. At 12:30 p.m. on 1/24/11, the resident was found lying on her left side near the recliner resulting in an abrasion to the mid-occipital region of the head. The report did not document whether the tab alarm was in use and/or sounded. The description to the pattern of the resident's falls was documented as "Resident has been falling frequently in her room near the recliner." "Resident's confusion" was documented as a "potential factor that may have contributed to the fall." "Further measures to be taken to prevent further falls" was documented as "Call light within reach, low bed frame, utilize Merry Walker more consistently." 18. On 2/7/11 at 3:05 p.m., a staff member witnessed the resident leaning on the TV tray which broke causing the resident to fall backwards onto her bottom against the bed resulting in two 1 cm skin tears to the right elbow. The report did not document whether the tab alarm was in use and/or sounded. "A potential factor that could have contributed to the fall" was listed as, "TV tray unstable." Further measures to be taken to prevent further falls" was documented as, "TV tray removed from room." 19. At 5:10 p.m. on 2/14/11, a CNA (Certified Nurse Aide) witnessed the resident pushing the overhead table and falling to her bottom on the floor beside the bed. According to the report the resident had reopened an old skin tear on the left elbow. The report did not document whether the tab alarm was in use and/or sounded. "Potential factors that could have contributed to the fall" was listed as, "continues to move over bed table, removed from room." 20. On 2/26/11 at 7:15 p.m., the barefooted resident was found sitting on the floor next to her recliner. "Potential factors that could have contributed to the fall," were listed as, "Resident does not wait for help to arrive." The report did not document whether the tab alarm was in use and/or sounded. The resident's blood pressure was documented as 100/58. "Potential factors that could contribute to the fall" were documented as, "resident attempts to get up myself without calling for help." "Further measures to be taken to prevent further falls," was documented as, "Encourage resident to call for help." 21. On 3/4/11 at 7:45 p.m., the resident was found sitting on her bedroom floor. "None" was the documented statement on the report if restraints/adaptive equipment were used. "Potential factors that could have contributed to the fall" were listed as, "poor safety awareness." "Further measures to be taken to prevent further falls," was documented as, "cont (continue) to re-educate on safety awareness." 22. On 3/23/11 at 9:05 p.m., the resident was found on the floor in the middle of her room. The resident sustained [REDACTED]. There was no indication that any alarms/restraints were being used at that time. "Further measures to be taken to prevent further falls," was documented as, "encouraged to use call light." 23. On 4/8/11 at 4:30 p.m., the resident was found on her left side on the floor of her room. The resident's injuries were described as a goose egg to the right forehead. The pattern to the resident's falls was described as, "does not call for help." "Further measures to be taken to prevent further falls," was documented as, "Resident may need alarms." 24. On 4/13/11 at 7:45 p.m., the resident was found with no apparent injuries sitting next to a chair on the floor in her room. According to the report the resident appeared to have misjudged the distance from the chair and bed. Despite the documentation on the previous fall report, that alarms were documented as a measure to prevent further falls, there was no indication that any alarms/restraints were being used at this time. "Further measures to be taken to prevent further falls," was documented as, "educate resident to use call light when transferring." 25. On 4/17/11 at 7 p.m., a CNA witnessed the resident slipping out of a chair in her room. The resident's blood pressure was documented as 94/44. The resident had no apparent injuries. There was no documentation on the report of further measures to prevent further falls. 26. On 4/23/11 at 8:40 p.m., the resident was found on the floor next to her recliner. The resident had sustained a laceration to the back of the head, described as approximately 1.5 inch x. 5 inch in size and a 5 cm x .01 cm laceration to the right upper arm. In addition the resident received 0.3 cm skin tear to the left thumb. The resident was sent to the emergency room . "Further measures to be taken to prevent further falls," was documented as, "Needs alarms." According to the hospital discharge summary, dated 4/26/11, the resident suffered a closed head injury and a subdural hematoma. In addition the resident was found to have a urinary tract infection and was treated with antibiotics and returned to the facility. The hospital record also indicated the resident had terminal lung cancer. IV. Observation The resident was observed in the television area with other residents on the secure unit on 6/27/11 at approximately 4:30 p.m. Resident #2 was seated in a recliner that was tilted back in a reclining position with the foot rest up and leaning on a large red ball. The resident was noted not wearing the helmet at this time. An alarm box and cord were attached to the resident's wheelchair that was parked beside the recliner, however, the alarm was not attached to the resident. V. Interviews The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed about resident #2's falls and interventions on 6/28/11 at 3:30 p.m. and again on 6/29/11 at 11:30 a.m. When asked about assessment for trends and review of her environment, medications, medical reasons, toileting, and hunger etc., after the first few falls, they replied the resident was independent as far as getting up and transferring. They went on to say that alarms annoyed the resident and she would remove them. In addition, with her dementia she would forget to ask for assistance. All of the resident's falls were reviewed with the DON and ADON at these times. They reported that when the resident was admitted to the facility she was receiving therapy. They stated on 11/24 and 11/25/10 the resident had taken the tab alarm off. On 12/6/10, the low bed and lip mattress were ordered. On 12/14/10, the tab alarm was on. On 1/7/11, the resident had an eye examination and it was discovered she was legally blind. On 1/24/11, a merry walker was used for strengthening; however, discontinued on 1/26/11, as she refused to use it. On 3/31/11, they stated the facility staff met again and discussed resident #2's falls. They found the resident had orthostatic blood pressure and discontinued her blood pressure medications at that time. They also looked at her room and decided to suggest a larger rug, reviewed her medications and checked her thyroid level. The fall on 4/17 was due to the resident slipping out of a wheelchair. They stated the resident was used to a walker and not a wheelchair which staff had put in her room. After the 4/23/11 fall, they stated the resident was "moved to the secure unit for more 1:1" . . . "is somewhat confused" and "therapy picked her back up." They stated the physician was in favor of transferring the resident to the unit where there "is a calmer atmosphere and more 1:1." They went on to say that falls had decreased for this resident since the move and the resident now only wears the helmet when transferring and when she is restless. Even though the facility had knowledge that this resident experienced short-term memory impairment, was assessed at moderate risk for falling, exhibited poor safety awareness, and would forget to request assistance when transferring, the facility repeatedly continued to re-educate the resident on the use of the call light and on requesting assistance. It was not until the resident had fallen 26 times, and suffered a subdural hematoma, that the facility increased supervision by placing the resident in the secure unit and placing a musical alarm mat in the resident's room.